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Headache and Migraine 

Study guide:



  • Migraines: Visual disturbances, Nausea and Vomiting, Aura.

    • Most common type of aura is bilateral homonymous scotoma.

  • Cluster: Frequent, Brief, extreme headache.

    • Affects men more 10:1.



  • There are no specific diagnostic tests for the three types of headaches mentioned above.

  • However some diagnostic tests are used to exclude the following:

    • Intracranial mass lesion: CT/MRI"

    • Pseudotumor Cerebri : CT/MRI and LP

    • Giant cell arteritis: ESR levels and Biopsy of the temporal artery   

Red Flags:

  1.  Worst headache in my life = SAH

  2.  Fever = Infection i.e. meningitis & encephalitis

  3.  Neck stiffness = meningeal irritation

  4.  Focal deficit = mass occupying lesion

  5.  Decreased level of consciousness = infection, Hydro. ​​ 

  6. Seizures = Focal lesion

  7. Papilledema = increased ICP

  8. Sinus tenderness and nasal discharges = sinusitis​​

  9. Temporal tenderness = Temporal arteritis

  10. Elderly (onset after age of 50)

  11. 11. Immunocomprimised individual  


Aura: Visual or sensory or dysphasic symptoms. Takes about 5-20 minutes and can last but not exceed 60, may come before or with the headache. Migraines with aura are called Classic Migraines. 



  • NSAIDs (1st line)

  • Triptan (2nd line)

  • Ergotes (rare)

  • Dopamine antagonist (3rd line)

  • 100% Oxygen (Only for Cluster)

  • Beta-blockers: propranolol (best prophylactic therapy for migraines) 

  • Tricyclic antidepressants (TCA): 
    amitriptyline (used with depression, insomnia, underweight patients)

  • Valproic acid

  • Topiramate

  • Verapamil (best prophylactic therapy for  cluster headache)

  • Methysergide (rarely used; SE: retroperitoneal fibrosis)

  • Lithium (Cluster only)

  • Steroids (Cluster only)

Triptans and ergots are contraindicated in CAD patients and pregnancy

In menstrual migraines abortive is like prophylaxis: long acting Triptans


  1. Fischer, Conrad. Master The Boards. Print.

  2. Agabegi, Steven S, Elizabeth D Agabegi, and Adam C Ring. Step8Up To Medicine. Philadelphia: Wolters

    Kluwer/Lippincott Williams & Wilkins, 2013. Print.

  3. Le, Tao, Vikas Bhushan, and Herman Singh Bagga. First Aid For The USMLE Step 2 CK. New York: McGrawLHill

    Medical, 2010. Print

  4. Le, Tao et al. First Aid For The® USMLE. Print.

  5. Yogarajah, Mahinda. Neurology. Edinburgh: Mosby/Elsevier, 2014. Print.  

Written by:        Abdullah AlAsaad

Reviewed by:     Roaa Amer

                         Haifa Al Issa

Web Publisher: Adel Yasky  

Audio recording:
​- Read by: Thakra AlGulaigah
​​- Directed by: Rana Alzahrani
- Audio production: Bayan Alzomaili

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