Headache & Pain Programme

Migraine is a neurological disorder, not simply a severe headache. Its biological basis involves waves of cortical activity (cortical spreading depression), trigeminal nerve activation, and release of the molecule CGRP, which drives the throbbing pain, nausea, and light and sound sensitivity that characterise an attack. A "regular headache" — typically tension-type headache — is characterised by a pressing or tightening sensation, is usually bilateral, does not worsen with activity, and is not associated with nausea or vomiting. The two conditions have different treatments, and correctly identifying which type you have is the first step toward effective management.

CGRP (calcitonin gene-related peptide) is the key molecule in migraine neurobiology. CGRP-pathway monoclonal antibodies — erenumab, fremanezumab, galcanezumab, and eptinezumab — are the first treatments specifically designed to prevent migraine by targeting the migraine mechanism directly, rather than working on other systems (blood pressure, epilepsy, depression) that happen to have a secondary effect on migraine. They are injected monthly or quarterly subcutaneously and are significantly better tolerated than older preventives because they act outside the brain and central nervous system. In clinical trials, they reduced monthly migraine days by 50% or more in 45–60% of patients who had previously failed multiple other preventives.

Botulinum toxin (Botox) is approved specifically for chronic migraine — defined as headache on 15 or more days per month for more than three months, with at least eight of those days meeting migraine criteria. To be eligible, patients should also have failed at least two adequate trials of preventive medication (e.g. topiramate, propranolol, amitriptyline, valproate). The treatment is administered every 12 weeks and typically requires at least two treatment cycles (6 months) to fully assess response. At KIMS, eligibility is confirmed at the headache specialist consultation.

Most oral preventive treatments for migraine (topiramate, propranolol, amitriptyline, valproate, candesartan) take 8–12 weeks to reach their full therapeutic effect. CGRP-pathway monoclonal antibody therapy typically shows response within the first 4 weeks, with full response assessment at 3 months. Botox for chronic migraine shows improvement after the first treatment cycle, with the best response usually seen after the second or third cycle (at 12 and 24 weeks). Many patients who have not given preventive medications enough time at adequate doses mistakenly believe the treatment has failed when it has simply not reached full effect.

Medication overuse headache (MOH) occurs when acute pain-relieving medications are taken too frequently: analgesics and NSAIDs on 15 or more days per month, or triptans on 10 or more days per month for more than three months. The brain adapts to the regular presence of these medications and begins to generate headache in their absence — creating a cycle in which more medication is taken to treat medication-caused headache. MOH is one of the most common causes of daily headache and is highly under-recognised. Treatment requires withdrawal of the overused medication under medical supervision, which typically produces a temporary worsening of headache for 7–14 days before significant improvement. Preventive medication is initiated simultaneously or after withdrawal. Both outpatient and inpatient withdrawal protocols are available at KIMS.

Trigeminal neuralgia is a condition characterised by sudden, intense, electric-shock or stabbing pain lasting seconds to two minutes, typically affecting one side of the face — the jaw, cheek, teeth, or gum. The pain can be triggered by light touch (eating, speaking, brushing teeth, wind). It is caused in most cases by a blood vessel pressing against the trigeminal nerve root near the brainstem. It is highly treatable. First-line treatment is carbamazepine or oxcarbazepine, which controls pain in 70–80% of patients when started at adequate doses. When medications are not tolerated or stop working, three procedural options are available at KIMS: Gamma Knife radiosurgery (non-surgical, outpatient), microvascular decompression (the most effective surgical option with 85–90% long-term success), and percutaneous balloon compression.

Yes. Cluster headache is specifically managed at KIMS as part of the Headache and Pain Programme. Acute attack management includes high-flow oxygen (100% oxygen at 12 litres/minute for 15 minutes), subcutaneous sumatriptan, and intranasal zolmitriptan. Preventive treatment during cluster periods includes verapamil (the first-line preventive), short-course corticosteroids as a bridge while verapamil is titrated, and lithium for chronic cluster headache. Sphenopalatine ganglion (SPG) block is also available for refractory cluster attacks. Patients with difficult-to-control cluster headache may also be evaluated for Gamma Knife radiosurgery targeting the sphenopalatine ganglion or posterior hypothalamus through the neurosurgery team.

The first appointment at the KIMS Headache Programme is longer than a standard neurology appointment — typically 45 to 60 minutes. The neurologist takes a detailed headache history covering the character, timing, duration, severity, and associated features of attacks; all previous medications tried and their effects; the impact on work, family, and daily activities; and any relevant medical history. Existing investigations (MRI, CT, blood tests) are reviewed. At the end of the consultation, a working diagnosis is established and a treatment plan is proposed, discussed, and agreed with the patient. Most patients leave the first consultation with a clearer diagnosis and a more targeted treatment plan than they have previously received.

Lifestyle and behavioural strategies are an important part of headache management but rarely sufficient on their own for chronic or frequent headache. Sleep regularisation (consistent sleep and wake times), hydration, trigger identification and management (stress, certain foods, hormonal changes, irregular meals), aerobic exercise three or more times per week, and biofeedback or cognitive behavioural therapy for headache are all evidence-supported non-pharmacological approaches. At KIMS, these are discussed and recommended alongside medical treatment — but for patients with chronic migraine, cluster headache, or trigeminal neuralgia, medication and procedural treatment remain the primary tools.

Not always. Most primary headache disorders — migraine, tension-type headache, cluster headache — are diagnosed clinically on the basis of the headache history and do not require an MRI to confirm the diagnosis. MRI is recommended when there is a new or changed headache pattern, when neurological symptoms accompany the headache, when a secondary cause is suspected, when the headache does not fit a recognised primary headache pattern, or when first-line treatments have not worked as expected. The headache specialist at KIMS will determine whether imaging is indicated at the initial consultation.