This talk summarizes the definition, diagnosis and management strategies of migraine. It will be useful for general public as well as healthcare professionals. This is more of a summary of recent evidence available on migraine management. It is easy to read and understand. Please post your queries and comments.

1. Prevention, Diagnosis and
Treatment of Migraine
Dr Sudhir Kumar MD DM
Prof & HOD, Neurology Unit
Apollo Hospitals, Hyderabad

2. My presentation would cover
Definition of
migraine
Prevalence of
migraine
Trigger factors for
migraine
Diagnosis of
migraine
When to do brain
scan in patients
with headache
Non-drug
measures to
prevent migraine
headaches
Medical treatment
of migraine
Medication
(analgesic)
overuse headache

3. What is
migraine?
• Repeated headaches after
variable intervals
• Headaches usually last for 4-72
hours,
• Accompanied with nausea,
vomiting, intolerance to noise or
bright lights
• Can occur in any age- more
common in young adults and
adolescents.

4. How common is migraine?
One-year prevalence of migraine in people aged 18-65 is 25% (as compared to
tension type headache, which is 35%)
This means, 60% of adult population suffer from either migraine or tension
type headache,
The prevalence of migraine is 2-times more in women as compared to men,
The prevalence of migraine in rural areas is 1.5 times more than that in urban
areas.

5. Triggers of migraine headache episodes
Lack of sleep
Fasting or delayed
meals
Stress Menstrual periods
Certain foods-
cheese, chocolates,
soft drinks, cakes,
Chinese food
Certain smells-
perfumes,
petrol/diesel
Exercise (in some)
Sexual activity
(rarely)

6. Diagnosis of
migraine
1. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully
treated)
2. Headache has at least two of the following characteristics:
• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine physical activity
(walking or climbing stairs)
3. During a headache, at least one of the following:
• Nausea and vomiting
• Photophobia and phonophobia

7. When should we order brain scan in a patient
with headache?
• Acute severe headache, especially if it is the first or worst episode (discard subarachnoid hemorrhage)
• Abnormal neurologic examination (confusion, stiff neck, papilledema, epilepsy)
• Changes in the patient's typical features or patterns
• New episodes in older (> 50 years of age) or immunosuppressed patients
• New neurological symptoms or signs on examination
• Headache not responding to treatment
• Headache lasting > 72 hours
• A significant change in the frequency, pattern, or severity of headaches
• Severe headache pain ("worst headache of life") or headache causing awakening from sleep
• New-onset headache in patients with HIV infection or cancer
• Associated symptoms or signs suggestive of meningitis or stroke

8. Non-drug measures to prevent headaches
Regular good night sleep/Avoid shift duties as much as possible
Stress-free life
Timely meals
Regular exercise (find the right dose of exercise)
Avoid migraine triggers
Avoid smoking & alcohol consumption

9. Medical Treatment of Migraine
Who needs preventive migraine treatment?
• Frequent or long-lasting headaches
• Attacks that cause significant disability and reduced quality of life
• Contraindications or failure to acute therapies
• Significant adverse effects of abortive therapies
• Risk of medication overuse headache
• Hemiplegic migraine
• Brainstem aura migraine
• Persistent aura without infarction
• Migrainous infarction

10. Drug options for preventive migraine therapy
Beta blocker: Propranolol
Antidepressant: Amitriptyline
Antiepileptic: Sodium valproate, divalproex, topiramate
Calcium channel blocker: Flunarizine
Calcitonin gene related peptide antagonist: Erunumab
Botulinum toxin injection

11. Drug options for
acute headache
episodes
• NSAIDS- Naproxen
• Triptans- Sumatriptan,
rizatriptan, zolmitriptan
• Ergot- Vasograin, Migranil
• Anti-emetics
• IV fluids, if dehydrated due to
vomiting

12. Medication Overuse
Headache (MOH)
• To be considered for a diagnosis of MOH,
• a patient must have a headache for 15 or more days
monthly in a patient with an established diagnosis of a
headache disorder such as migraine or tension-type.
• Additionally, they must be utilizing one or more
symptomatic medications regularly (10 to 15 days per
month, depending on the type of drug consumed) for
over three months.
• Management: reduce, replace or stop overused
analgesics; start preventive medications

13. Take home messages
Migraine is common and has multiple negative effects on the sufferer,
Diagnosis can be made on the basis of clinical history
Brain imaging is not mandatory, however, it may be needed to exclude other causes of headaches (on case-to-case basis)
Several lifestyle habits can reduce the migraine attacks
Preventive medicines are needed for those with frequent headaches
There are good medicines for treating acute headache episodes.

14. Comments/queries
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