Migraine

Migraine is a primary neurological disorder that causes recurring attacks involving headache and other nervous system symptoms. An attack can include nausea, sensitivity to light or sound, temporary aura symptoms and substantial loss of function. A new or unusual headache still needs assessment because several urgent conditions can resemble migraine.

What migraine is Migraine is a primary neurological headache disorder. Primary means the migraine process itself is the disorder rather than pain caused by another identified disease. It is not simply a severe version of an ordinary headache. Migraine can affect vision, sensation, speech, digestion, concentration and energy as well as causing head pain. A disorder of brain networks Migraine involves altered activity across brain networks that process pain, sensation and internal body signals. The trigeminal nerve and pain sensitive tissues around the brain become activated during an attack. Chemical messengers, including calcitonin gene related peptide, contribute to pain transmission and inflammation like signalling. This process does not mean that the brain is being damaged during an ordinary attack. Migraine is not just a blood vessel problem Older explanations described migraine mainly as blood vessels expanding and contracting. Blood vessel changes can occur, but they do not explain the whole disorder. Current understanding involves nerve networks, sensory processing, inherited susceptibility and chemical signalling. This broader model explains why migraine can cause symptoms before and after the headache. Migraine susceptibility Some nervous systems are more susceptible to entering the migraine state. Genetic factors contribute, especially when close relatives also experience migraine. Hormonal changes, sleep, illness and sensory load can alter the threshold for an attack. The exact combination differs between people and can change over time. Migraine attacks vary One person may experience several severe attacks each month. Another may have occasional attacks separated by years. The symptoms, duration and response to treatment can also vary between attacks. A change from the established pattern should not automatically be labelled as usual migraine. The four commonly described phases Migraine is often described through prodrome, aura, headache and postdrome phases. Not every person experiences every phase. The phases can overlap rather than appearing as four sharply separated stages. Aura occurs in only a minority of people with migraine. The prodrome The prodrome can begin hours or occasionally days before head pain. Possible features include tiredness, yawning, thirst, neck stiffness, mood change and difficulty concentrating. Some people notice food cravings or increased urination. These features are non specific and are often recognised only after repeated attacks. Cravings can be mistaken for triggers A person may crave chocolate or another food during the prodrome. The food is then eaten shortly before the headache begins. This sequence can create the impression that the food caused the attack. A diary can help separate a true reproducible trigger from an early migraine symptom. Aura Aura is a temporary neurological disturbance that develops before or during some migraine attacks. It can also occur without a later headache. Typical aura is fully reversible, develops gradually over at least five minutes and lasts between five and sixty minutes. Several aura symptoms can occur one after another. Visual aura Visual aura is the most common aura form. A person may see flickering lights, zigzag lines, spots or a spreading shimmering area. A patch of reduced vision can follow or accompany positive visual symptoms. Typical visual aura usually affects the visual field of both eyes, even when it seems stronger on one side. Checking whether vision loss is in one eye Covering one eye and then the other during a stable recurring symptom can sometimes clarify whether both visual fields are involved. This must not delay urgent care for sudden or unfamiliar vision loss. Symptoms affecting only one eye need assessment because retinal and vascular conditions can resemble aura. Sensory aura Sensory aura can cause pins and needles that gradually spread across a hand, arm or face. Numbness can follow the tingling. The gradual progression helps distinguish typical aura from some sudden vascular events. However, new one sided numbness still requires clinical assessment rather than self diagnosis. Speech aura Aura can temporarily affect speech or language. The person may struggle to find words, produce incorrect words or understand language normally. Speech disturbance can also indicate stroke. A first, sudden or atypical episode should be treated as a possible emergency. Migraine without aura Most people with migraine do not have aura with their attacks. Migraine without aura is diagnosed from the recurring headache pattern and associated symptoms. The absence of aura does not make the condition less genuine or necessarily less disabling. Migraine with aura Migraine with aura includes reversible neurological symptoms meeting the typical timing and progression pattern. The headache can begin during the aura, after it or occasionally not occur. The aura diagnosis matters because it affects differential diagnosis and contraceptive safety. Atypical aura features NICE advises further investigation or referral for aura involving motor weakness, double vision or poor balance. Visual symptoms affecting only one eye also need further assessment. Reduced consciousness is not a typical uncomplicated aura feature. Symptoms lasting longer than one hour or not fully resolving also need urgent review. Sudden symptoms are less typical of aura Typical aura usually spreads or develops over several minutes. Stroke and transient ischaemic attack commonly cause sudden loss of function, although real presentations overlap. New sudden weakness, speech disturbance or visual loss should therefore follow a stroke pathway. Do not wait to see whether a headache develops. The headache phase Migraine headache commonly lasts between four and seventy two hours in adults when untreated or unsuccessfully treated. Pain can be one sided or affect both sides. It is often pulsating, moderate or severe and worsened by ordinary physical activity. Not every attack has every characteristic. Functional impairment Migraine commonly makes ordinary activity difficult. Walking, bending, using screens or continuing work can worsen symptoms. A person may need to stop activity and rest in a quiet, dark place. Functional disruption helps distinguish migraine from many mild everyday headaches. Nausea and vomiting Nausea is common during a migraine attack. Vomiting can prevent oral medicines from being absorbed reliably. The digestive tract can slow during an attack even before vomiting occurs. This is one reason an antiemetic or non oral treatment can sometimes help. Photophobia and phonophobia Photophobia means unusual sensitivity to light. Phonophobia means unusual sensitivity to sound. Smells, touch or movement can also become difficult to tolerate. These symptoms reflect altered sensory processing rather than eye or ear damage by themselves. The postdrome After the main headache settles, a person can feel drained, confused or physically sore. Concentration and mood can remain altered for several hours or longer. Some people describe this as a migraine hangover. The postdrome is part of the attack rather than proof that treatment failed. Episodic and chronic migraine Episodic migraine occurs on fewer than fifteen headache days each month. Chronic migraine involves headache on at least fifteen days monthly for more than three months. At least eight of those days have migraine features. Medication overuse can coexist with chronic migraine and make the pattern harder to treat. Diagnostic pattern Migraine is diagnosed clinically from repeated attacks and their associated features. The pattern commonly includes moderate or severe headache, functional impairment, nausea or vomiting, and sensitivity to light or sound. The headache can be pulsating and aggravated by activity. A clinician does not need every feature to be present during every attack. Diagnosis is positive but safety focused A typical stable pattern with a normal examination can support a positive migraine diagnosis. Routine brain imaging is not required solely for reassurance. The clinician still checks for features suggesting infection, bleeding, raised intracranial pressure, cancer, vascular disease or another secondary headache. The headache diary A diary can record attack frequency, duration, severity and associated symptoms. It should include acute medicines and possible triggers. Recording menstruation can identify a hormonal pattern. The diary supports decisions but should not become constant symptom surveillance that increases anxiety. Examination The clinician checks blood pressure, temperature and neurological function when appropriate. They may examine the eyes for papilloedema, which is swelling of the optic disc region caused by raised pressure. A normal examination supports a primary headache diagnosis but cannot override a dangerous history. Tests are not routinely diagnostic There is no blood test, EEG or brain scan that confirms ordinary migraine. Tests are selected when what the person describes or the examination suggests another condition. Incidental scan findings can create anxiety without explaining the headache. This is why NICE advises against imaging a typical diagnosed migraine solely for reassurance. Headache red flags A red flag means that another cause needs urgent consideration. It does not mean that a dangerous disease has already been diagnosed. The urgency depends on the exact pattern and associated findings. A new or substantially changed headache deserves reassessment even in someone with established migraine. Thunderclap headache A thunderclap headache reaches maximum intensity within seconds or a few minutes. It can result from subarachnoid haemorrhage and several other vascular conditions. Call 999 for a sudden extremely painful headache, particularly when it is new. A previous migraine diagnosis does not make thunderclap onset safe. Fever and neck stiffness Headache with fever, neck stiffness, confusion, a new rash or reduced consciousness can indicate meningitis or encephalitis. Severe migraine can cause light sensitivity and vomiting, but infection must not be assumed away. Emergency assessment is required when this pattern is present. New neurological deficit Persistent weakness, facial droop, speech disturbance, loss of vision or severe imbalance can indicate stroke. Typical aura is fully reversible and develops gradually. A deficit that is sudden, new, prolonged or different from the usual aura requires emergency assessment. Papilloedema Papilloedema is an examination finding suggesting raised pressure around the brain. It can accompany brain tumours, venous sinus thrombosis, hydrocephalus or idiopathic intracranial hypertension. It requires urgent investigation rather than treatment as routine migraine. The person cannot reliably check for papilloedema at home. New headache after age 50 Migraine can continue into later life, but first onset after age fifty is less typical. New headache at this age raises concern about giant cell arteritis, cancer and other secondary causes. Scalp tenderness, jaw pain while chewing, visual symptoms or systemic illness need urgent same day assessment. Cancer and immunosuppression A new headache in someone with a cancer capable of spreading to the brain needs assessment. Compromised immunity can increase the risk of infection and some cancers. Vomiting, neurological change or altered consciousness increases concern. Pregnancy and the postnatal period A new or severe headache during pregnancy or after birth needs prompt assessment. Pre eclampsia can cause severe headache, visual disturbance, upper abdominal pain, vomiting and sudden swelling. Cerebral venous thrombosis, stroke and other secondary headaches are also more likely around pregnancy. Do not assume that visual symptoms are ordinary aura without assessment. Head injury A new or worsening headache after recent head injury requires assessment. Vomiting, confusion, seizure, weakness or increasing drowsiness makes the situation more urgent. Headache triggered by physical activity or pressure A new headache triggered by coughing, sneezing, straining, exercise or sexual activity needs assessment. A headache that changes strongly with posture can also indicate altered pressure or a spinal fluid leak. These patterns have benign causes but should not be assumed to be migraine initially. Painful red eye Headache with a painful red eye, blurred vision, haloes or a fixed abnormal pupil can indicate acute angle closure glaucoma. This is an eye emergency rather than a migraine treatment problem. Migraine triggers A trigger is a factor that appears to increase the probability of an attack. Commonly reported examples include missed meals, dehydration, sleep disruption, hormonal change, illness and stress. Triggers are individual and inconsistent rather than universal rules. The same factor may trigger an attack on one occasion but not another. Stress and let down attacks Some people develop attacks during intense stress. Others develop them when stress reduces, such as at the start of a weekend or holiday. This does not mean the person is choosing the symptoms or failing to cope. Stress is one biological influence among many. Sleep Too little sleep, excessive sleep or a major change in sleep timing can contribute. Regular sleep can reduce variability for some people. Rigid schedules are not always realistic, and imperfect sleep does not mean an attack is the person's fault. Food and drink Specific foods are not universal migraine triggers. Cheese and chocolate should not be removed automatically from everyone's diet. Alcohol, caffeine withdrawal or a clearly reproducible individual food association can matter. Broad exclusion diets can harm nutrition and quality of life. Hormonal change Changing oestrogen levels can influence migraine susceptibility. Attacks can cluster around menstruation, pregnancy, the postnatal period or perimenopause. Migraine often improves during pregnancy but can worsen or change in some people. A new pattern still needs appropriate assessment. Menstrual related migraine NICE suspects menstrual related migraine when attacks occur mainly from two days before to three days after menstruation begins. The pattern should occur in at least two of three consecutive cycles. A diary covering at least two cycles supports diagnosis. The attacks can occur with other migraines at different times. Acute treatment goals Acute treatment aims to reduce pain, nausea and disability during an attack. It should work quickly enough for the person's usual pattern. Medicine choice depends on age, pregnancy, vascular history, gastrointestinal risk and previous response. The safest plan is agreed before the next severe attack where possible. Simple analgesia Paracetamol, aspirin or an NSAID can be considered for acute migraine when suitable. Aspirin is not offered to people under sixteen because of Reye's syndrome risk. NSAIDs can cause gastrointestinal bleeding, kidney injury and cardiovascular harm in susceptible people. The medicine should not be selected only because it is available without prescription. Triptans Triptans are migraine specific medicines acting at serotonin receptors. They reduce trigeminal pain signalling and constrict selected blood vessels. NICE commonly offers an oral triptan with an NSAID or paracetamol. A different triptan can work when the first is consistently ineffective. When to take a triptan A triptan is generally taken when the migraine headache begins rather than during a typical aura alone. The exact instruction depends on the product and individual plan. Repeating doses or combining triptans must follow prescribed limits. Frequent use can contribute to medication overuse headache. Triptan vascular cautions Triptans are unsuitable for many people with previous heart attack, ischaemic heart disease or coronary vasospasm. They are also generally contraindicated after stroke or transient ischaemic attack and in peripheral vascular disease. Uncontrolled hypertension can be another contraindication. A clinician or pharmacist must check the individual product and cardiovascular history. Antiemetics An antiemetic treats nausea and can improve stomach movement during migraine. NICE considers adding one even when nausea is not prominent. Non oral options can help when vomiting or delayed absorption makes tablets ineffective. These medicines have their own movement, heart rhythm and sedation risks. Gepants for acute migraine Gepants block the calcitonin gene related peptide pathway. NICE recommends rimegepant for selected adults when at least two triptans were ineffective. It can also be considered when triptans are contraindicated or not tolerated and ordinary analgesics were ineffective. This is a defined prescribing pathway rather than a first self selected treatment. Opioids are not migraine treatment NICE advises against opioids for acute migraine. They can cause sedation, dependence, constipation and medication overuse headache. They may also make future migraine treatment more difficult. Treat early but track frequency Acute medicine often works best when taken early in the headache phase. This must be balanced against the number of treatment days each month. A diary can reveal when repeated rescue treatment is contributing to a worsening pattern. Medication overuse headache Medication overuse headache develops when frequent acute headache treatment contributes to more frequent or persistent headache. It can occur in someone who began with migraine. The medicine has not necessarily been taken in an addictive way. The biological problem is repeated exposure and increasing headache frequency. NICE medication overuse thresholds NICE raises concern when triptans, opioids, ergots or combination analgesics are used on at least ten days monthly for three months or more. For paracetamol, aspirin or NSAIDs, the threshold is at least fifteen days monthly for three months or more. These are diagnostic warning thresholds rather than recommended maximum targets. Prevention planning should usually begin before frequent use reaches this point. Treating medication overuse Treatment involves withdrawing the overused acute medicine with explanation and support. NICE usually advises stopping the overused medicine for at least one month. Headache can worsen temporarily before improving. Strong opioid use, relevant comorbidity or unsuccessful previous withdrawal can require specialist management. When prevention is considered Preventive treatment is considered when attacks are frequent, prolonged or disabling. It can also help when acute treatments are ineffective, contraindicated or being overused. The decision should reflect quality of life rather than one rigid attack number. Treatment aims to reduce frequency and severity rather than guarantee complete elimination. First preventive options Current NICE options include propranolol, topiramate and amitriptyline after an individual safety discussion. The choice depends on other illnesses, pregnancy potential, interactions, side effects and personal preference. A medicine is usually started at a low dose and reviewed after an adequate trial. Do not use another person's preventive medicine. Propranolol Propranolol is a beta blocker that can reduce migraine frequency. It may be unsuitable with asthma, some heart conditions or low blood pressure. It can be dangerous in overdose, so mental health and self harm risk must form part of safe prescribing. Amitriptyline Amitriptyline changes pain processing and can support sleep in some people. The migraine dose can be lower than doses used for depression. Drowsiness, dry mouth, constipation and heart rhythm effects can occur. Its use does not mean that migraine is considered psychological. Topiramate Topiramate is an antiseizure medicine also used to prevent migraine. Possible effects include tingling, cognitive slowing, weight loss, mood change and kidney stones. It must not be used for migraine prevention during pregnancy. Women able to become pregnant require the MHRA Pregnancy Prevention Programme and highly effective contraception. Reviewing prevention Preventive treatment needs enough time at a tolerated dose to judge benefit. NICE advises reviewing the need for ongoing prevention three to six months after starting. A useful response can mean fewer attacks, less severe attacks or improved function. Stopping is usually planned rather than abrupt when withdrawal effects or seizure risk apply. CGRP targeted prevention Calcitonin gene related peptide is an important messenger in migraine pathways. CGRP targeted treatments include monoclonal antibodies and oral gepants. NICE recommends specified options for adults with at least four migraine days monthly after at least three preventive treatments fail, are not tolerated or are unsuitable. Response is reviewed against defined episodic or chronic migraine thresholds. CGRP monoclonal antibodies Erenumab, fremanezumab, galcanezumab and eptinezumab are NICE approved options within defined criteria. Some are injected under the skin, while eptinezumab is given by intravenous infusion. Constipation and injection reactions can occur with some products. Long term and pregnancy decisions require specialist review. Oral preventive gepants Atogepant can prevent episodic or chronic migraine in eligible adults. Rimegepant is an option for selected episodic migraine. These medicines use specific NICE eligibility and stopping rules. They do not make accurate diagnosis or medication overuse management unnecessary. Botulinum toxin treatment Botulinum toxin type A is an option for selected adults with chronic migraine. At least three preventive treatments must have failed, been unsuitable or not tolerated. Medication overuse must be appropriately managed. Injections are delivered across defined head and neck sites by trained clinicians. Non medicine prevention Regular meals, adequate fluid, consistent sleep and physical activity can support migraine management. Relaxation or cognitive behavioural approaches can help some people manage triggers and disability. NICE also considers acupuncture after standard preventives are ineffective or unsuitable. These approaches support neurological care rather than proving that migraine is stress caused. Migraine with aura and stroke risk Migraine with aura is associated with a small increased risk of ischaemic stroke. The absolute risk for most younger people remains low. Smoking, hypertension and oestrogen containing combined hormonal contraception can add preventable vascular risk. This association does not mean that an ordinary aura is a stroke. Combined hormonal contraception Combined hormonal contraception includes the combined pill, patch and vaginal ring containing oestrogen. UK medical eligibility guidance classifies combined hormonal contraception as category 4 for migraine with aura. Category 4 means the method represents an unacceptable health risk and should not be used. Alternative contraception can usually be offered after individual assessment. New aura while using combined contraception A person developing new migraine aura while using combined hormonal contraception needs prompt contraceptive review. They should not ignore the change or repeatedly assume it is harmless. Sudden or persistent neurological symptoms still require emergency stroke assessment. Migraine without aura and contraception Migraine without aura does not carry the same absolute restriction on starting combined hormonal contraception. Age, smoking, blood pressure and other vascular factors still matter. New migraine beginning after combined contraception starts requires review because continuation may become unsuitable. Pregnancy treatment Migraine treatment during pregnancy requires medicine specific advice. NICE offers paracetamol first for an acute attack. A triptan or NSAID is considered only after discussing timing and risks. Preventive treatment during pregnancy requires specialist advice. Living with migraine Migraine can disrupt education, employment, parenting, relationships and mental health. Invisible symptoms and intermittent disability can lead to stigma. A positive diagnosis and practical plan are important even when tests are normal. The goal is improved function without turning every sensation into a medical emergency. What this lesson should not be used for This lesson cannot diagnose migraine from one headache, one visual symptom or response to a triptan. Do not use a previous migraine diagnosis to dismiss thunderclap pain, fever, papilloedema or a new neurological deficit. Do not start frequent analgesics, triptans or preventive medicines without checking suitability. Do not use combined hormonal contraception when migraine with aura has been identified without specialist contraceptive review. Call 999 for a sudden extremely painful headache, persistent stroke like symptoms, seizure, confusion or reduced consciousness.

Migraine is a primary neurological disorder causing recurring attacks of headache and sensory, digestive or neurological symptoms. Most people do not experience aura. Diagnosis is based on a characteristic recurring pattern after checking carefully for secondary headache red flags, while treatment balances effective acute relief, prevention and avoidance of medication overuse.