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Migraine

SNOMED: 377960091049 words•Updated 03/03/2026
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Exam Tips

  • Use ICHD logic: migraine without aura requires at least 5 attacks; with aura requires at least 2 attacks with reversible focal symptoms and typical time course.
  • Remember chronic migraine definition: headache on at least 15 days/month for more than 3 months, with migraine features on at least 8 days/month.
  • Aura red flags needing urgent assessment: motor weakness, monocular visual loss, diplopia, reduced consciousness, prolonged or first atypical aura after age 40.
  • In OSCEs, always screen for secondary headache red flags (sudden thunderclap onset, fever/meningism, focal deficit, immunosuppression, cancer history, pregnancy/postpartum).
  • Medication-overuse thresholds are high-yield: triptans/opioids/ergots on at least 10 days/month or simple analgesics on at least 15 days/month can perpetuate headache.
  • Migraine with aura plus combined hormonal contraception increases stroke risk; discuss safer contraceptive options.

Definition

Migraine is a common primary headache disorder caused by disordered brain sensory processing rather than structural intracranial disease. It presents with recurrent attacks of moderate-to-severe headache (often throbbing and activity-limiting), typically with nausea and/or photophobia/phonophobia, and may occur with reversible focal neurological aura.

Pathophysiology

Migraine is best understood as a disorder of neuronal hyperexcitability involving cortical, thalamic, hypothalamic and brainstem networks, with impaired excitatory-inhibitory balance. In many attacks, cortical spreading depression contributes to aura, then activates the trigeminovascular system, causing release of neuropeptides (especially CGRP, substance P and neurokinin A), sterile neurogenic inflammation, meningeal vasodilation, and peripheral/central sensitization; this explains throbbing pain, cutaneous allodynia, and why normally non-painful stimuli become painful. Premonitory symptoms (for example yawning, mood/cognitive change, neck stiffness) likely reflect hypothalamic and brainstem involvement before pain onset, while postdrome symptoms reflect persistent network dysregulation after headache resolution (see figure of trigeminovascular pathway/cortical spreading depression in standard neurology headache chapters).

Risk Factors

  • Female sex (especially reproductive years)
  • Family history/genetic susceptibility (heritability around 40%)
  • High-frequency episodic migraine
  • Medication overuse (frequent acute analgesic/triptan use)
  • Excess caffeine intake
  • Sleep disturbance, snoring, or other sleep disorders
  • Obesity and low physical activity
  • Stress and major life events
  • Irregular or missed meals/dehydration
  • Menstruation and hormonal fluctuation
  • Comorbid anxiety, depression, chronic pain disorders, head injury
  • Asthma/allergy, hypothyroidism, lower socioeconomic status

Clinical Features

Symptoms

  • Recurrent headache attacks lasting 4-72 hours in adults (2-72 hours in adolescents)
  • Typically unilateral but can be bilateral (especially in children)
  • Pulsating/throbbing quality, moderate to severe intensity
  • Worse with routine physical activity (for example walking stairs) and causes activity avoidance
  • Nausea and/or vomiting
  • Photophobia and phonophobia
  • Aura in a subset: fully reversible visual (scintillations, fortification spectra, scotoma), sensory (paraesthesia/numbness), or speech/language disturbance
  • Aura usually develops gradually over at least 5 minutes, each symptom 5-60 minutes, followed by headache within 60 minutes
  • Premonitory phase: yawning, fatigue, mood change, concentration difficulty, neck stiffness, thirst, urinary frequency
  • Postdrome: tiredness, cognitive slowing, drowsiness, sound sensitivity

Signs

  • Neurological examination is usually normal between attacks
  • During attacks: photophobia/phonophobia and preference for dark quiet room
  • Possible cutaneous allodynia on scalp/face during severe attacks
  • No persistent focal neurological deficit in typical migraine; persistent or atypical deficits are red flags

Investigations

Clinical diagnosis using ICHD-3/NICE criteria plus headache diary:Pattern consistent with recurrent migraine attacks; diary helps identify aura pattern, menstrual association, triggers, and medication overuse
Full neurological examination:Usually normal in primary migraine
MRI brain (or urgent CT if acute emergency suspected):No structural cause in typical migraine; performed when red flags/atypical aura/new focal deficit/first aura after age 40 suggest secondary pathology
ESR/CRP (in older patients with new headache, jaw claudication, scalp tenderness):May be raised in giant cell arteritis, helping differentiate from migraine
Pregnancy test where relevant before teratogenic preventives:Guides safe prescribing (for example avoid topiramate/valproate in pregnancy)

Management

Lifestyle Modifications

  • Explain diagnosis and provide migraine education; validate disability impact
  • Use a headache diary to identify patterns/triggers and monitor treatment response
  • Regular sleep, hydration, meals, exercise; reduce excessive caffeine
  • Stress management and treatment of comorbid anxiety/depression
  • Avoid frequent acute medication use to prevent medication-overuse headache
  • Review contraception and vascular risk, especially in migraine with aura

Pharmacological Treatment

Acute analgesia (first-line)

  • Aspirin 900 mg oral at onset
  • Ibuprofen 400-600 mg oral at onset
  • Naproxen 500-750 mg oral at onset
  • Paracetamol 1 g oral if NSAIDs/aspirin unsuitable

Give early in attack; combine with antiemetic if nausea. Avoid opioid-containing analgesics for routine migraine.

Antiemetics (adjunct; also improve oral drug absorption)

  • Metoclopramide 10 mg oral/IM at onset
  • Prochlorperazine 3-6 mg buccal or 5-10 mg oral

Useful even without vomiting. Warn about extrapyramidal adverse effects (especially metoclopramide/prochlorperazine).

Triptans for moderate-severe attacks or NSAID failure

  • Sumatriptan 50-100 mg oral at onset; may repeat after at least 2 hours (max 300 mg/day)
  • Sumatriptan 6 mg subcutaneous; may repeat after at least 1 hour (max 12 mg/day)
  • Zolmitriptan 2.5-5 mg oral, or 5 mg nasal spray

Do not use in ischaemic heart disease, previous stroke/TIA, peripheral vascular disease, uncontrolled hypertension, or hemiplegic/brainstem migraine. Avoid within 24 hours of ergotamine; avoid combining different triptans on same day.

Preventive therapy (consider if frequent/disabling attacks)

  • Propranolol 40 mg twice daily initially; titrate (commonly 80-160 mg/day)
  • Topiramate 25 mg nightly initially; titrate to 50 mg twice daily
  • Amitriptyline 10 mg at night initially; titrate (commonly 25-75 mg at night)
  • Candesartan 4-8 mg daily initially; titrate up to 16 mg daily

Assess benefit after 8-12 weeks at target/tolerated dose. Topiramate is teratogenic (avoid in pregnancy; follow UK pregnancy prevention requirements). Beta-blockers may be unsuitable in asthma/bradycardia. Counsel regarding adverse effects and taper rather than abrupt stop where appropriate.

Menstrual migraine prophylaxis (short-term perimenstrual)

  • Frovatriptan 2.5 mg twice daily starting 2 days before expected menses for 5-6 days
  • Zolmitriptan 2.5 mg two to three times daily for perimenstrual prophylaxis

Use in predictable menstrual-related migraine; avoid overuse and apply standard triptan contraindications.

Refractory/chronic migraine (specialist care)

  • Botulinum toxin type A injections (for chronic migraine under specialist protocol)
  • CGRP monoclonal antibodies, e. g. erenumab 70-140 mg subcutaneously every 4 weeks

Reserved for selected patients after failure/intolerance of standard preventives. Monitor response and continue only with meaningful reduction in monthly migraine days.

Pregnancy and breastfeeding safety

  • Paracetamol 1 g as needed is preferred first-line
  • Sumatriptan is the preferred triptan if a triptan is needed in pregnancy
  • Avoid NSAIDs in third trimester

Avoid ergot derivatives in pregnancy. Avoid valproate for migraine prophylaxis in women/girls of childbearing potential unless strict specialist conditions are met; topiramate generally avoided in pregnancy.

Complications

  • Medication-overuse headache
  • Progression from episodic to chronic migraine
  • Status migrainosus (attack >72 hours)
  • Persistent aura without infarction
  • Migrainous infarction
  • Aura-triggered seizure
  • Increased risk of ischaemic stroke (especially with aura)
  • Possible increased haemorrhagic stroke risk
  • Higher stroke risk in women with migraine who use combined hormonal contraception
  • Pregnancy complications: pre-eclampsia, venous sinus thrombosis, preterm birth, low birth weight
  • Depression and reduced quality of life/functional impairment

Prognosis

Overall prognosis is variable but often improves with age; many patients remit or become less frequent over time, and migraine often improves after menopause. During pregnancy, attacks commonly improve in the second and third trimesters (especially migraine without aura), though some patients worsen or present for the first time. Prognosis is poorer with chronic migraine, medication overuse, and migraine complications.

Sources & References

💊BNF Drug References(38)

✅NICE Guidelines(1)

📖Textbook References(1)

  • Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 616)[context]

Sources

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