Next to muscle contraction, migraine is the most common type of headache. As many as 15 percent of the general population have recurring migraines, and well over half of the population will experience a migraine attack sometime during their lives.

• A migraine, described as a unilateral, throbbing type headache, can last from at least 30 minutes up to many hours. It is less common for true migraines to last more than 24 hours. In most people, the attacks seem to occur in batches, with several bad attacks over a week or two. (Be careful of terminology with headaches that recur in groups. There is a specific syndrome called Cluster Headache - see below - which is a distinct clinical entity, not just clusters of migraines.) Migraines have a diurnal pattern. They occur more often in morning than afternoon or evening, and often present on awakening. A migraine may even awaken a patient at night. This is in contrast to muscle contraction headaches that develop over the course of a day, usually in the afternoons or evenings. The patient with a migraine usually prefers to be alone in a dark quiet place and the headache is frequently relieved with a short nap.

• In the classical migraine type of headache, the patient has a prodrome, (which is the early stage of the attack) lasting several minutes to several hours. For some patients, this is an uncomfortable feeling, which they recognize to be a warning. Most classical migraine prodromes are visual in nature. Scintillating scotoma, the visual symptoms usually occupying one visual field, are described as elaborate zig-zag patterns, flashing lights, crescents, or other patterns. Gastrointestinal symptoms most often accompany or follow the headache.

• Migraines usually begin during adolescence and not uncommonly in childhood. Frequently attacks diminish or disappear in the early twenties age group and return unexpectedly in the thirties age group. These may appear as a new onset headache attack. In all cases, the physician should inquire about any migraine qualities as well as past history of headaches.

• There is a definite chemical and dietary aspect in migraine headaches. Certain foods rich in nitrites or certain amino acids provoke attacks in many patients. Some products include preserved meats, chocolate, tyramine in some aged cheeses, and spices such as monosodium glutamate. Alcohol, especially beer and red wines, are provocative for other patients. Successful migraine treatment includes dietary counseling for all patients. In some cases a small number dietary adjustments can control attacks.

• Aspirin 650 mg every four hours, is effective for some patients. The second order medications are NSAIDs such as ibuprofen. These are effective in about half of patients. The stalwart in migraine is ergotamine tartrate, 2 mg by mouth or per rectal suppository at the onset of attack, and can be repeated to a maximum total dose of 6 mg over a 24-hour period. Dihydroergotamine (DHE) could also be used in a nasal spray form. Ergotamine is a potent vasoconstrictor and is contraindicated in hypertension or coronary artery disease. It is also a smooth muscle contractor, and has been known to cause intolerable stomach cramps and nausea in some patients. Various forms of Sumatriptin are presently available; self injection for subcutaneous administration, oral tablets (25mg and 50mg), and nasal spray. Sumatriptin is effective in 70 to 80% of cases. Remember that it is a potent vasoconstrictor so it should be used judiciously. Avoid using in any patients with evidence of coronary artery disease.

For those patients who have more than 4 severe attacks per month, preventive medication may be advisable. First line therapy is aspirin (ASA). Doses of ASA 325 mg every morning may significantly reduce frequency and severity of attacks in 25 percent of patients. Beta-blockers such as propranolol, atenolol, or metoprolol, in doses used to treat hypertension, are useful in some patients. The majority of patients can control their headaches to no more than two a month with diet or preventive medications (NSAIDs or ergotamine).

Narcotics should never be used for migraines. It is a chronic condition, which will recur over many years and the combination of adaptation, and preventive medications should be tailored for each patient.

True migraine is disqualifying for flight and several other special duties in the military, primarily because of the risk for visual disturbance. According to the Manual of the Medical Department, severe or disabling migraine is disqualifying for naval service. If a patient fits into any of these categories, the GMO should consider referral to a medical board or operational specialty such as diving medical officer or flight surgeon.

Cluster headache is a unique clinical entity related to migraine but less common in frequency. It occurs more often in men than women, and causes a stereotypical, excruciating pain behind the eye. Attacks are always exactly alike, even if separated by many years.

• Pain is usually of a sudden onset, occurring very late at night, and can last from 30 to 90 minutes. The conjunctiva on the affected side is red, the eye tears copiously, and there may be ptosis and slight meiosis in the pupil. The attacks come several nights every week during the course of a cluster that can last for 2 to 6 weeks, seldom longer. The clusters disappear and may not recur for many years, but when they do, the patient recognizes them instantly.

• There is no proven therapy for cluster headaches. Initial therapy should include 100 percent oxygen by face mask initially since this provides good relief in many patients. Because of the short-lived nature of episodic cluster headaches, narcotics are not indicated for management. Methysergide, 8 mg per day in divided doses, seems to reduce the severity in most patients, but gastrointestinal side effects make it intolerable for a third of patients. In this author's opinion, nothing yet discovered works for cluster headache.

Remember, with all patients obtain information about timing and frequency of the headache, location, quality of pain, precipitating events and associated complaints. Don’t forget to test for cerebellar function and gait. If focal neurologic findings are found referral is necessary. Arrange for adequate follow-up, document treatment instructions, and ensure the patient understands the treatment plan.