This document summarizes information about migraines and other primary headaches. It begins by classifying headaches as either primary, meaning the headache itself is the disease, or secondary, meaning the headache is a symptom of an underlying condition. It then describes the characteristics and treatment approaches for primary versus secondary headaches. The bulk of the document focuses on describing migraines in particular, including the diagnostic criteria for migraine with and without aura, common symptoms and triggers, pathophysiology, treatment strategies including abortive and preventative options. It also briefly mentions some other less common primary headache types such as cluster headaches.

1. Migraine and other
headaches
Dr Pramod Krishnan,
Consultant Neurologist, Epileptologist,
Sleep Medicine Specialist,
Manipal Hospital, Bengaluru.

2. Classification of headaches
Primary headaches
• Headache itself is the disease.
• No other disease in the
background
• TREAT THE HEADACHE!
Secondary headaches
• The headache is only a
symptom of an underlying
disease.
• TREAT THE UNDERLYING
DISEASE!
The differentiation between 1 and 2 is critical as it dictates
diagnostic approach and guides treatment and prognosis.

3. Primary headaches
• Long history of headaches.
• Stereotyped symptoms.
• Normal neurological
examination.
• Normal investigations.
• Benign.
• Treatment is only for patient
comfort.
• Only control, not cure.

4. Secondary headaches
• Short history.
• Signs and symptoms of
underlying disease.
• Investigations are needed and
are often abnormal.
• Need treatment to prevent
complications.
• Can be cured.

5. Meningitis/ SAH
Brain tumor
ICH
Glaucoma
Refractory errors
Allergic rhinitis
Sinusitis
Dental abscessCervical spondylosis
Muscle spasms
TMJ
Temporal arteritis
Brain abscess
Skull fracture
SDH/ EDH or abscess
Systemic infection
Metabolic abnormalities

6. Are there different types of
migraine?
• Migraine WITHOUT AURA (common
migraine)
• Migraine WITH AURA (classical
migraine)

7. What is an aura ?
• Transient, stereotyped sensory
phenomenon experienced prior
to the onset of headache.
• Lasts several minutes.
• Usually visual; can be sensory
or language disturbance.
• Seen in 15- 20% migraineurs.
• Rarely, different auras may
occur in sequence.

8. Migraine aura
• Scintillating scotoma.
• Fortification spectra.
• Usually colourless.
• Aura can occur without
headache.
• Headache can occur without
aura.

9. Migraine without aura
A. Atleast 5 headaches with:
B. Duration > 4 hours.
C. 2 out of the following:
1. Unilateral location.
2. Pulsating quality.
3. Moderate/ severe intensity
4. Aggravation with activity.
D. During headache, atleast one of :
1. Nausea/ vomiting.
2. Photophobia/ phonophobia.
E. Exclusion of other diagnosis.
Migraine with aura
A. Atleast 2 attacks fulfilling
criteria B.
B. Atleast 3 of the following:
1. Fully reversible aura symptoms.
2. Aura evolves gradually over 4 min.
3. Aura duration < 60 min.
4. Headache starts within 60 min of
aura.
C. Exclusion of organic
diagnosis.

10. Migraine epidemiology
Prevalence of 18 % in females and 6% in males.

11. Age and Gender
• Can begin at any age.
• The usual onset is in
adolescence, peaks between 20-
50 years of age.
• Reduces by age of 60 years.
• Positive family history in 90%
of patients.
• Life long tendency.

13. Migraine: Pathophysiology
• Strong family history suggests
a genetic basis.
• Symptoms are not restricted to
headache.
• Migraine attacks can occur
without headache.
• Exact mechanism is unclear.

15. Cortical spreading depression

16. Clinical features

18. Headache
• Unilateral/ bilateral.
• Throbbing.
• Moderate to severe degree.
• Aggravates with activity.
• Sleep relieves pain.
• Usually does not disturb sleep.
• Photophobia, phonophobia,
osmophobia.
• Nausea, vomiting, giddiness.

19. • Headache can be very severe
and disabling.
• May require hospitalisation.
• Repeated vomiting may require
intravenous hydration.
• Patient may faint during severe
headaches.

20. • Can build up slowly or rapidly.
• Can last several days.
• Occurs in close temporal
association with triggers, but
lasts even after the trigger is
withdrawn.

21. • Mood changes are prominent.
• Often start several hours before
the headache.
• Become prominent during the
headache.
• Become irritable, low threshold
for anger, can become violent
as well.
BETTER LEAVE THE
PATIENT ALONE !!

22. Common location of migraine headaches

25. Uncommon/ rare symptoms
• Irritability
• Double vision
• Drooping of eyelids.
• Watering from eyes.
• Speech disturbances.
• Limb weakness.
• Imbalance.
• Numbness.
• Scalp tenderness

26. Migraine triggers
• Multiple triggers are usually
present in a single patient.
• Triggers are unique for a
patient.
• Consistency.
• Threshold varies according
to internal and external
factors.

29. Migraine Triggers
• Menstruation is an important
trigger.
• Usually on day -2 to +3.
• Occurs in 60% of migraineurs.
• True menstrual migraine
(TMM)
• Premenstrual migraine: day -7
to -3.

31. Chronic migraine

33. Migraine diagnosis
• Diagnosis is based purely on
headache description.
• Usually examination is normal.
• No tests are required in a
typical patient.
• Investigations are required in
atypical cases.

34. Treatment of Migraine
• Sleeping off an attack.
• Tying a cloth around the head.
• Balms.
• Coffee.
• Head massage.
• Inducing vomiting.
SEEMS TO WORK !!

35. Principles of therapy
• Lifelong condition.
• No cure, only control.
• Adequate sleep, regular meals.
• Rest and relaxation.
• Avoid variation in daily schedule.
• Identify and avoid triggers.
• Use medicines sparingly.
• Migraine has no harmful effects,
but treatment has.

36. Preemptive
treatment
Migraine trigger
time-limited and
predictable
Preventative
Decrease in
migraine frequency
severity, and duration
Acute
treatment
To stop pain
and prevent
progression
Treatment Strategies and Goals

40. Abortive therapy: Regular analgesis
To be used sparingly for immediate pain relief.
Relief is temporary but often a single dose is sufficient.
Use of > 1/week on a regular basis is not recommended.

41. Abortive therapy: Migraine specific analgesics
• Triptans are the drug of
choice.
• Dihydroergotamine is equally
effective.
• Relief is within 30 minutes.

42. Abortive therapy: Injections
• Triptans and DHE are
available as injections.
• Relief is within 5 minutes.
• Expensive.
• Prefilled syringes.

43. Abortive therapy: Transdermal patch
• Battery operated.
• Wraps around arm or thigh.
• Electric current is used to
move the medicines through
the skin.
• May cause local skin reaction.

44. Abortive therapy: Nasal spray
• Triptans and DHE are
available as nasal spray.
• Relief is within 15 min.
• Single puff is enough.
• Dose can be repeated only after
2 hours (if needed).

45. Abortive therapy: Sphenopalatine block

46. Prophylaxis: Anti-epileptics
Used when headache frequency is 1/week or more.
To be used daily for several months.
Slow and steady benefit.

47. Prophylaxis: Anti-depressants
Preferred when stress, emotional disturbances and lack of sleep are
contributory factors.

48. Prophylaxis: Other medications
• Relief is temporary.
• Acts as a bridge to implement
more lasting changes in
lifestyle.
• Very safe and effective.
• Yoga, Meditation, reiki are
probably effective.

49. Prophylaxis: Cefaly
• Battery operated device to
stimulate the trigeminal nerve
region.
• To be used for 20 min every
day.
• Useful in pregnant women in
whom no medicine is safe
except paracetamol.
• Cost Rs 22000- 25,000/-.
• Consumables: Rs 500/ month.

50. Prophylaxis: Botox
• Safe and effective.
• Chronic migraine.
• Cost: Rs 30,000- Rs 35,000 per
session.
• Effective for 3-6 months.

51. Prophylaxis: Botox

52. Conclusion
• Common, benign headache.
• Genetic, therefore lifelong.
• Can be controlled, not cured.
• Lifestyle changes are the
cornerstone of therapy.
• Medications should be the last
resort.
• Not associated with any
complications.
• Frequently misdiagnosed.

53. Is migraine the only type of primary headache?
• Cluster headache
• Paroxysmal hemicrania
• SUNCT
• Hemicrania continua
• Tension type headache
• Primary stabbing headache
• Primary cough headache
• Primary exertional headache
• Primary headache with sexual activity.

55. Suicide headache. More common in men. Patient avoid lying down and become
very restless. Occurs with clockwork regularlity. No nausea, vomiting, photophobia
or phonophobia. Aura may be seen rarely.

56. Tension type headache
• Muscle contraction headache.
• Dull pressure / tightness.
• Can last 30 min to 7 days.
• Mild to moderate.
• No aura.
• No nausea/ vomiting.
• Photophobia/ phonophobia
may be present, but not both.
• Not aggravated by activity.

57. THANK YOU…..