Migraine and Chronic Headaches: Evidence-Based Management

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The Disability of Migraine

Migraine is far more than a bad headache. It is the second leading cause of disability worldwide (Global Burden of Disease study) — more disabling than diabetes, epilepsy, or asthma in terms of years lived with disability for those under 50. Migraine affects approximately 1 in 7 people globally — 150 million Indians — predominantly women (3:1 female:male ratio). Despite its enormous prevalence and impact, migraine remains dramatically underdiagnosed and undertreated.

Migraine Biology

Migraine is a neurological disorder characterised by recurrent attacks of moderate-to-severe headache (typically unilateral, pulsating, aggravated by physical activity) accompanied by nausea/vomiting and light/sound sensitivity. The current understanding: migraine involves cortical spreading depression (a wave of neuronal depolarisation followed by suppression, moving across the cortex — generating the aura), activation of the trigeminovascular system (trigeminal nerve innervating cranial blood vessels — the pain generator), and central sensitisation (the brain becomes “amplified” during attacks — explaining allodynia, where even light touch is painful).

Migraine With and Without Aura

Without aura (~75%): headache phase directly without preceding neurological symptoms. With aura (~25%): Preceding the headache by 20–60 minutes — visual symptoms (most common — flashing lights, zigzag lines, blind spots); sensory symptoms (tingling spreading up one hand and arm — cheiro-oral distribution); speech disturbance (dysphasia). Aura symptoms are fully reversible within 60 minutes. Migraine with aura increases stroke risk — particularly in women on combined oral contraceptives who smoke — COCPs contraindicated.

Migraine Triggers

Individual triggers vary: sleep changes (too much or too little); skipping meals; stress and stress let-down (weekend migraines); alcohol (especially red wine and beer — tyramine, histamine, sulphites); hormonal changes (menstrual migraine — attack 2 days before to 3 days after menstruation); bright lights; strong smells; barometric pressure changes; dehydration. Identifying personal triggers through a headache diary — then systematic avoidance — reduces frequency.

Acute Treatment

NSAIDs: First-line for mild-moderate attacks — aspirin 900mg + metoclopramide, ibuprofen 400–600mg, naproxen 500mg. Triptans: First-line for moderate-severe attacks or when NSAIDs fail — sumatriptan (oral 50–100mg; subcutaneous 6mg for fastest onset), rizatriptan, zolmitriptan, almotriptan; all work by agonising 5-HT1B/1D receptors, constricting cranial vessels and inhibiting trigeminal nerve firing. Take early in the attack (within 30–60 minutes of onset) for best effect. CGRP antagonists (gepants): Ubrogepant, rimegepant — newer oral alternatives effective within 2 hours; no vasoconstriction (safe in cardiovascular risk patients who cannot take triptans). Anti-emetics: Metoclopramide or domperidone with analgesic — improve gastric absorption and reduce nausea. Medication overuse headache (MOH): Acute medications taken >10 days per month (triptans) or >15 days (NSAIDs) cause MOH — worsening headache frequency paradoxically; detoxification required.

Preventive Treatment

Indicated when: ≥4 migraine days per month; severe or prolonged attacks; significant disability; medication overuse. Evidence-based preventives: Propranolol (40–160mg daily) — first-line; reduces frequency ~50% in responders; Topiramate (25–100mg daily) — effective; weight-neutral or reducing; cognitive side effects at higher doses; Amitriptyline (10–75mg at bedtime) — for migraine + tension headache combination; Candesartan — good evidence; well-tolerated; CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) — the most effective preventives available; monthly or quarterly subcutaneous injection; ~50% of patients achieve >50% frequency reduction; well-tolerated; expensive; appropriate for frequent/severe refractory migraine.

Chronic Migraine and Botulinum Toxin

Chronic migraine (≥15 headache days per month, ≥8 being migraine) is particularly disabling. BOTOX (onabotulinumtoxinA) 155–195 units injected across 31 sites on the scalp and neck every 12 weeks — FDA and NICE approved for chronic migraine; reduces headache days by approximately 8–9 per month vs 6–7 for placebo; safe; well-tolerated. Available at Akkineni Hospitals.

Conclusion

Migraine is a complex neurological condition that demands proper diagnosis, trigger management, appropriate acute therapy, and prophylaxis for frequent sufferers. At Akkineni Hospitals, our neurology team provides comprehensive migraine management.

For appointments and consultations, contact Akkineni Hospitals — Neurology Department.