Migraine

Last updated: February 21, 2023

Summarytoggle arrow icon

Migraine is a primary headache characterized by recurrent episodes of unilateral, localized pain that are frequently accompanied by nausea, vomiting, and sensitivity to light and sound. In approximately 25% of cases, patients experience an aura preceding the headache, which involves reversible focal neurological abnormalities, e.g., visual field defects (scotomas) or paresis lasting less than an hour. Migraine is a clinical diagnosis and imaging is generally not indicated. Treatment of attacks consists of general measures (e.g., minimizing light and sound) together with administration of nonsteroidal antiinflammatory drugs (e.g., aspirin) and antiemetics (e.g., prochlorperazine) if nausea is present. In severe cases, triptans may be added. Prophylactic treatment (e.g., beta blockers) may be indicated if migraines are especially frequent or long-lasting, or if abortive therapy fails or is contraindicated.

  • Prevalence: ∼ 17% of females and ∼ 6% of males [1]
  • Peak incidence: 30–39 years [2][3]
  • Migraine is the second most common type of headache.

Among patients presenting to the emergency department with a headache, migraine is the most common cause. [4]

Epidemiological data refers to the US, unless otherwise specified.

Vasodilatation is now considered an epiphenomenon rather than the primary cause of migraine headache. [6]

Migraine is characterized by recurrent attacks and may occur with aura (∼ 25% of cases) or without aura (∼ 75% of cases). A typical migraine attack passes through four stages, and the aura (if present) typically occurs before the headache. However, migraine patterns may differ and not follow the characteristic stages.

1. Prodrome (facultative)

  • 24–48 hours before the headache starts
  • Excessive yawning
  • Difficulties with writing or reading
  • Sudden hunger or lack of appetite
  • Mood changes

2. Aura

Paroxysmal, focal, neurological symptoms that precede (or, in some cases, occur during) the headache.

  • Typical aura [9][10]
    • Visual disturbances, sensory and/or speech symptoms (positive ; and/or negative ;)
      • Scintillating scotoma: an arch-shaped scotoma that starts centrally and shifts peripherally (appears for ∼ 15–30 minutes)
      • Central scotoma
      • Flashing lights
      • Distorted color perception
      • Fortification spectra: star-like, zigzag figures
      • Sensory deficits, paresthesia
      • Aphasia
    • No motor symptoms
    • Develops gradually
    • Completely reversible
    • Symptoms last ≤ 60 minutes each
  • Atypical aura

3. Headache

  • Localization
    • Typically unilateral, but bilateral headache is possible
    • Especially frontal, frontotemporal, retro-orbital
  • Duration: usually 4–24 hours (rarely over 72 hours)
  • Course: progression of pulsating, throbbing, or pounding pain
  • Exacerbated by physical activity
  • Accompanying symptoms: photophobia, phonophobia, and nausea/vomiting

4. Postdrome (facultative)

  • Feeling of exhaustion or euphoria
  • Muscle weakness
  • Anorexia or food cravings

The typical migraine headache is “POUND”: Pulsatile, One-day duration, Unilateral, Nausea, Disabling intensity.

All variants of acute migraine should raise suspicion for other diagnoses (e.g., transient ischemic attack), especially if the first aura occurs after 40 years of age, auras last an atypical amount of time, or symptoms are predominantly negative.

Migraine with brainstem aura [9]

Vestibular migraine [9][11]

  • Most common cause of spontaneous episodic vertigo
  • Diagnosed migraine plus ≥ 5 episodes of vestibular symptoms (e.g., vertigo) lasting ≤ 72 hours
  • Treatment may be complemented with antivertigo agents (e.g., dimenhydrinate ).

Hemiplegic migraine [9]

  • May be familial or sporadic
  • Main differential diagnosis: epilepsy
  • Fully reversible aura (lasts ∼ 72 hours) consisting of both motor weakness and visual, sensory, or speech impairment

Retinal migraine [9]

  • Aura consists of monocular visual phenomena (e.g., scintillation, scotoma, blindness).
  • All symptoms are fully reversible.
  • Aura fulfills ≥ 2 of the following criteria:
    • Spread: gradually over ≥ 5 minutes
    • Duration: 5–60 minutes
    • Onset of headache: within 60 minutes

Typical aura without headache (silent migraine) [9]

  • Aura symptoms are present.
  • Aura lasts for ≥ 60 minutes before the onset of the headache, which might not develop at all.
  • Episodes may coexist with typical migraine symptoms.

Chronic migraine [9]

  • Patients with migraine diagnosis (with or without aura) presenting with a ≥ 3-month history of the following:
    • Headaches (variable in intensity and type ) ≥ 15 days/month
    • ≥ 8 days/month headache has migraine characteristics or is relieved by migraine-specific medication (triptans, ergotamine).
  • A headache diary is recommended for patients to help optimize treatment.
  • Main differential diagnosis: medication overuse headache

Migraine is a clinical diagnosis based on history and physical examination. The most important step is to exclude red flags for headache that suggest a secondary headache (e.g., infection, hemorrhage, intracranial mass) and require more exhaustive investigation (e.g., imaging). Suspect a primary headache when no red flags are identified, and confirm the diagnosis using the diagnostic criteria for migraine. [9][12]

Migraine is a clinical diagnosis that is based on patient history and physical examination.

Diagnostic criteria

Diagnostic criteria for migraine [9]
Migraine without aura Migraine with aura
Number of attacks (total lifetime)
  • ≥ 5
  • ≥ 2
Duration
  • 4–72 hours
  • N/a
Characteristics
  • ≥ 2 of the following:
    • Unilateral
    • Pulsating
    • Moderate or severe pain
    • Worsened by routine physical activity
  • ≥ 1 of the following aura symptoms:
    • Visual
    • Sensory
    • Speech
    • Motor
    • Brainstem
    • Retinal
  • ≥ 3 of the following aura characteristics:
    • ≥ 1 spreads gradually over ≥ 5 minutes.
    • ≥ 2 occur in succession.
    • Each one lasts 5–60 minutes.
    • ≥ 1 is unilateral.
    • ≥ 1 involves a positive symptom.
    • Accompanied or followed by headache (within 60 minutes)

Avoid anchoring bias in patients with known migraines and pursue a diagnostic workup for headache in patients with red flags for headache.

Laboratory studies

  • Not routinely indicated
  • Consider a urine pregnancy test to guide pharmacotherapy choices in women of childbearing age.

Imaging [12][13][14]

Neurological imaging is not routinely indicated for uncomplicated migraine.

Avoid imaging in patients presenting with a recurrent known migraine unless new concerning features are present, e.g., seizures, focal neurological deficits, or recent change in headache pattern.

The differential diagnoses listed here are not exhaustive.

See “Migraine management in pregnancy” for abortive and preventative agents that are safe for pregnant individuals. The following recommendations are consistent with American Headache Society (AHS) guidelines. [15][16][17][18]

Abortive therapy for migraines [18][19]

All patients

Avoid opioids as first-line treatment for acute migraines, given their unclear efficacy and potential harm (e.g., worse nausea and vomiting). [15][20]

Mild to moderate headache [9][15]

Moderate to severe headache [9][15][20]

Trial a parenteral antidopaminergic agent OR start a migraine-specific agent.

Parenteral antidopaminergics (i.e., IV metoclopramide or IV prochlorperazine) are effective first-line agents for migraine regardless of GI symptoms or ability to tolerate oral medication.

In the emergency department, consider IV dexamethasone to reduce the risk of recurrent migraine after discharge. [15]

Overview of migraine-specific agents

Migraine-specific agents
Triptans

Ergotamine

Agents
  • Sumatriptan, zolmitriptan, almotriptan, rizatriptan
Mechanism of action
Indications
Side effects
Contraindications

Remember to check for drug interactions (e.g., with SSRIs or macrolides) before starting triptans or ergotamines to avoid adverse events. Coronary spasm and/or serotonin syndrome can occur if triptans and ergotamines are combined.

Ergotamines are contraindicated in pregnancy. [24]

A SUMo wrestler TRIPs ANd falls on his head: SUMaTRIPtANs are used for headaches (cluster and migraine).

Prophylactic therapy of migraine

Nonpharmacological [25]

  • Lifestyle modifications
    • Exercise in moderation
    • Maintain a healthy diet
    • Identify and try to avoid potential triggers
    • Follow a regular sleeping schedule
  • Other: There is some evidence that the following nonpharmacological interventions have some benefits for patients with migraine

Pharmacological [27]

Status migrainosus [9]

  • Description: Debilitating migraine attack in a patient with a known migraine diagnosis (with or without aura)
    • Exceptional in duration (≥ 72 hours) and severity
    • Often related to medication overuse
  • Treatment: stepwise therapy with reassessment between drug administration [31]

We list the most important complications. The selection is not exhaustive.

Management of migraine in pregnancy [24][37]

Abortive therapies

Prophylactic therapy

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

  1. Orr SL, Friedman BW, Christie S, et al. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache: The Journal of Head and Face Pain. 2016; 56 (6): p.911-940. doi: 10.1111/head.12835 . | Open in Read by QxMD
  2. Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: Acute treatment of migraine in children and adolescents. Neurology. 2019; 93 (11): p.487-499. doi: 10.1212/wnl.0000000000008095 . | Open in Read by QxMD
  3. American Headache Society. The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache: The Journal of Head and Face Pain. 2018; 59 (1): p.1-18. doi: 10.1111/head.13456 . | Open in Read by QxMD
  4. Marmura MJ, Silberstein SD, Schwedt TJ. The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies. Headache: The Journal of Head and Face Pain. 2015; 55 (1): p.3-20. doi: 10.1111/head.12499 . | Open in Read by QxMD
  5. Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies.. Am Fam Physician. 2018; 97 (4): p.243-251.
  6. Friedman BW. Managing Migraine. Ann Emerg Med. 2017; 69 (2): p.202-207. doi: 10.1016/j.annemergmed.2016.06.023 . | Open in Read by QxMD
  7. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38 (1): p.1-211. doi: 10.1177/0333102417738202 . | Open in Read by QxMD
  8. Volpi-Abadie J, Kaye AM, Kaye AD. Serotonin syndrome. Ochsner J. 2013; 13 (4): p.533-540.
  9. Colman I, Friedman BW, Brown MD, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008; 336 (7657): p.1359-1361. doi: 10.1136/bmj.39566.806725.be . | Open in Read by QxMD
  10. Brunton L. Goodman and Gilman's The Pharmacological Basis of Therapeutics, 13th Edition. McGraw-Hill Education / Medical ; 2017
  11. Amundsen S, Nordeng H, Nezvalová-Henriksen K, Stovner LJ, Spigset O. Pharmacological treatment of migraine during pregnancy and breastfeeding. Nature Reviews Neurology. 2015; 11 (4): p.209-219. doi: 10.1038/nrneurol.2015.29 . | Open in Read by QxMD
  12. Puledda F, Shields K. Non-Pharmacological Approaches for Migraine. Neurotherapeutics. 2018; 15 (2): p.336-345. doi: 10.1007/s13311-018-0623-6 . | Open in Read by QxMD
  13. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews. 2016 . doi: 10.1002/14651858.cd001218.pub3 . | Open in Read by QxMD
  14. Loder E, Burch R, Rizzoli P. The 2012 AHS/AAN Guidelines for Prevention of Episodic Migraine: A Summary and Comparison With Other Recent Clinical Practice Guidelines. Headache. 2012; 52 (6): p.930-945. doi: 10.1111/j.1526-4610.2012.02185.x . | Open in Read by QxMD
  15. Estemalik E, Tepper. Preventive treatment in migraine and the new US guidelines. Neuropsychiatric Disease and Treatment. 2013 : p.709. doi: 10.2147/ndt.s33769 . | Open in Read by QxMD
  16. Silberstein S, Goadsby P. Migraine: Preventive Treatment. Cephalalgia. 2002; 22 (7): p.491-512. doi: 10.1046/j.1468-2982.2002.00386.x . | Open in Read by QxMD
  17. Frampton JE, Silberstein S. OnabotulinumtoxinA: A Review in the Prevention of Chronic Migraine. Drugs. 2018; 78 (5): p.589-600. doi: 10.1007/s40265-018-0894-6 . | Open in Read by QxMD
  18. Dodick DW. Migraine. The Lancet. 2018; 391 (10127): p.1315-1330. doi: 10.1016/s0140-6736(18)30478-1 . | Open in Read by QxMD
  19. Marshall RS, Mayer SA. On Call Neurology. Elsevier ; 2020
  20. Shahien R, Saleh SA, Bowirrat A. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011; 123 (4): p.257-265. doi: 10.1111/j.1600-0404.2010.01394.x . | Open in Read by QxMD
  21. Miller AC, K. Pfeffer B, Lawson MR, Sewell KA, King AR, Zehtabchi S. Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review. Headache: The Journal of Head and Face Pain. 2019; 59 (10): p.1674-1686. doi: 10.1111/head.13648 . | Open in Read by QxMD
  22. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  23. Silberstein SD. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000; 55 (6): p.754-762. doi: 10.1212/wnl.55.6.754 . | Open in Read by QxMD
  24. Holle D, Obermann M. The role of neuroimaging in the diagnosis of headache disorders. Therapeutic Advances in Neurological Disorders. 2013; 6 (6): p.369-374. doi: 10.1177/1756285613489765 . | Open in Read by QxMD
  25. Tepper D. Pregnancy and Lactation - Migraine Management. Headache: The Journal of Head and Face Pain. 2015; 55 (4): p.607-608. doi: 10.1111/head.12540 . | Open in Read by QxMD
  26. Lipton RB, Bigal ME, Diamond M, et al. Migraine prevalence, disease burden, and the need for preventive therapy.. Neurology. 2007; 68 (5): p.343-9. doi: 10.1212/01.wnl.0000252808.97649.21 . | Open in Read by QxMD
  27. Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II.. Headache. 2001; 41 (7): p.646-57. doi: 10.1046/j.1526-4610.2001.041007646.x . | Open in Read by QxMD
  28. Straube A, Andreou A. Primary headaches during lifespan.. The journal of headache and pain. 2019; 20 (1): p.35. doi: 10.1186/s10194-019-0985-0 . | Open in Read by QxMD
  29. Luciani M, Negro A, Spuntarelli V, Bentivegna E, Martelletti P. Evaluating and managing severe headache in the emergency department. Expert Rev Neurother. 2021; 21 (3): p.277-285. doi: 10.1080/14737175.2021.1863148 . | Open in Read by QxMD
  30. Sathasivam S, Sathasivam S. Patent foramen ovale and migraine: what is the relationship between the two?. J Cardiol. 2013; 61 (4): p.256-259. doi: 10.1016/j.jjcc.2012.12.005 . | Open in Read by QxMD
  31. Goadsby P. Pathophysiology of migraine. Annals of Indian Academy of Neurology. 2012; 15 (5): p.15. doi: 10.4103/0972-2327.99993 . | Open in Read by QxMD
  32. Burstein R, Noseda R, Borsook D. Migraine: multiple processes, complex pathophysiology. J Neurosci. 2015; 35 (17): p.6619-6629. doi: 10.1523/jneurosci.0373-15.2015 . | Open in Read by QxMD
  33. Pescador Ruschel MA, De Jesus O. Migraine Headache. StatPearls. 2020 .
  34. Bisdorff AR. Management of vestibular migraine. Therapeutic Advances in Neurological Disorders. 2011; 4 (3): p.183-191. doi: 10.1177/1756285611401647 . | Open in Read by QxMD
  35. Micieli A, Kingston W. An Approach to Identifying Headache Patients That Require Neuroimaging. Frontiers in Public Health. 2019; 7 . doi: 10.3389/fpubh.2019.00052 . | Open in Read by QxMD
  36. Weatherall MW. The diagnosis and treatment of chronic migraine. Therapeutic Advances in Chronic Disease. 2015; 6 (3): p.115-123. doi: 10.1177/2040622315579627 . | Open in Read by QxMD
  37. Evans RW, Burch RC, Frishberg BM, et al. Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence‐Based Guideline. Headache: The Journal of Head and Face Pain. 2019; 60 (2): p.318-336. doi: 10.1111/head.13720 . | Open in Read by QxMD
  38. Bajwa Zh, Smith JH. Acute treatment of migraine in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults?source=search_result&search=triptans&selectedTitle=1~115#H6.Last updated: February 27, 2017. Accessed: April 2, 2017.
  39. Bajwa Zh, Smith JH. Preventive treatment of migraine in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/preventive-treatment-of-migraine-in-adults?source=search_result&search=migraine&selectedTitle=3~150#H23.Last updated: February 27, 2017. Accessed: April 2, 2017.
  40. Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician. 2006; 73 (1): p.72-78.
  41. Shevel E. The extracranial vascular theory of migraine: an artificial controversy. J Neural Transm (Vienna).. 2011; 118 (4): p.525-530. doi: 10.1007/s00702-010-0517-1 . | Open in Read by QxMD
  42. Rossi P, Lorenzo CD, Faroni J, Cesarino F, Nappi G. Advice Alone Vs. Structured Detoxification Programmes for Medication Overuse Headache: A Prospective, Randomized, Open-Label Trial in Transformed Migraine Patients With Low Medical Needs. Cephalalgia. 2006; 26 (9): p.1097-1105. doi: 10.1111/j.1468-2982.2006.01175.x . | Open in Read by QxMD
  43. Evers S, Jensen R. Treatment of medication overuse headache - guideline of the EFNS headache panel. Eur J Neurol. 2011; 18 (9): p.1115-1121. doi: 10.1111/j.1468-1331.2011.03497.x . | Open in Read by QxMD
  44. Altieri M, Di Giambattista R, Di Clemente L, et al. Combined Pharmacological and Short-Term Psychodynamic Psychotherapy for Probable Medication Overuse Headache: A Pilot Study. Cephalalgia. 2009; 29 (3): p.293-299. doi: 10.1111/j.1468-2982.2008.01717.x . | Open in Read by QxMD
  45. Krymchantowski A, Barbosa J. Prednisone as Initial Treatment of Analgesic-Induced Daily Headache. Cephalalgia. 2000; 20 (2): p.107-113. doi: 10.1046/j.1468-2982.2000.00028.x . | Open in Read by QxMD
  46. Bendtsen L, et al. EFNS guideline on the treatment of tension-type headache - Report of an EFNS task force. European Journal of Neurology. 2010; 17 (11): p.1318-1325. doi: 10.1111/j.1468-1331.2010.03070.x . | Open in Read by QxMD
  47. Wakerley BR et al.. Medication-overuse headache.. Pract Neurol. 2019; 19 (5): p.399-403. doi: 10.1136/practneurol-2018-002048 . | Open in Read by QxMD
  48. Kristoffersen ES, Lundqvist C. Medication-overuse headache: epidemiology, diagnosis and treatment.. Therapeutic advances in drug safety. 2014; 5 (2): p.87-99. doi: 10.1177/2042098614522683 . | Open in Read by QxMD
  49. Pascual J, Colás R, Castillo J, et al.. Epidemiology of chronic daily headache.. Curr Pain Headache Rep. 2001; 5 (6): p.529-36. doi: 10.1007/s11916-001-0070-6 . | Open in Read by QxMD
  50. Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem.. The Lancet. Neurology. 2004; 3 (8): p.475-83. doi: 10.1016/S1474-4422(04)00824-5 . | Open in Read by QxMD
  51. Da Silva AN, Lake AE. Clinical Aspects of Medication Overuse Headaches. Headache: The Journal of Head and Face Pain. 2013; 54 (1): p.211-217. doi: 10.1111/head.12223 . | Open in Read by QxMD
  52. Katsarava Z, Obermann M. Medication-overuse headache. Curr Opin Neurol. 2013; 26 (3): p.276-281. doi: 10.1097/wco.0b013e328360d596 . | Open in Read by QxMD
  53. Créac’h C, Frappe P, Cancade M, et al. In-patient versus out-patient withdrawal programmes for medication overuse headache: A 2-year randomized trial. Cephalalgia. 2011; 31 (11): p.1189-1198. doi: 10.1177/0333102411412088 . | Open in Read by QxMD
  54. Tassorelli C, Jensen R, Allena M, et al. A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study. Cephalalgia. 2014; 34 (9): p.645-655. doi: 10.1177/0333102414521508 . | Open in Read by QxMD
  55. Tepper SJ. Medication-Overuse Headache. CONTINUUM: Lifelong Learning in Neurology. 2012; 18 : p.807-822. doi: 10.1212/01.con.0000418644.32032.7b . | Open in Read by QxMD
  56. Drucker P, Tepper S. Daily sumatriptan for detoxification from rebound.. Headache. 1998; 38 (9): p.687-90. doi: 10.1046/j.1526-4610.1998.3809687.x . | Open in Read by QxMD
  57. Krymchantowski AV, Moreira PF. Out-patient detoxification in chronic migraine: comparison of strategies.. Cephalalgia. 2003; 23 (10): p.982-93. doi: 10.1046/j.1468-2982.2003.00648.x . | Open in Read by QxMD
  58. Pageler L, Katsarava Z, Diener H, Limmroth V. Prednisone vs. Placebo in Withdrawal Therapy Following Medication Overuse Headache. Cephalalgia. 2007; 28 (2): p.152-156. doi: 10.1111/j.1468-2982.2007.01488.x . | Open in Read by QxMD
  59. Diener H-C, Bussone G, Oene JV, Lahaye M, Schwalen S, Goadsby P. Topiramate Reduces Headache Days in Chronic Migraine: A Randomized, Double-Blind, Placebo-Controlled Study. Cephalalgia. 2007; 27 (7): p.814-823. doi: 10.1111/j.1468-2982.2007.01326.x . | Open in Read by QxMD
  60. Rizzato B, Leone G, Misaggi G, Zivi I, Diomedi M. Efficacy and Tolerability of Pregabalin Versus Topiramate in the Prophylaxis of Chronic Daily Headache With Analgesic Overuse. Clin Neuropharmacol. 2011 : p.74-78. doi: 10.1097/wnf.0b013e318210ecc9 . | Open in Read by QxMD
  61. Silberstein SD, Blumenfeld AM, Cady RK, et al. OnabotulinumtoxinA for treatment of chronic migraine: PREEMPT 24-week pooled subgroup analysis of patients who had acute headache medication overuse at baseline. J Neurol Sci. 2013; 331 (1-2): p.48-56. doi: 10.1016/j.jns.2013.05.003 . | Open in Read by QxMD

3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer