1. Headache – Practical Scenario
Dr. Thomas Mathew
MD,DNB,DM(Neurology)
Associate Professor
Department of Neurology
St.John’s Medical College and Hospital
Bangalore-560034

2. Case 1

3. On history…
• 24 year old lady
• Episodic vertigo lasting 30 minutes
• 1-2/ week for the past 2 years
• No history of tinnitus/deafness
• No history of loss of consciousness

4. On examination…
• No focal neurological deficits
• Fundus normal

5. What will you ask next ?

6. Options are…
A. Postural variation
B. Head trauma
C. Alcohol intake
D. History of headache

7. Diagnosis
Migraine related vertigo

8. How will you manage ?
Options are…
A. Cinnarizine
B. Prochlorperazine
C. Betahistine
D. None of the above

9. What you should do ?
• Flunarizine
• Topiramate
• Betablockers
• Amitriptyline
• Valproate

10. Flunarizine – Practical Scenario
Prof. A.V. SRINIVASAN,
MD, DM, Ph.D,DSc(HON) F.A.A.N, F.I.A.N.
Emeritus Professor
The Tamilnadu Dr. M.G.R. Medical University
Former Head
Institute of Neurology, Madras Medical College
Adjunct Prof.
IIT Madras

11. Flunarizine: Indications
• Prophylaxis of migraine
• Symptomatic treatment of dizziness
• (Peripheral vascular disease)
• (Alternating hemiplegia)
• (Epilepsy adjuvant)

12. Contra-indications
• Parkinson’s disease
• History of EP syndromes
• History of depression
• Breast feeding
• (Pregnancy)
Caution
• Elderly
• Hepatic disease

13. Adverse effects
• Weight gain
• Sedation
• Depression
• EP syndrome (de Melo-Souza syndrome)
• Headache/insomnia/asthenia/GI

14. Interactions
• Alcohol
• Hypnotics /tranquilizers
• COC
• Anticholinergics
• Anticonvulsants

15. HC Deiner et al
Cephalalgia 2002;22:209-221
• 808 patients
• Double blind 16 week treatment phase
• Flunarizine 10mg(5days/week) v Flunarizine
5mg v Propranolol 160mg
• Responders (50% reduction)
5mg:46%. 10mg:53%. Propranolol:48%
• Drop out due to adverse effects
5mg:16.7%. 10mg: 19.3%. Propranolol:16.7%

16. M. Thomas
Headache 31:613-615, 1991
• India
• 29 patients (14 dropped out)
• 6months double blind crossover
• 10mg v placebo
• No decrease in migraine frequency
• Reduced duration and severity

17. Experience of use
• Reduce if excessive daytime drowsiness
• Watch for mood change
• Use 5-15mg
• Very useful even for refractory patients/prolonged
aura/hemiplegic aura/severe migrainous vertigo

19. Headache – Practical Scenario
Dr. Thomas Mathew
MD,DNB,DM(Neurology)
Associate Professor
Department of Neurology
St.John’s Medical College and Hospital
Bangalore-560034

20. Case 2

21. On history…
• 28 year old
• Episodic headaches
• 12 hours
• 4-5/week
• Severe/throbbing/worsens with exertion

22. On History…
• Photo/phonophobia/vomiting
• Family history of headache present
• Feels like crying/sad/thought of even suicide
• Takes vasograine 4-5/week

23. On examination…
• Obese . BP 130/90 mm of Hg
• BMI >35
• No deficits
• Fundus normal

24. What is the drug of choice?
A. Flunarizine
B. Betablocker
C. Amitriptyline
D. Valproate
E. Topiramate

25. Patient was started on topiramate
• 25 mg per day

26. What else you will advise ?

27. Options are…
A. Stop vasograine abuse
B. Identify precipitating factors
C. Life style modification
D. All the above

28. Patient comes back after 1 week of
Topiramate
• “ I can’t see clearly from today morning”

29. What will you do ?

30. Options are…
A. Fundus examination
B. Urgent ophthalmological consult
C. Check Intraocular pressure
D. IV mannitol
E. All the above

31. Diagnosis
Topiramate induced acute angle closure glaucoma

32. Thank you

33. Practice Patterns in Headache
Management
E- Voting Module

34. When would you initiate prophylaxis
for migraine?
A. Patients with 4 or 5 migraine days per month
with normal functioning
B. 3 migraine days with some impairment
C. 2 migraine days with severe impairment
D. Any one of the above

35. What can be the duration of therapeutic
trial for a migraine prophylactic drug?
A. Less than 1 week
B. 2-4 weeks
C. 2- 6 months
D. 4-6 weeks

36. What are the ‘red flags’ in headache
history?
A. New headache onset in an older patient
B. Rapid onset of headache
C. Systemic Symptoms such as fever or weight
loss
D. All of the above

37. Which channels are blocked by
Flunarizine?
A. Calcium channels
B. Sodium channels
C. Both
D. None of the above

38. What is the typical characteristic of
migraine headache?
A. Pulsating, throbbing
B. Pressing, tightening but not pulsating
C. Boring, searing
D. None of the above

39. Thank you