PassFinals
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.

Definition

Migraine is a primary headache disorder of recurrent moderate-to-severe attacks, typically pulsating and aggravated by activity, with nausea or sensory hypersensitivity and sometimes a fully reversible aura.

Epidemiology

Migraine is common and often begins in childhood or early adult life. It is more common in women and can be episodic or chronic.

Pathophysiology

Migraine reflects altered sensory processing with cortical spreading depression producing aura in some attacks and trigeminovascular activation producing pain and associated sensory symptoms.

First principles

Migraine is a clinical brain disorder, not simply a vascular headache

Migraine involves abnormal sensory processing and activation of trigeminovascular pain pathways. Cortical spreading depression can produce aura; trigeminal activation and neuropeptide signalling produce headache, nausea and sensory hypersensitivity. The mechanism explains the stereotyped attack but does not replace clinical diagnosis.1,2

A typical aura evolves gradually and is fully reversible

Typical aura symptoms develop over at least 5 minutes, may occur in succession, and last 5 to 60 minutes. Visual, sensory and speech symptoms are typical. Abrupt maximal symptoms, persistent deficit, one-eye visual loss, motor weakness, diplopia, poor balance or reduced consciousness require further assessment rather than being assumed to be migraine aura.1

The diagnosis is made from the attack pattern

Migraine is usually diagnosed from recurrent attacks of unilateral or bilateral pulsating pain, nausea or vomiting, photophobia or phonophobia, and aggravation by routine activity. A normal examination and absence of red flags support a primary headache; routine imaging is not needed for reassurance.1,2

Acute treatment and prevention solve different problems

Acute treatment aborts an attack, while prevention reduces attack frequency and disability. Take acute treatment early, use a headache diary to assess response and frequency, and avoid escalating acute medicines when medication-overuse headache is developing.1,2

Presentation

Recurrent attacks of moderate-to-severe unilateral or bilateral pulsating headache lasting 4 to 72 hours in adults, aggravated by activity and associated with nausea, vomiting, photophobia or phonophobia; a gradually evolving reversible aura may precede or accompany the pain.1,2

Cardinal features

  • Pulsating moderate-to-severe headache
  • Aggravation by routine activity
  • Nausea or vomiting
  • Photophobia and/or phonophobia
  • Fully reversible visual, sensory or speech aura developing over at least 5 minutes
  • Attack duration 4 to 72 hours in adults

Red flags

  • Thunderclap headache reaching maximum intensity within 5 minutes
  • Fever, meningism, impaired consciousness or a new neurological deficit
  • New or substantially changed headache, including after head trauma
  • Headache triggered by cough, Valsalva, sneeze, exercise or posture
  • New headache with symptoms of giant cell arteritis or acute narrow-angle glaucoma
  • Atypical aura with motor weakness, diplopia, monocular visual loss, poor balance or reduced consciousness

Investigations

Clinical history and headache diary

The attack pattern and associated symptoms establish the diagnosis, identify menstrual-related or chronic migraine, and reveal medication overuse. NICE recommends recording frequency, duration, severity, associated symptoms, all acute medicines, precipitants and menstrual relationship for at least 8 weeks when a diary is used.

Expected finding: Stereotyped attacks with a consistent migraine phenotype and no secondary red flag.

1,2

Neurological examination and fundoscopy

Examination should look for a focal deficit, altered consciousness, meningism or papilloedema. A normal examination supports a primary headache but does not override a concerning history.

Expected finding: Normal between attacks; any persistent focal sign or papilloedema redirects the pathway.

1,3

Neuroimaging or specialist investigation when indicated

Do not image a typical diagnosed migraine solely for reassurance. Investigate or refer when NICE red flags, atypical aura, a new pattern or another secondary-headache concern is present.

Expected finding: No routine imaging finding is expected in uncomplicated migraine; the test is selected to assess the suspected alternative diagnosis.

1,3

Management

StepDetailSource
Treat the acute attack earlyOffer an oral triptan with an NSAID or paracetamol. If the person prefers one medicine, consider an oral triptan, NSAID, aspirin 900 mg or paracetamol, taking comorbidity and adverse-event risk into account. Consider an antiemetic even without nausea or vomiting. Review the BNF and contraindications before prescribing; do not use opioids or ergots for routine acute migraine.1,4NICE CG150 recommendations 1.3.10 to 1.3.13, updated 2025
Use the diary to identify menstrual, chronic and overuse patternsRecord frequency, duration, severity, associated symptoms, acute medicines, precipitants and menstrual relationship. Suspect menstrual-related migraine when attacks occur predominantly from 2 days before to 3 days after menstruation in at least 2 of 3 cycles. Chronic migraine is 15 or more headache days per month for more than 3 months, with at least 8 migraine-feature days.1,2NICE CG150 recommendations 1.1.3 to 1.2.6, updated 2025
Offer migraine prevention when appropriateConsider propranolol, topiramate or amitriptyline after discussing benefits, risks, comorbidities and suitability. If the first option fails or is not tolerated, discuss a second and then the remaining option unless unsuitable. Do not offer gabapentin for migraine prevention. Consider specialist migraine options after failure or intolerance of appropriate preventive medicines and follow the relevant current NICE technology appraisal.1,5,6,7NICE CG150 recommendations 1.3.18 to 1.3.22, updated 2025
Apply topiramate and pregnancy safeguardsDo not use topiramate for migraine prophylaxis in pregnancy. Do not prescribe it to women and girls able to become pregnant unless the MHRA Pregnancy Prevention Programme conditions are fulfilled. Discuss contraception, pregnancy plans and alternatives; seek specialist advice if prevention is needed during pregnancy. For migraine during pregnancy, NICE recommends paracetamol and consideration of a triptan or NSAID only after discussing risks and need.1,8,6NICE CG150 recommendation 1.3.18 and MHRA topiramate safety update
Recognise and treat medication-overuse headacheBe alert when headache develops or worsens during 3 months of triptans, opioids, ergots or combination analgesics on 10 or more days per month, or paracetamol, aspirin or NSAIDs on 15 or more days per month. Explain the diagnosis, stop all overused acute headache medicines abruptly for at least 1 month, warn that symptoms may worsen initially, provide support, consider prevention for the underlying migraine and review after 4 to 8 weeks. Seek specialist or inpatient help for strong opioids, relevant comorbidity or repeated failed withdrawal.1,9NICE CG150 recommendations 1.2.7 and 1.3.42 to 1.3.48

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

Differentials

Tension-type headache

Bilateral pressing pain without nausea or typical activity aggravation.

Cluster headache

Short severe strictly unilateral orbital attacks with ipsilateral autonomic signs and restlessness.

Medication-overuse headache

Headache developed or worsened with frequent acute medication use.

Subarachnoid haemorrhage

Thunderclap headache maximal at onset.

Giant cell arteritis

New headache with scalp tenderness, jaw claudication or visual symptoms in an older person.

Complications

  • Chronic migraine
  • Medication-overuse headache
  • Medication adverse effects and reproductive risk
  • Substantial functional and psychological burden

Prognosis

Migraine is benign but can be disabling and relapsing. Most people benefit from appropriate acute treatment, prevention when needed and avoidance of medication overuse.

Guidelines

  • Headaches in over 12s: diagnosis and management (CG150) (NICE, 2025)

References

  1. NICE CG150: Headaches in over 12s, recommendations (CG150, updated 3 June 2025)
  2. NHS: Migraine (NHS condition information, reviewed 2026)
  3. NHS: Headaches (NHS symptom information)
  4. BNF: Sumatriptan (BNF medicine monograph)
  5. BNF: Propranolol hydrochloride (BNF medicine monograph)
  6. BNF: Topiramate (BNF medicine monograph)
  7. BNF: Amitriptyline hydrochloride (BNF medicine monograph)
  8. MHRA: Topiramate safety measures and Pregnancy Prevention Programme (Drug Safety Update)
  9. NICE CG150: Treatment for medication-overuse headache (CG150 public information and recommendations)
  10. NICE CG150: Update information (CG150 update, 3 June 2025)

Evidence checked: 2026-08-03

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.