Migraine
Migraine is a common primary headache disorder, meaning it is not caused by another underlying condition.
This updated UKMLA guide to migraine is based on NICE CG150, which covers types (including migraine without aura, migraine with aura, hemiplegic migraine), causes, risk factors, symptoms, diagnosis, and management.
Causes and Risk Factors
Migraine is considered to be a disorder of neuronal excitability involving multiple neural networks and anatomical regions in the brain
- The exact underlying cause and pathophysiology are not fully understood, involving a combination of genetic, environmental and lifestyle factors
- Headache in migraine is thought to be a result of neurogenic inflammation of the CN V1 (trigeminal nerve 1st division), altering the way the brain processes pain, so non-painful stimuli may be interpreted as painful
Risk factors for developing migraine:
- Females
- Family history of migraine
- Low socio-economic status
- Allergies or asthma
- Hypothyroidism
Risk factors associated with chronic migraine:
- High frequency episodic migraine
- Overuse of acute migraine medications
- Excessive caffeine intake
- Obesity
- Snoring and sleep disorders
- Comorbid complications (e.g. head injury, pain disorders, anxiety, depression)
- Major life events (e.g. divorce, marriage, loss of job)
Triggers
Common triggers:
- Sleep disturbances
- Excessive caffeine intake
- Stress
- Lack of exercise
- Irregular or missed meals
- Menstruation
However, it is not always possible to identify a trigger
Complications
Possible acute complications:
- Status migrainosus – migraine attack lasting for >72 hours
- Migrainous infarction – aura symptoms lasting >60 min + ischaemic infarct on neuroimaging
- Migraine aura-triggered seizure
Migraine itself increases the risk of ischaemic stroke (and possibly also haemorrhagic stroke).
Long-term complications:
- Medication-overuse headache – migraine is the most common underlying primary headache disorder associated with medication overuse
- Reduced functional ability and QoL
- Progression to chronic migraine
- Depression
- ↑ Complications in pregnancy (more likely to experience pre-eclampsia, cerebral venous sinus thrombosis, preterm birth, low birth weight baby)
Diagnosis
Clinical Features
Typical Migraine Features
Typical migraine often refers to:
- Migraine with aura, and
- Migraine without aura
Migraine attacks are often described in several phases, although not every patient experiences every phase.
Typical phases in adults:
| Phase (in order) | Clinical features |
|---|---|
| Prodromal phase | Possible symptoms:
|
| Aura | Aura is characterised by transient focal neurological symptoms that usually precede the headache (or may accompany the headache)
Typical aura symptoms:
|
| Headache | Typical headache feature:
The headache is typically aggravated by, or causes avoidance of, ADLs Associated features:
Patients typically prefer to lie still in a dark, quiet room |
| Postdromal phase | “Migraine hangover”:
|
Menstrual-related migraine is a specific predictable subtype of typical migraine, characterised by:
- Migraine occurring predominantly between 2 days before and 3 days after the start of menstruation for at least 2 out of 3 consecutive menstrual cycles
Migraine in the paediatric population has slightly different presentations: [Ref1][Ref2]
- Location
- Often bilateral (more commonly unilateral in adults)
- Frequently frontal or temporal rather than hemicranial
- Character
- Pounding or throbbing, but in younger children may be less distinctly pulsatile
- Duration
- Usually shorter
- Associated symptoms
- More likely to experience prominent gastrointestinal symptoms, especially vomiting and nausea
Migraine Subtypes / Variants
The following are often considered as “atypical migraines”:
| Migraine subtype / variant | Clinical features |
|---|---|
| Typical aura without headache (“silent migraine”) | Occurs in older people in particular:
The absence of headache makes excluding a TIA and other causes difficult. Aura develops over at least 5 min and lasts 5-60 min and should be fully reversible
|
| Hemiplegic migraine | Motor aura symptoms:
Usually a typical migraine headache follows or overlaps with the aura Hemiplegic migraine is a classic TIA / stroke mimic. |
| Migraine with brainstem aura | Brainstem aura symptoms:
There should be NO motor weakness or retinal symptoms. Usually a typical migraine headache follows or overlaps with the aura |
| Retinal migraine | Aura in retinal migraine:
This contrasts with a typical visual aura, which is usually a cortical visual-field phenomenon, often perceived through both eyes and sometimes still visible with eyes closed |
Patients with any of the following atypical neurological symptoms should be considered for urgent specialist assessment and/or hospital admission, depending on clinical judgement:
- Motor weakness
- Double vision
- Visual symptoms affecting only one eye
- Poor balance / ataxia
- Reduced level of consciousness
Headache Red Flags
If the headache has ANY of the following red flags, consider the need for further investigations and/or referral:
| Category | Red Flag | Explanation |
|---|---|---|
| Infection / inflammation | Worsening headache with fever | Suggests possible central nervous system infection (e.g., meningitis, encephalitis) or inflammatory disease. |
| Symptoms suggestive of giant cell arteritis (e.g., jaw claudication, age >50, visual symptoms) | Points to vasculitis with risk of vision loss or stroke. | |
| Immunocompromised status (HIV, immunosuppressive drugs) | Increases risk for opportunistic infections and neoplastic processes. | |
| Vascular / haemorrhagic | Sudden-onset headache reaching maximum intensity within 5 minutes (thunderclap) | Characteristic of subarachnoid haemorrhage, reversible cerebral vasoconstriction syndrome, or other acute vascular events. |
| New-onset neurological deficit | May indicate stroke, intracranial mass, encephalitis, or other structural or metabolic brain disorders. | |
| New cognitive dysfunction, personality change, or impaired level of consciousness | Suggests stroke, intracranial mass, encephalitis, or other significant brain pathology. | |
| Raised ICP / structural | Headache triggered by cough, valsalva manoeuvre, sneeze, or exercise | Can be a sign of increased intracranial pressure (e.g., due to intracranial mass). |
| Vomiting without other clear cause | May reflect increased intracranial pressure or mass effect. | |
| Substantial change in headache characteristics | May signal a new secondary process, such as neoplasm or infection. | |
| Intracranial hypotension | Orthostatic headache | Typical of intracranial hypotension, often due to CSF leak. |
| Trauma-related | Recent head trauma (within 3 months) | Raises concern for traumatic intracranial haemorrhage (e.g. subdural haematoma). |
| Oncology-related | Age <20 with history of malignancy | Raises suspicion for metastatic or recurrent disease affecting the CNS. |
| History of malignancy known to metastasise to the brain | Increases risk for intracranial metastases. | |
| Ophthalmic emergencies | Symptoms/signs of acute narrow-angle glaucoma (painful red eye, visual loss) | Requires urgent ophthalmological evaluation. |
If there is a new-onset headache with ANY of the following, consider the need for further investigations and/or referral:
- Immunocompromised (e.g. HIV, use of immunosuppressive drugs)
- <20 y/o + history of malignancy
- History of malignancy known to metastasise to the brain
- Vomiting without other obvious causes
Investigation and Diagnosis
Migraine, like other primary headache disorders, is primarily a clinical diagnosis.
Consider using a headache diary for at least 8 weeks to help diagnose primary headaches. The patient should record the following:
- Frequency, duration and severity of headaches
- Any associated symptoms
- Possible precipitants
- Relationship of headaches to menstruation
- All medications taken to relieve headaches
Do NOT refer people diagnosed with tension‑type headache, migraine, cluster headache or medication-overuse headache for neuroimaging solely for reassurance.
Diagnostic Criteria
Migraine is primarily a clinical diagnosis
Diagnostic criteria (for typical migraine):
| Migraine type | Diagnostic criteria |
|---|---|
| Migraine without aura | At least 5 attacks fulfilling the following criteria:
|
| Migraine with aura | At least 2 attacks fulfilling the following criteria:
|
Frequency of migraine attack:
- Median: 1-2 attacks per month
- Episodic migraine: migraine occurs on <15 days per month
- Chronic migraine: occurring ≥15 days per month for >3 months
Management
Adults
Acute Management
Educate patients about prescribed acute treatment:
- Take the medication early while pain is mild
- If using a triptan for migraine with aura, it should be taken at the start of the headache, not at the start of the aura (unless the aura and headache start simultaneously)
- If acute treatment has not been effective within 2 hours, it is unlikely to work for that migraine attack (consider higher doses or alternative treatment or combination treatment)
Restrict acute medication use to a maximum of 2 days per week to avoid the risk of developing medication-overuse headache.
Choice of acute drug treatment:
| 1st line | Combination therapy of:
If the person prefers taking 1 drug → monotherapy of oral paracetamol / aspirin (900 mg) / NSAID / triptan |
| 2nd line | Consider non-oral medications:
Consider adding non-oral NSAID (e.g. rectal diclofenac) or triptan (e.g. nasal spray) if they have not been tried |
| 3rd line | Oral rimegepant (CGRP inhibitor), if
|
Consider an antiemetic in addition to other acute treatment for migraine, even in the absence of nausea and vomiting
Do NOT offer ergots or opioids.
Long-Term Management
| Management aspect | Description / recommendation |
|---|---|
| Conservative / general management |
Ensure that women who have migraine with aura are NOT using COCP, which is contraindicated. |
| Preventive / prophylactic treatment | Do NOT routinely offer preventive / prophylactic treatment.
Only consider if ANY of the following:
If migraine is of an uncommon type (for example, hemiplegic migraine, or migraine with prolonged aura) — refer or seek expert advice before considering preventative medication. Choice of preventive / prophylactic treatment:
Riboflavin (vitamin B2) may be effective in reducing migraine frequency and intensity for some people Treatments may take up to 6 weeks to provide a benefit Do not offer gabapentin for the prophylactic treatment of migraine |
Menstrual-Related Migraine
If not responding adequately to standard acute treatment, consider frovatriptan or zolmitriptan on the days migraine is expected
Ensure that women who have migraine with aura are NOT using COCP, which is contraindicated.
Young People (12-17 y/o)
Acute management:
- 1st line: monotherapy of paracetamol or NSAID
- 2nd line: nasal triptan (oral triptan is not licensed for use <18 y/o)
- 3rd line: combination therapy of nasal triptan + paracetamol / NSAID
Preventive / prophylactic treatment should only be started by a specialist
Do NOT offer aspirin in those <16 yo due to risk of Reye’s syndrome.
Pregnant / Breastfeeding Women
Acute management:
- 1st line: non-pharmacological measures (e.g. relaxation technique, CBT, avoidance of triggers)
- 2nd line: paracetamol
- 3rd line: ibuprofen (if <20 weeks gestation) or triptan
Metoclopramide and prochlorperazine can be used as short-term treatment options for nausea and vomiting in pregnancy.
Preventive / prophylactic treatment should only be started by a specialist
Do NOT offer aspirin (or opioids) for the acute management of migraines in pregnancy or breastfeeding.
References
Related Articles
Transient Ischaemic Attack (TIA)
Subarachnoid haemorrhage (SAH)