- Clinical science
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 neurologic 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 anti-inflammatory 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.
- The exact pathophysiology is unclear.
- Genetic predisposition
- Potential triggers
The pathophysiology of migraine is not fully understood. Different aspects contribute to the development and severity of migraine, such as
- Vascular dysregulation: vasodilation appears to play a role and there is an association between migraine and disorders with generalized vasospasms
- Dysregulation of pain sensitization in the trigeminal system
- Cortical spreading depression: continuously spreading depolarization of neuronal cells in the cortex
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
Paroxysmal, focal, neurologic symptoms that precede (or, in some cases, occurring during) the headache.
Typical aura 
- Visual disturbances; sensory and/or speech symptoms (positive and/or negative ;)
- No motor symptoms
- Develops gradually
- Completely reversible
- Symptoms last ≤ 60 minutes each
- Persistent or long-lasting symptoms
- 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.
- Previously known as basilar migraine
- Patients have episodes of migraine preceded at least some of the time by brainstem aura (but can also be preceded by typical aura).
- Criteria for brainstem aura
Vestibular migraine 
- 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 ).
- 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 
- Aura consists of monocular visual phenomena (e.g., scintillation, scotoma, or 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
- 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 
- Patients with migraine diagnosis (with or without aura) presenting with ≥ 3-month history of the following:
- 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. 
|Diagnostic criteria for migraine |
|Migraine without aura||Migraine with aura|
|Number of attacks (total lifetime)|| || |
|Duration|| || |
Neurological imaging is not routinely indicated for uncomplicated migraine.
- Clinical features suggest a secondary headache (see red flags for headache and high-risk headache).
- Migraine with the following characteristics: 
Procedure: MRI is preferred over CT (except in emergency settings if there is suspicion of a vascular hemorrhagic event).
- See imaging for headaches
- Typically normal
- Non-specific white-matter changes may be seen 
Medication overuse headache
- Stop causative medication.
- Abrupt withdrawal is preferred.
- Consider tapered withdrawal in the inpatient setting.
- Consider short-term psychotherapy. 
- Adjunct medication
- Outpatient treatment is recommended; admit patients only in complicated cases. 
- Stop causative medication.
The differential diagnoses listed here are not exhaustive.
- Limit stimuli (i.e., light, loud noises) and activity.
- Start abortive treatment as soon as possible.
- Treat nausea/vomiting, if present.
Mild to moderate headache 
- First-line treatment consists of NSAIDs, acetaminophen, acetylsalicylic acid, or combinations including caffeine.
- Second-line: proceed to “Moderate to severe headache” below
- Children: ibuprofen and family counseling
Moderate to severe headache 
- Start a migraine-specific agent: triptans (e.g., sumatriptan) or ergotamine (do not combine these agents!)
- First-line: oral or parenteral triptans
- Second-line: consider one of the following
- Consider recurrence prevention with dexamethasone . 
Overview of migraine-specific agents
|Mechanism of action|| |
|Side effects|| |
Triptans and ergotamine have severe pharmacological interactions (e.g., coronary spasm, serotonin syndrome) with one another and with other drugs (e.g., SSRI, macrolides). ALWAYS take a detailed history of the patient's usual and recent medications before selecting a drug.
A SUMo wrestler TRIPs ANd falls on his head: SUMaTRIPtANs are used for headaches (cluster and migraine).
- 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
- ≥ 2 attacks/month that produce disability that lasts ≥ 3 days
- Severe disability regardless of frequency (e.g., hemiplegic migraine)
- ≥ 2 attacks/week regardless of severity
- Failure/contraindications/major side effects from acute medications
General considerations 
- Consider comorbidities when selecting a drug.
- Encourage headache diary to assess response to treatment.
- Start with a low dose and increase until reaching the therapeutic goal.
- Goals of prophylaxis
- Reduce frequency, severity, and duration of attacks.
- Improve response to acute treatment.
- General prophylaxis
Menstrual-related migraine 
- First-line: frovatriptan 
- Naratriptan 
- Zolmitriptan 
- Chronic migraine
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 
- Consider inpatient management by a specialist if there is no improvement.
We list the most important complications. The selection is not exhaustive.
Migraine of any severity 
- Consider CT/MRI of the brain with or without contrast if the presentation is atypical or red flags for headache are present. 
- Reduce light/noise in the patient's environment.
- Fluid hydration
- Begin pharmacologic treatment within 1 hour of symptom onset, if possible.
- Treat nausea/vomiting, if present.
- Mild to moderate headache
- Moderate to severe headache, or if the above treatments fail
- Status migrainosus refractory to above