Ace neurologist Dr Pravin Thomas has spent years exploring the complexities of headaches and facial pains. As the founder-chairman of World Headache Society, he has been collaborating with global experts to advance modern treatment, awareness and advocacy to alleviate suffering.
Now with his new initiative named Masthishkam Foundation, Dr Pravin seeks to spotlight a larger ‘brain challenge’: cognitive security. He calls for urgent intervention to protect India’s brain capital from manipulation, a frontier where neuroscience meets national security.
Excerpts
What made you choose headache and facial pain as a speciality in neurology?
There was a huge need for academic study, but no established discipline in India. I went to the UK for advanced training and did a fellowship there. Pain was traditionally handled by anaesthesiologists, though neurologists also saw many patients with headaches. Treatment largely meant painkillers. I wanted to explore further.
Headaches are a major drag on productivity worldwide. What was different in the UK?
Neurologists do the same job everywhere; the difference is approach. Doctors here see 70 to 80 patients a day and may not be able to look into every aspect of a patient. Time and thorough investigation help arrive at the right diagnosis and treatment.
What prompted you to start the World Headache Society?
Lack of awareness, knowledge, training and education among doctors and the public. Others were doing part of the job, but the need was huge, especially in India and the Global South. Our primary focus is training doctors across specialities. Pain can occur anywhere in the head, neck and shoulders because the nerves are interconnected. Headache patients consult physicians, ophthalmologists, ENT specialists, dentists, paediatricians, critical care doctors and even psychiatrists. Each group needs its own training module and credentialling. Neurology has government certification for stroke, movement disorders and epilepsy.
For headache, most countries, India included, have none. Some places have no doctors at all. I train healthcare workers in parts of Africa where there is not a single neurologist. We also train nurses and physiotherapists in the full spectrum of headache disorders.
Are all headaches related to migraine?
Mostly. Some, such as those caused by infection, are specific. But many people have a genetic propensity for migraine, which can start in childhood, even as abdominal pain or vestibular migraine. Headache is only one symptom. Some patients present with brain fog or dizziness.
Is a headache a symptom or a disease?
Both. A headache triggered by a skipped meal or overeating may be migraine. The migraine brain likes homeostatic equilibrium — a predictable schedule. Disturbing it can trigger an attack through excessive brain activity.
Is migraine genetic?
Yes, but ‘genetic’ doesn’t necessarily mean familial. It isn’t a single-gene disorder. Like hypertension and diabetes, it raises your child’s risk. What matters is how genes interact with the environment. A healthy lifestyle can delay or prevent its manifestation. For example, someone who follows a healthy diet and sleep routine may never develop headaches despite having the genetic predisposition. There was a reason our elders insisted on ‘chitta’ and ‘dinacharya.’
Is migraine a form of disability?
Yes. The WHO recognises it as a cause of disability. Severe migraine can leave you unable to get out of bed, with light and sound unbearable. During an episode, you can be as disabled as someone paralysed in all four limbs.
Is there a real pain scale?
No universal medical scale can objectively rank pain. It is subjective. Most migraines are moderate to severe. Cluster headaches are worse and are called ‘suicide headaches’. People who contemplate suicide over a headache disorder are mostly cluster patients. Hopelessness arises from never getting a diagnosis, without which there is no treatment. “It’s just a headache” is a dangerous phrase. Behind it lie different disorders of varying severity. You can even get a headache from an ingrown toenail.
There are high-altitude headaches, too. Some people experience coital headaches, triggered by sexual activity. Each needs different treatment.
Is there a psychological side to pain?
The mind is the product of complex brain processes, and working on these can ease pain. Stress worsens pain; a calm or soothing ambience may reduce it. Thoughts influence pain, but generally do not cause it.
Is there a gender difference?
Migraine is more common in women, with hormonal changes playing a part. Cluster headache is more common in men.
Another common cause of suffering is sinusitis…
The head comprises everything above your shoulders, so facial and neck pain can fall within headache disorders. Much of what the world calls ‘sinus headache’ is actually migraine. Confusion arises from facial pain, a stuffy nose, puffiness and weather triggers. Sinusitis caused by infection usually involves fever and purulent nasal discharge.
Is relying on over-the-counter painkillers, balms and sprays dangerous?
They may work temporarily, but can be a double-edged sword. Repeated use of certain painkillers can cause medication-overuse headache, while some nasal sprays can produce rebound congestion.
When should one consult a doctor?
Think of a splinter. You decide whether to remove it today or let it go. A stereotyped headache you’ve had for years — one triggered by a missed meal, for instance, that goes away after eating — is less worrying. But whenever something feels unusual, seek medical advice.
What advanced treatments exist, such as pain-block injections?
Treatment is broadly classified as medical, surgical or interventional. In headache medicine, interventions target nerves and muscles. One example is the greater occipital nerve block for migraine. It has existed for years, but few doctors are trained to administer it. It isn’t rocket science; it can be done in an outpatient clinic. The latest American Headache Society guideline says it should be offered to migraine patients in the emergency department. How many Indian hospitals do that?
If it relieves suffering, shouldn’t it be more common?
Absolutely, and it is becoming so. I have trained hundreds of clinicians, many in underserved areas here and abroad.
For milder, familiar headaches, what can people do?
This applies only to familiar, episodic migraine. Early action can abort an attack. Take a simple analgesic such as paracetamol or naproxen, avoid opioids like tramadol, apply a cold gel pack to the neck and rest in a dim, quiet place for about half an hour. If symptoms are atypical, see a doctor.
Should offices have a headache policy?
Every institution should. We’ve moved from an agrarian to a knowledge economy. Employees need adjustments, with safeguards against misuse. Where possible, they could be allowed to switch to lighter tasks during a migraine episode.
What’s your take on home remedies such as essential oils?
Myths and science keep trading places, so we can only speak of the evidence available. Some oils may soothe temporarily, but others can worsen migraine. Massage and touch work through gate control: other sensory input competes with pain signals along the same pathways, masking them. Whether this is appropriate depends on the diagnosis.
Many people swear by such remedies.
Even an inert substance can influence the brain. That’s the placebo effect. If I give you a liquid and call it a secret family remedy, your headache may subside. The opposite is the nocebo effect: if you believe something will harm you, it can. This can be linked to witchcraft and curses. There is neuroscience behind placebos. In a trial, you don’t know what you’re taking, and even if it’s neutral, some part of you expects it to work. The body has built-in pain-reducing mechanisms, and belief activates them.
Do prayers have a similar effect?
I shall bless you, and may you have a placebo effect (laughs). This isn’t about demonising anything. Plenty of people benefit from alternative methods, and if they do no harm, that’s fine. The real question is whether a therapy has been proven beyond placebo. Only then can a doctor prescribe it.
What about alternative therapies such as acupuncture or breathing exercises?
Acupuncture has been shown in trials to help with a specific type of migraine. Some US hospitals run acupuncture units alongside headache clinics. Combining therapies is fine if patients benefit. I recommend them only where there is evidence.
How effective is yoga?
A colleague at AIIMS studied a particular yoga sequence for migraine, and I wrote a chapter on it with an international group. Done safely, yoga and meditation can benefit people with many disorders, including cancer. But when patients ask, “Can I try yoga?”, I have no straightforward answer because it can mean different things. A patient recently told me she practises ‘power yoga’. I can’t assess that. It could just as well be bhakti, hatha or jnana yoga.
Technique matters. A physician known to my family was paralysed when a neck twist during a practice damaged her spinal cord. Any therapy done or taught wrongly carries risks.
People interpret this caution as allopathic doctors protecting their system and disliking ayurveda or homoeopathy. It isn’t that. In evidence-based medicine, our hands are often tied.
You recently started the Masthishkam Foundation. How did you get from headaches to cognitive security?
It all comes down to the brain. Security is no longer just about borders or data — it is about the brain itself. We take attention and judgement for granted, assuming they are protected. They are not. Deception, coercion and manipulation have always existed. As neurologists, we see diseases that affect judgement, attention and choice. But other factors can compromise these faculties, too, making their protection the responsibility of individuals and the state. Take ‘digital arrest’ scams. They breach cognitive security by making victims believe something untrue. We think such things don’t apply to us because we’re smarter than others. But every scam victim thought the same. It is a false assurance about our cognitive abilities. Like immunity, judgment can weaken. Strengthening cognitive security is now a scientific discipline, not a metaphysical idea.
Why do you view this as a national issue?
Like health, cognitive security is more than an individual asset. If you fool an entire population with misinformation, a nation or region can be lost and societies can break down. It deserves protection comparable to that against a pandemic. The question is how to use science to protect ourselves.
Are other countries working on cognitive security?
I didn’t coin the term. Many people around the world are working on it, mainly in the context of cognitive warfare. But this isn’t limited to conflict between nations. In our own country, you see uprisings, sense an unseen hand behind them, and still thousands dance to its tune. Manipulation happens among individuals, groups and entire populations. We must identify it.
Should India worry about external forces influencing young minds? Have you approached the government?
Yes. We offer our services to Central and state governments pro bono. Threats needn’t come from outside. They exist at every level, including offices. Even if only two people remained in the world, one could threaten the other’s thinking. What makes us human is our ability to function as a society. Even if some individuals are vulnerable, society should have systems to support them. Arguably, this is the state’s responsibility. The idea is simple: recognise the importance of brain capital and use neuroscience to protect it.
Could you elaborate on brain capital?
We have measured a nation’s development first through agriculture and manual labour, then industrial capacity, and later human capital, including education, female literacy and under-five mortality. Today, we must consider the brain’s capacity to function optimally, from the labourer to the policymaker. Public health followed a similar path, from communicable diseases to lifestyle disorders. Now we must protect human activity from the perspective of the brain. Brain capital is being discussed at the World Economic Forum and the UN. Of its many aspects, cognitive security is particularly relevant to India.
Brain health goes beyond disease. It involves attention, memory, mood and protecting yourself from those who would deceive or manipulate you, so you don’t become someone’s puppet without realising it. Consider your information diet: a WhatsApp forward in the morning, a neighbour’s chat, channels, newspapers, cable, Instagram and X. All bombard you. How do you make sense of it, and how much benefits you and society? We should evaluate these sources critically.
My daughter told me recently that she was considering joining the CJP [Cockroach Janata Party]. I said, “It’s up to you. But why?” She replied, “I don’t know… I have been seeing all of these reels.” Repeated exposure influences us. And even when the information proves false, people don’t simply reset. Psychology calls this the continued influence effect. Add the illusory truth effect, where repetition makes a lie behave like the truth, and you see how the brain gets worked.
Why do habits persist even when they no longer make sense?
That’s memetics: ideas and habits that spread like a virus. Take my belt. My trousers are stitched and won’t fall down, but I wear one because my father did, and perhaps his father before him.
I learnt long ago why belts exist. Did I stop wearing one? No. Without this belt, I would be Rs 3,000 richer. Here I am giving a big speech about cognitive biases while falling victim to the very phenomenon I combat. So am I intelligent or stupid (laughs)? That’s the point. Knowing something doesn’t change behaviour, and intelligence doesn’t protect you from misinformation. Everyone is gullible to some extent.
And now we have AI…
Absolutely. We are in the GPT era. A 2023 study showed that modelling a GPT system in a particular way can influence its users. These systems do a lot of good but aren’t foolproof. Don’t surrender your judgment because a machine gives you an answer. Protect your cognitive capital by understanding how your mind can be influenced.
You say this must begin in schools. Many argue that children should be kept off social media. How would the guardrails work?
Children should use social media but be trained to use it responsibly. I’m working with the Odisha government on an adolescent programme built on inoculation, which works like a vaccine. I give trainees a ‘dose’ of misinformation and later reveal it was an exercise. They realise they are vulnerable. It’s a pre-emptive strike. We all have biases. During a football match, if the referee calls a foul against your team, you shout at him. If it goes against the other side, he’s right.
Even within a family, people can support opposing teams or political parties. Awareness of our biases and how manipulation works can help protect younger minds. Many also refuse to accept realities out of fear: of being doomed socially or in the afterlife, or of exclusion. My daughter taught me FOMO (‘fear of missing out’). It is an artificial fear created to make people conform.
How vulnerable is India?
By 2047, today’s adolescents will be leading the country, and India will have an older population. Cognitive resilience falls as we age. The greatest potential lies in the young, whose brains are less opinionated and more able to remember and change.
You seem to have moved from neurology into psychology…
A century and a half ago, there was no such division. Sigmund Freud was a neurologist. I won’t become a psychiatrist. But the mind cannot be separated from the brain. Neurologists see and treat disorders of memory, attention, mood, judgement, perception and hallucination every day. This is about working preemptively, rather than waiting for chaos.
To what extent can we train our brains?
To a considerable extent, as with the heart, but within limits. Your brain is shaped by genes and environment, and their interaction — epigenetics — matters. You can’t look at brain training independently of the environment.
Is there a physical difference between the most and least intelligent brains? Much has been said about Albert Einstein’s brain…
There is. It is about connectivity — networks of nodes. Two schools of thought exist on Einstein’s brain. One says it is almost like any other, while the other found specific areas suggesting more mathematical intelligence. Even within a family, some people excel at mathematics while others struggle; some draw well and others don’t. These are brain faculties, so there must be differences. In Einstein’s case, researchers sliced the brain and examined it. In living people, functional MRI can show differences in network activity, though these are often subtle.
Practice shapes the brain, too. If you excel at a sport or a task requiring dexterity, the corresponding brain areas may be better represented.
So, is it nature or nurture?
People say nurture can change everything. That’s the biggest lie you can sell anybody. Nurture changes particular aspects. You can’t teach a fish to fly. But humans are trainable to a large extent. A top film star in Kerala invited me to his son’s wedding, where I met a famous musician. I asked if I could learn music at my age. He said, “Why not? There’s no age barrier.” That was encouraging. But it doesn’t mean I will excel at it. Though debatable, excellence is largely pre-programmed.
Is it true we use only a small part of our brains?
That’s motivational-talk hype. We use the whole brain. Some areas are more active at different times, that’s all.
What will be your closing message to our readers?
Embrace knowledge. Our forefathers described a path, Jnana Yoga: knowledge can liberate you, provided it teaches you that you aren’t superior to others.