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Presented by, Unni Krishnan.SV M.Sc Nursing – II YEAR COLLEGE OF NURSING –JIPMER

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Page 1: Cephalgia.Unni Krishnan.S.V JIPMER

Presented by,Unni Krishnan.SV


Page 2: Cephalgia.Unni Krishnan.S.V JIPMER
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eadache→Cephalgia ; one of the most common human complaints. Headache is a symptom rather than a disease.

→It is a condition of pain in the head; sometimes neck or upper back pain may also be interpreted as a headache. It ranks amongst the most common local pain complaints.

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Headache is defined as pain in the head that is located above the eyes or the ears, behind the head (occipital), or in the back of the upper neck.

- IHS-2004

Source :International Headache Society

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Primary headaches are those in which headache and

its associated features are the disorder in itself.

Primary headache often results in considerable

disability and a decrease in the patient’s quality of life.

Secondary headaches are those caused by exogenous

disorders. Cont…

Source :International Headache Society

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Mild secondary headache, such as that seen in

association with upper respiratory tract infections, is

common but rarely worrisome.

Life-threatening headache is relatively uncommon,

but vigilance is required in order to recognize and

appropriately treat patients with this category of

head pain.

Source :International Headache Society

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INCIDENCE Headache Is a Major Public Health Problem

Up to 4% of ED Visits

Over 20 Million Outpatient Visits

78 % of Women and 60% of Men Experienced at Least One Headache in the Year

36% of Women and 19% Men Suffered From Recurrent Headaches

Source :International Headache Society

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1. Pain usually occurs when peripheral nociceptors are stimulated in response to tissue injury, visceral distension, or other factors.

2. In such situations, pain perception is a normal physiologic response mediated by a healthy nervous system.

3. Pain can also result when pain-producing pathways of the peripheral or central nervous system (CNS) are damaged or activated inappropriately.

4. Headache may originate from either or both mechanisms.


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• Relatively few cranial structures are pain-producing; these include the scalp, middle meningeal artery, dural sinuses, falx cerebri, and proximal segments of the large pial arteries.

• The ventricular ependyma, choroid plexus, pial veins, and much of the brain parenchyma are not pain-producing.

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Causes of headaches.

1. Traction or dilatation of intracranial or extracranial arteries.

2. Traction of large extracranial veins3. Compression, traction or inflammation of cranial

and spinal nerves4. Spasm and trauma to cranial and cervical muscles.5. Meningeal irritation and raised intracranial

pressure6. Disturbance of intracerebral serotonergic


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Common causes of headache

Primary Headache Incidence % Secondary Headache Incidence % 1. Migraine 16 1. Systemic infection 63 2. Tension Type 69 2. Head injury 4 3. Cluster 0.1 3. Vascular disorders 1 4. Idiopathic stabbing 2 4. Subarachnoid hemorrhage <1 5. Exertional 1 5. Brain tumor 0.1

Source: The Headaches. Philadelphia, Lippincott Williams and Wilkins


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Clinical evaluation of acute new onset headache• History collection • Physical examination • Diagnostic assessment

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PHYSICAL EXAM• Does the patient look ill?• Vital signs: fever, BP• Neurological exams most important!

Fundoscopic exam Cranial nerves Mental Status Meningeal irritation Gait and reflexes Tenderness on palpation

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Investigating HeadacheIs any special investigation warranted?

When there is diagnostic difficulty or history suggests a serious disorder, investigation becomes obligatory!



Lumbar Puncture

Blood Count/ESR

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1. Worst headache ever

2. First severe headache

3. Subacute worsening over days or weeks

4. Abnormal neurologic examinations

5. Fever or unexplained systemic signs

6. Vomiting that precedes headache

7. Pain induced by bending, lifting or cough

8. Pain that disturbs sleep or presents immediately upon awakening

9. Known systemic illness

10.Onset after age 55 pain associated with local tenderness, eg., region of temporal


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Types Primary


Source :International Headache Society

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A primary headache is a headache that is due to the headache condition itself and not due to another cause.

Source :International Headache Society

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1. Migraine 2. Tension Type 3. Cluster 4. Idiopathic stabbing 5. Exertional

Source :International Headache Society

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A secondary headache is a headache that is present because of another condition. The management of secondary headache focuses on diagnosis and treatment of the underlying condition.

Source :International Headache Society

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1.Systemic infection E.g.Meningitis, NCC2.Head injury 3.Vascular disorders E.g. Aneurysm Rupture, Stroke 4.Subarachnoid hemorrhage 5.Brain tumor

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International headache society classificationPrimary headaches1)Migraine• Migraine without aura• Migraine with aura• Retinal migraine• Childhood periodic syndrome• Complications of migraine• Migraneous disorders not fulfilling above criteria

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2) Tension-type headache (TTH)• Episodic tension-type headache• Frequent episodic tension-type headache• Chronic tension-type headache• Headache of the tension – type not fulfilling above criteria 3)Cluster headache and chronic paroxysmal hemicrania• Cluster headache• Chronic Paroxysmal hemicrania• Cluster headache- like disorder not fulfilling above criteria

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4)Miscellaneous headaches unassociated with structural lesion

Idiopathic stabbing headachePrimary cough headacheExternal compression headaceadacheBenign exertional headacheCold stimulus headacheBenign cough headache headache associated with sexual activity

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Secondary headaches

5)Headache attributed to head and/or neck trauma

• Acute post-traumatic headache• Chronic post-traumatic headache

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6)Headache associated with vascular disorder• Headache attributed to ischaemic stroke or transient ischaemic attack•  intracranial haemorrhage•  intracerebral haemorrhage• Headache attributed to subarachnoid haemorrhage (SAH)• unruptured vascular malformation• Arteritis• Carotid or vertebral dissection• Venous thrombosis• Arterial hypertension• Head ache associated with other vascular disorder

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7)Headache associated with non-vascular intracranial disorder

• High cerebrospinal fluid pressure• Low cerebrospinal fluid pressure• Intracranial infection intracranial sarcoidosis• Headache related to intrathecal injections• Intacranial neoplasm• Headache associated with other intracranial disorder

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8)Headache attributed to a substance or its withdrawal

• Headache induced by acute substance use or exposure

• Headache induced by chronic substance use or exposure

• Headache from substance withdrawl (acute or chronic)

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9)Headache associated with noncephalic infection• Viral infection• Bacterial infection• Headache related to other infection

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10)Headache associated with metabolic disorderHypoxiaHypercapniaMixed hypoxia and hypercapniaHypoglycemiaDialysisHeadache related to other metabolic abnormality

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11)Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures

• cranial bone• Neck• Eyes• Ears• Nose and sinuses• Teeth,jaws, and related structure• Temporomandibular joint disease

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12)Cranial neuralgias, nerve trunk pain,deafferentation pain

Persistent (in contrast to tic-like)pain of cranial nerve originTrigeminal neuralgiaGlossopharyngeal neuralgiaOccipital neuralgiaCentral causes of head and facial pain other than tic

douloureux Facial pain not fulfilling criteria in groups 11 or 1213)Headache not classifiable

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Primary headaches are disorders in which

headache and associated features occur in the

absence of any exogenous cause .The most

common are migraine, tension-type headache, and

cluster headache.


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It is a recurrent throbbing headache that

typically affects one side of the head and is often

accompanied by nausea and disturbed vision.


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• Migraine, the second most common cause of headache.

• The World Health Organization (WHO) has identified migraine among the world’s top 20 leading causes of disability.

• Afflicts approximately 15% of women and 6% of men.

• Females are most commonly affected during the menstrual cycle( Research finding )

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• Migraines may run in families• Changes in hormone levels during a woman's

menstrual cycle or with the use of birth control pills

• Changes in sleep patterns• Exercise or other physical stress• Missed meals• Smoking or exposure to smoke

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Triggering factors of migraine headache Certain foods can trigger migraine attack ;• Any processed, fermented, pickled, or marinated foods, as

well as foods that contain monosodium glutamate (MSG)• Baked foods, chocolate, nuts, peanut butter, and dairy

products• Foods containing tyramine, which includes red wine, aged

cheese, smoked fish, chicken livers, figs, and certain beans• Fruits (avocado, banana, citrus fruit)• Meats containing nitrates (bacon, hot dogs, salami, cured

meats)• Onions

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Clinical Features • Nausea• Photophobia• Lightheadedness• Scalp tenderness• Vomiting • Visual disturbances like photopsia,fortification spectra • Paresthesias• Vertigo • Alteration of consciousness like syncope seizure,

confusional state • Diarrhea

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Pathophysiology• Headache is experienced when there is traction,

pressure,displacement, inflammation,or dilation of

nociceptors in areas sensitive to pain.

• Pain is transmitted from the periphery by small

myelinated fibers and unmyelinated C-fibers.

• These fibers terminate in the dorsal horn of the

spinalcord and the terminal nucleus caudalis

Cont …..

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• Secondary neurons from the dorsal horn reach the thalamus

through the spinal thalamic pathways.

• Neurotransmitters also have a role in pain. Substance P, a

neuropeptide, is a pain neurotrasmitter for the primary

sensory neurons.

• Interneurons in the dorsal horn use enkephalins and

possibly (GABA) as inhibitory neurotransmitters to block

pain trasmission.

Cont …..

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• The ascending pain pathways from the supratentorial

space(the anterior and middle fossa) carry pain sensation by

the trigeminal (CN V).

• Pain sensation from the infratentorial space (post fossa) is

carried by the glossopharyngeal (CNIX), the vagus (CNX)

nerves, and the second and third cervical nerves.

• The pain pathways ascend through the brain stem to

neurons in the midbrain raphe area.Cont …..

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Lateral spinothalamic tract

• Acute pain(fast pain) carried by a delta fibre

(myelinated fibres)

• Chronic pain (slow pain) carried by C- fibre

(non myelinated).

• Lateral spinothalamic tract carries pain and

temperature. Cont …..

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•Mutation theory •Vascular theory

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Mutation theory

• Proposed by Ducros and Dichgans • Migrane is genetically inherited .• Mutation in three different genes are responsible for

familial hemiplegic migraine (FHM1,FHM2,FHM3)• Which is responsible for alteration in cellular

excitability that leads to migraine .

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Vascular theory

• Proposed by Wolff• Pain is based on dilatation of cranial vessels• Migraine is so called neurovascular disorder ,which

arise due to primary dysfunction of the brain and brain stem.

• Activation and further sensitization of the trigemino-vascular system ( TGVS).

• When the TGVS is activated, neuropeptides such as calcitonin gene related peptide (CGrP) and substance P are released from peripheral nerve endings.

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• Increase in plasma levels of CGrP• CGrP plays an important Role in the transmission of

meningeal inputs to the brain.• Substance P is not released during migraine attacks. • For pain generation in migraine there are central as

well as peripheral events. The peripheral events include meningeal inflammation, vasodilation, plasma protein extravasations, once the trigeminal system is activated, the central trigeminal nucleus caudalis in the brainstem is activated.

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• Central sensitization is important for the key clinical manifestations of migraine viz. cutaneous allodynia and for chronic migraine.18

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International Headache Society Classification-2004Criteria 1

• Repeated attacks of headache lasting 4-72 hours in patients with a normal physical examination ,no other reasonable cause for the headache .

Criteria 2With atleast 2 of the following features • Unilateral pain • Throbbing pain • Aggravation by movement • Moderate or severe intensity Plus at least 1 of the following features • Nausea or vomiting • Photophobia • Phonophobia •

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• Nonpharmacologic Management • Pharmacological Management

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Pharmacological Management Nonsteroidal Anti - Inflammatory Drugs (NSAIDs) - Both the severity and duration of a migraine attack can be reduced significantly by anti-inflammatory agents.eg Aspirin.5-HT1 AgonistsThese drugs can stop an acute migraine attack by maintaining normal serotonin level in blood . Eg.Ergotamine and dihydroergotamineDopamine AntagonistsThese drugs decrease nausea/vomiting and restore normal gastric motility. e.g., chlorpromazine, prochlorperazine, metoclopramide

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The term tension-type headache (TTH) is commonly

used to describe a chronic head-pain syndrome

characterized by bilateral tight, bandlike discomfort.The

pain typically builds slowly, fluctuates in severity, and

may persist more or less continuously for many days. The

headache may be episodic or chronic (present >15 days

per month).

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• Treated and managed with simple analgesics such as acetaminophen, aspirin, or NSAIDs.

• Behavioral approaches like relaxation • Amitriptyline is the only proven treatment

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Cluster Headache

• Cluster headache is a rare form of primary headache

• The pain is deep, usually retroorbital, often excruciating in intensity, non- fluctuating, and explosive in quality.

• A core feature of cluster headache is periodicity.

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• Cluster headache is associated with ipsilateral

symptoms of cranial parasympathetic autonomic

activation: conjunctival injection or lacrimation,

rhinorrhea or nasal congestion, or cranial

sympathetic dysfunction such as ptosis.

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• oxygen inhalation 10–12 L/min for 15–20 min

following acute attacks

• Sumatriptan (20 mg) and zolmitriptan (5 mg) nasal

sprays are both effective in acute cluster headache

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NEUROSTIMULATION THERAPY .• Deep-brain stimulation of the region of the posterior

hypothalamic gray matter has proven successful in a

substantial proportion of patients. Favorable

results have also been reported with the less-

invasive approach For occipital nerve stimulation.

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Paroxysmal Hemicrania

• Paroxysmal hemicrania (PH) is characterized by

frequent unilateral, severe, short-lasting episodes of


• It is managed by Indomethacin (25–75 mg tid),

which can completely suppress attacks

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• The broad diagnosis of chronic daily headache (CDH)

can be applied when a patient experiences headache on

15 days or more per month. CDH is not a single entity; it

encompasses a number of different headache syndromes,

including chronic TTH as well as headache secondary to

trauma, inflammation, infection, medication etc This is

managed by using valproate, and gabapentin.

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Secondary headache • Low CSF volume headache• Raised CSF pressure headache• Post-traumatic headache

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Other secondary type head aches includes • Hemicrania Continua• Cough Headache• Exertional Headache• Sex Headache• Stabbing Headache

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NURSING MANAGEMENT• The goal is to lessen or relieve pain.

• Administer abortive medications if needed, as soon as possible.

• Provide dark, quiet and peaceful environment.

• Elevate head of the patient by 30º

• May allow cold or hot compress on the forehead.

• May decrease pain by introduction of pressure or massage.

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HeadacheNursing Management

• Nursing assessment• Health history

• Seizures, cancer, stroke, trauma, asthma or allergies, mental illness, stress, menstruation, exercise, food, bright lights, noxious stimuli

• Medications• Surgery and other treatments


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HeadacheNursing Management

• Nursing assessment• Health history (cont’d)

• Specific details about the headache • Location• Type of pain• Onset• Frequency• Duration, time of day• Relation to outside events


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HeadacheNursing Management

•Nursing assessment (cont’d)•Objective data

• Anxiety or apprehension• Diaphoresis, pallor, unilateral flushing with cheek edema, conjunctivitis


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Headache Nursing Management

• Nursing diagnoses • Acute pain• Anxiety• Hopelessness


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HeadacheNursing Management

• Planning • Have decreased or no pain• Experience increased comfort and reduced anxiety• Demonstrate understanding of triggering events and

treatment strategies


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HeadacheNursing Management

• Planning • Use positive coping strategies to deal with

chronic pain.• Experience ↑ quality of life


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Headache Nursing Management

• Nursing implementation• Daily exercise, relaxation periods, and

socializing help reduce recurrence and should be encouraged.

• Suggest alternative pain management such as relaxation, meditation, yoga, and self-hypnosis.


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Headache Nursing Management

• Nursing implementation (cont’d)• Massage and heat packs can help with tension-type.• Patient should make a written note of medications to

prevent accidental overdose.


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Headache Nursing Management

• Nursing implementation (cont’d)• Teach patient about prophylactic treatment.• Dietary counseling for food triggers• Avoid smoking and smoke exposure and other

environmental triggers.


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Case Study


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Case Study

• 25-year-old woman presents to clinic with throbbing headaches with photosensitivity.Her headaches become so intense, they cause nausea and occasionally vomiting. She states that the OTC pain medication has not provided much relief for her pain.She began to develop the intermittent headaches about a year ago


Case Study -Davidsons Clinical Practice For Junior Doctors

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Cont ……She believes her headaches have been getting worse over time.To obtain relief, she usually shuts herself in a dark room. She has a family history of headaches.MRI and CT are negative for abnormalities.She is diagnosed with migraine headaches. She believes her headaches have been getting worse over time.To obtain relief, she usually shuts herself in a dark room. She has a family history of headaches.MRI and CT are negative for abnormalities.She is diagnosed with migraine headaches.


Case Study -Davidsons Clinical Practice For Junior Doctors

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Discussion Questions

1. What can you tell her about treatment with medications?

2. What alternative therapies may help her?

3. What possible triggers should she avoid?


Case Study -Davidsons Clinical Practice For Junior Doctors

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Organic Factors such as brain tumors or aneurysmFluid and Electrolyte Imbalance (Dehydration, Fluid volume excess)Medications overuse (NSAIDS, Anti-Hypertensive, Diuretics, etc.)Emotional and Physical stressToxic Substance Exposure

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Where does the pain exist?

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Journal reference

Prevalence and characteristics of migraine in medical students

Bindu Menon Neeharika KinneraNarayana Medical College, Nellore, Andhra Pradesh, IndiaAnnals of Indian Academy of Neurology2014 Jun 10

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68% of medical students had headache. One fourth of the students had weekly or daily attacks with

31% students reporting increase in their headache intensity and frequency.

44% percent of students had severe headaches. Dizziness, allodynia, and neck stiffness were reported as accompanying symptoms.

Trigger factors were identified in 99% students, predominant of which were poor sleep hygiene, environmental changes, head movements, and mental stress.

Only 4% of students did regular exercise. 27 %of students reported self medication use of analgesics.One fourth of the students had migraine associated disability

but only 6% realized that they had migraine.

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• Ropper AH, Samuels MA. Adams and Victor’s Principles of Neurology. Boston;McGraw Hill Education: 2012

• Donaghy M, Brain’s Diseases Of The Nervous System. Oxford. Oxford university press: 2009

• Hauser SL, Josephson AS. Harrison’s Neurology in Clinical Medicine. Newyork: McGraw Hill; 2013

• Daroff RB, Fenichel GM, Jankovic K, Maziotta JV. Bradley’s Neurology in Clinical Practice. Philaldelphia, Elsevier Saunders; 2012

• Fauci AS, Harrison TR. Harrisons Principles of Internal Medicine. Newyork: McGraw Hill; 2008

• Davidsons case book for JUNIOR DOCTORS -