Neurology

Migraine

A recurrent primary headache disorder causing stereotyped moderate-to-severe attacks, often with nausea and light or sound sensitivity, sometimes preceded by a gradually evolving reversible aura.

In a nutshell

Migraine is diagnosed from recurrent stereotyped attacks of pulsating moderate-to-severe headache with nausea or sensory sensitivity, sometimes with a gradual reversible aura. Treat attacks early with a triptan plus an NSAID or paracetamol, offer prevention when needed, and limit acute medicines to prevent medication-overuse headache.

Classic presentation

A person with recurrent unilateral or bilateral pulsating headache lasting 4 to 72 hours, aggravated by activity and associated with nausea, photophobia or phonophobia, sometimes preceded by gradual visual or sensory aura.

Key points

Aura develops gradually over at least 5 minutes and lasts 5 to 60 minutes; abrupt or persistent neurological symptoms need another pathway.
Typical migraine does not need neuroimaging solely for reassurance.
Use a triptan with an NSAID or paracetamol, and consider an antiemetic even without vomiting.
Consider propranolol, topiramate or amitriptyline for prevention; review the choice and safety, especially pregnancy and overdose risk.
Triptans or combination analgesics on 10 or more days per month, or simple analgesics on 15 or more, can cause medication-overuse headache.

First-line investigation

None routinely: clinical diagnosis with examination and a headache diary when useful.

Management

Screen for a secondary headache

Assess for thunderclap onset, fever, meningism, neurological deficit, altered consciousness, exertional or positional headache, GCA, glaucoma, trauma or substantial pattern change.^1,3

Treat the attack and record the pattern

Use an oral triptan plus an NSAID or paracetamol and consider an antiemetic; use a diary for frequency, associated symptoms, medicines and triggers.^1,4

Prevent recurrent migraine safely

Consider propranolol, topiramate or amitriptyline after discussing suitability, and reassess after the initial preventive trial.^1,5,6,7
Apply the MHRA Pregnancy Prevention Programme before prescribing topiramate to anyone able to become pregnant.^8,1

Address chronic migraine and medication overuse

Withdraw overused acute medicines abruptly for at least 1 month with support, consider prevention for the underlying headache and refer when strong opioids, comorbidity or repeated failed withdrawal complicate care.⁹
Seek specialist advice for refractory chronic or atypical migraine and current NICE technology-appraisal options.^1,10

Review control and safety

Review preventive need after 3 to 6 months, treatment response, pregnancy plans, adverse effects, acute medicine days and functional impact.^1,2

Exam traps

Thunderclap headache is not migraine until dangerous secondary causes are assessed.
Aura is gradual and reversible; abrupt maximal deficit, persistent deficit or monocular visual loss is atypical.
Do not offer opioids for routine migraine.
Topiramate requires current MHRA pregnancy-prevention safeguards.
Medication overuse thresholds differ: 10 days for triptans/opioids/ergots/combination analgesics and 15 days for simple analgesics.

Illustrations

Cortical spreading depression and auraDiagram of a slow cortical wave correlating with gradually spreading visual or sensory aura.PassFinals · original

Trigeminovascular pathwayDiagram of trigeminal afferents and meningeal pain signalling in migraine.PassFinals · original

Migraine versus secondary headache onsetTimeline comparing gradual aura with abrupt TIA and thunderclap headache patterns.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.