Contents
Episodic throbbing disabling headache usually associated with nausea and of > 6 months duration with normal neurological examination.
Classification
International Headache Society (IHS) classification of primary headaches:
- Migraine
- Tension headache
- Trigeminal autonomic cephalalgias (of which cluster headache is the most prominent variety)
- Group 4 “other primary headache disorders”: Consists of 10 rare headache syndromes with well-established primary nature
- Benign exertional headaches
- Primary stabbing headaches (“jabs and jolts syndrome”)

Migraine
Episodic throbbing disabling headache usually associated with nausea and of > 6 months duration with normal neurological examination.
- Episodic migraine (EM): Distinguished by recurrent, slowly developing attacks with lateralized and reversible visual, sensory, speech/language, motor, brainstem, or retinal symptoms; attacks are accompanied or followed by headache and migraine symptoms
- Migraine without aura (common migraine) (M/C, 80%)
- Migraine with aura (classical migraine)
- Chronic migraine (CM): Migraines experienced ≥ 15 days/month

Rare variants:
- Ophthalmoplegic migraine: Transient unilateral CN III palsy (reversible) → ptosis
- Basilar type migraine: Transient posterior cerebellar symptoms (reversible
- Ataxia, tinnitus, diplopia, vertigo
- Hemiplegic migraine: Transient hemiplegia (reversible)
- Familial hemiplegic migraine (seen in children)
- Retinal migraine: Transient monocular visual loss
Pathophysiology
Trigeminovascular complex (centre for pain in migraine):

Pathogenic hypothesis:
- Vascular theory:
- Intracerebral blood vessel vasoconstriction
- Intracranial/extracranial blood vessel vasodilation
- Serotonin theory:
- ↓ Serotonin
Aura phenomenon:

- Cortical spreading depression: Propagating wave of depolarization followed by neural suppression

Presentation
Prodrome (60% cases):
- Onset: 2 hours-2 days before aura or pain
- Symptoms:
- Altered mood, irritability, depression/euphoria
- Fatigue
- Craving for certain foods
- Stiff muscles (especially neck)
- Constipation/diarrhoea
- Sensitivity to smells/noise
Aura: Only in classical migraine
Transient focal neurological phenomenon that occurs before or during the headache.
- Visual aura (M/C) > Auditory > Sensory
- Visual aura: Zigzag lines (fortification spectra), scintillating scotomas
- Onset: ≤ 60 minutes before headache
Headache:
- Increase in frequency & severity over time
- Localization:
- Unilateral → holocranial
- Frontotemporal > orbital
- Throbbing/pounding quality
- Duration: 4-72 hr
- Associated conditions:
- Nausea, vomiting
- Photophobia/phonophobia/osmophobia (patient prefers dark, quiet room)
Management

Acute migraine:
- Analgesics or NSAIDs (mild attacks)
- Triptans (5HT 1B/1D agnoists) (moderate-to-severe attacks)
- Constrict blood vessels and block pain pathways in the brain
- M/effective: Rizatriptan, Eletriptan
- Others: Sumatriptan, Zolmitriptan
- Ergot alkaloids (if triptans ineffective)
- Dihydroergotamine
- Opiates (severe cases)
Preventive medications:
- 1st line: Propranolol. tricyclic antidepressants (TCA), topiramate
- 2nd line: Telmisartan, venlafaxine, valproate
- 3rd line: Pizotifen (5-HT 2C agonist), flunarizine (CCB), clonidine
Novel treatments:
- Monoclonal antibody: Erenumab (CGRP antagonist)
- Greater occipital nerve block
- Onabotulinum toxin A
- Supraorbital transcutaneous stimulation
