Headache & Migraine

Migraine diagnosis is clinical — based on the pattern of attacks. The ICHD diagnostic criteria require at least 5 attacks lasting 4-72 hours, with at least 2 of: unilateral location, pulsating quality, moderate-severe intensity, worsened by routine activity; and at least 1 of: nausea/vomiting, or sensitivity to both light and sound. You don't need all of these every attack, and migraine can occasionally be bilateral. A headache diary tracking frequency, duration, severity, location, associated symptoms, and potential triggers over 4-8 weeks is the most useful tool — both for diagnosis and for identifying your personal trigger patterns. Many people with frequent headaches have undiagnosed migraines.

Common migraine triggers include: sleep changes (too much or too little, even on weekends), dehydration, skipping meals, strong smells, bright or flickering lights, loud noise, stress and stress let-down (the weekend migraine after a stressful week), hormonal fluctuation (many women have migraines around menstruation), alcohol (particularly red wine), aged cheese, caffeine excess or withdrawal, and weather changes. Triggers are highly individual — what triggers one person's migraine may not affect another's. A headache diary identifying your personal triggers is more useful than following generic lists. Note: not every attack has an identifiable trigger; migraine is a brain condition with a lowered threshold, not purely a reaction to avoidable exposures.

For mild-moderate attacks: paracetamol, ibuprofen, or aspirin taken early in the attack (before pain peaks) can be effective. For moderate-severe attacks, triptans (sumatriptan, rizatriptan, eletriptan) are the most specific and effective acute treatments — they work on the serotonin receptors involved in migraine and typically bring relief within 1-2 hours. They work best taken at the first sign of headache, not during aura, and not in people with cardiovascular disease. An anti-nausea medication (metoclopramide, domperidone) taken with the painkiller speeds absorption and reduces nausea. Avoid taking acute headache medication on more than 10-15 days per month — overuse causes medication-overuse headache, making the condition worse.

Preventive treatment is recommended if you have 4 or more migraine days per month, attacks are severe and disabling even when acute treatments work, acute medications are overused or contraindicated, or quality of life is significantly impacted. Preventive options include: propranolol, metoprolol (beta-blockers), amitriptyline (low-dose antidepressant), topiramate or valproate (anticonvulsants), and candesartan or lisinopril. Newer CGRP-targeted treatments — monoclonal antibodies (fremanezumab, galcanezumab, erenumab, injectable monthly) and gepants (oral) — are highly effective with minimal side effects and now available in India, though costly. Most preventives take 2-3 months to assess efficacy. A neurologist or headache specialist guides selection based on your other conditions and preferences.

Go to emergency immediately for: a sudden, explosive headache that peaks within seconds ('thunderclap headache' — worst of your life — possible subarachnoid haemorrhage), headache with fever, stiff neck, rash, and sensitivity to light (meningitis), headache with neurological symptoms — weakness, speech change, vision loss, confusion, facial drooping (stroke or brain bleed), new headache in someone with cancer or HIV, headache after a head injury, and progressively worsening headache that builds over days. A severe migraine that fits your usual pattern and doesn't respond to medication is distressing but not typically dangerous. A new type of headache you have never had before warrants prompt medical evaluation even if not an emergency.