Chronic Migraine & Headache Guide

When to Seek Specialist Care

Headaches are one of the most common reasons people visit a doctor — and one of the most misunderstood. Most headaches, even severe ones, have no sinister cause. But understanding the type of headache you have, recognising warning signs, and knowing when to seek specialist input can make a significant difference to your quality of life.

1. Types of Headache

Headaches are broadly divided into primary (the headache is the condition itself) and secondary (the headache is a symptom of something else).

Primary headaches include:

• Tension-type headache: The most common type. Described as a dull, pressing, “band-like” tightness around the head. Usually bilateral, not worsened by activity, and without nausea.
• Migraine without aura: Moderate to severe throbbing or pulsating pain, usually one-sided, worsened by physical activity, often accompanied by nausea, vomiting, and sensitivity to light and sound.
• Migraine with aura: As above, but preceded by neurological symptoms (visual disturbances, tingling, speech changes) lasting 20–60 minutes before the headache phase.
• Cluster headache: Severe, strictly one-sided pain centred around the eye or temple, lasting 15–180 minutes, occurring in clusters over weeks to months. Associated with eye redness, tearing, nasal congestion, and restlessness.

Secondary headaches are caused by an underlying condition — infection, medication side effects, raised intracranial pressure, vascular problems, or tumours. Identifying red flags (see Section 4) is key to distinguishing these.

2. Migraine: What’s Actually Happening in the Brain

Migraine is a neurological disorder — not simply a “bad headache.” During a migraine attack, a wave of electrical activity spreads across the brain cortex (cortical spreading depression), triggering the release of inflammatory neuropeptides — particularly CGRP (calcitonin gene-related peptide). This activates the trigeminal nerve system, which supplies pain sensation to the head and face, producing the characteristic pain, nausea, and sensory sensitivity.

The brain of a person with migraine is neurologically different: more sensitive to stimulation, with a lower threshold for triggering an attack. This is a biological condition, not a psychological one, and it is not caused by stress alone — though stress is a common trigger.

3. Chronic Migraine vs Episodic Migraine

Migraine is classified as chronic when headaches occur on 15 or more days per month for more than 3 months, with at least 8 of those days fulfilling migraine criteria.

Episodic migraine involves fewer than 15 headache days per month.

The transition from episodic to chronic migraine is often driven by:

• Overuse of pain-relief medication (see Section 10)
• Poor sleep
• Obesity
• Anxiety or depression
• High attack frequency without adequate preventive treatment

Chronic migraine significantly impacts quality of life and requires a structured, proactive management approach — not just reactive treatment of individual attacks.

4. Red Flag Symptoms That Change Everything

The SNOOP4 framework is used by neurologists to identify headaches that need urgent investigation. In plain language, seek immediate medical attention if your headache:

• S — Systemic symptoms: Fever, weight loss, or known cancer or immunosuppression alongside the headache.
• N — Neurological symptoms: New confusion, weakness, numbness, speech difficulty, or visual loss accompanying the headache.
• O — Onset: Sudden, explosive onset — a “thunderclap” headache that reaches maximum severity within seconds to minutes. This must be investigated urgently for subarachnoid haemorrhage.
• O — Older age: New headache type in someone over 50 years of age warrants investigation.
• P — Positional: Headache that is consistently worse when lying down or on waking, and relieved by sitting up (suggesting raised intracranial pressure).
• P — Papilloedema: Swelling of the optic disc seen on examination, indicating raised intracranial pressure.
• P — Progressive: A headache that is steadily worsening over weeks, without improvement.
• P — Prior headache history changed: A previously stable headache pattern that has changed significantly in character, frequency, or severity.

If any of these apply, do not wait. Attend an emergency department or seek urgent specialist review.

5. When a Headache Is a Brain Tumour Symptom

This is a concern many patients carry silently, and it deserves an honest answer.

The vast majority of people with chronic headache — including severe, disabling migraine — do not have a brain tumour. Brain tumours are uncommon, and headache alone, without other neurological symptoms, is rarely the sole presenting feature.

When a brain tumour does cause headache, it is typically because of raised intracranial pressure — and this headache has a characteristic pattern: worse in the morning, associated with nausea or vomiting, and often accompanied by other symptoms such as visual changes, personality change, progressive weakness, or seizures.

If your headaches fit a clear migraine or tension-type pattern, have been present for years without progression, and are not accompanied by neurological symptoms, the likelihood of a structural cause is very low. Your doctor will perform a thorough assessment and arrange imaging if there is any clinical reason to do so.

6. How is Chronic Headache Diagnosed?

• Headache diary: The single most useful diagnostic tool. Recording headache days, duration, severity, triggers, medications used, and their effect allows your doctor to identify patterns and classify your headache type accurately.
• Clinical assessment: A detailed history and neurological examination. Most headache diagnoses are clinical — made without any investigations.
• MRI brain: Recommended when red flags are present, when the headache pattern is atypical, or when there is diagnostic uncertainty. Not routinely required for straightforward chronic migraine.
• Lumbar puncture (LP): Indicated when thunderclap headache is being investigated (to look for blood in the cerebrospinal fluid after a normal CT), or when infection or raised pressure (idiopathic intracranial hypertension) is suspected.

7. Medical Treatment Options

Headache treatment is divided into two categories:

Abortive (acute) treatment — taken during an attack to stop it:

• Simple analgesia (paracetamol, NSAIDs) for mild attacks
• Triptans (e.g., sumatriptan, rizatriptan) — first-line for moderate to severe migraine; act on serotonin receptors to abort the attack
• Anti-emetics for nausea
• CGRP receptor antagonists (gepants) — newer agents that block the CGRP pathway; effective with fewer side effects than triptans for some patients

Preventive treatment — taken daily to reduce attack frequency:

• Beta-blockers (propranolol, metoprolol)
• Tricyclic antidepressants (amitriptyline)
• Anticonvulsants (topiramate, valproate)
• Anti-CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) — monthly or quarterly injections; highly effective for chronic and refractory migraine
• Botulinum toxin (Botox) injections: NICE-approved for chronic migraine (≥15 headache days/month); injected across 31 sites on the scalp and neck every 12 weeks

8. Interventional Options

For patients who do not respond adequately to medication:

• Greater occipital nerve (GON) block: Injection of local anaesthetic (with or without steroid) around the occipital nerve at the back of the skull. Can provide weeks of relief and is used both diagnostically and therapeutically.
• Sphenopalatine ganglion block: Delivered intranasally; useful for cluster headache and some migraine patients.
• Occipital nerve stimulation (ONS): A small electrode is implanted beneath the skin over the occipital nerves, delivering continuous low-level electrical stimulation. Reserved for refractory chronic migraine and chronic cluster headache that has failed all medical options. Evidence shows meaningful reduction in headache days in carefully selected patients.

9. Lifestyle Management

Lifestyle factors have a substantial impact on migraine frequency:

• Sleep: Irregular sleep is one of the most potent migraine triggers. Consistent wake and sleep times — even on weekends — significantly reduce attack frequency.
• Caffeine: Moderate, regular caffeine intake is generally acceptable, but irregular use, excessive consumption, or sudden withdrawal are common triggers.
• Hydration: Dehydration lowers the migraine threshold. Aim for consistent fluid intake throughout the day.
• Stress management: While stress does not cause migraine, it lowers the threshold. Mindfulness-based stress reduction (MBSR), CBT, and biofeedback have all shown benefit in clinical trials.
• Trigger identification: Use a headache diary to identify personal triggers — not everyone shares the same ones, and some common “triggers” (like certain foods) are actually prodromal cravings rather than true causes.

10. Managing Medication Overuse Headache (MOH)

Medication overuse headache — previously called “rebound headache” — develops when acute headache medications are used too frequently:

• Triptans or combination analgesics: More than 10 days per month
• Simple analgesics (NSAIDs, paracetamol): More than 15 days per month

The brain adapts to regular medication exposure by becoming more sensitive to pain, paradoxically increasing headache frequency. MOH is very common and often goes unrecognised.

Management involves withdrawal of the overused medication, which typically causes a temporary worsening before improvement. This process should be supervised by a doctor. Preventive treatment is usually started simultaneously. Most patients experience significant improvement within 2–3 months.

11. Questions to Ask Your Doctor

1. What type of headache do I have, and how confident are you in that diagnosis?
2. Do my symptoms require an MRI or any further investigation?
3. Am I overusing my acute medications?
4. What preventive treatment is most appropriate for me?
5. Am I a candidate for CGRP monoclonal antibody therapy or Botox?
6. How long will I need to take preventive medication before seeing a benefit?
7. Should I be referred to a neurologist or headache specialist?
8. Are there any interventional options that might help my specific situation?
9. How do I manage a severe attack at home versus when to go to hospital?
10. What resources or support groups are available for chronic migraine patients?

Schedule Your Consultation

If you are experiencing frequent, disabling headaches, have noticed a change in your usual headache pattern, or are concerned about red flag symptoms, a specialist assessment will give you clarity and a structured management plan.

Dr Nor Faizal provides comprehensive evaluation for patients with headache disorders, including assessment for secondary causes and interventional options where appropriate.

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