Migraine Headache

How to recognize migraine, distinguish it from other headache types, and apply evidence-based acute and preventive treatments.

Topic: Headache disorders Level: Intermediate Tags: migraine, tension headache, cluster headache, treatment

Overview

Migraine is a common and disabling primary headache disorder characterized by recurrent, often unilateral, throbbing attacks with systemic symptoms such as nausea, photophobia, and phonophobia. Careful clinical history is key for differentiating migraine from tension-type and cluster headaches. Correct diagnosis guides therapy and improves quality of life.

Clinician tip: Ask specifically about activity-related worsening and light/sound sensitivity—these are high-yield clues to migraine.

Core features

  • Recurrent attacks lasting 4–72 hours, often unilateral and pulsating.
  • Moderate to severe intensity; aggravated by routine activity.
  • Associated symptoms: nausea/vomiting, photophobia, and phonophobia.

Subtypes / related entities

Tension-type headache

Bilateral, pressing or tightening quality, milder intensity, minimal associated symptoms.

Cluster headache

Excruciating unilateral orbital/temporal pain, autonomic signs (lacrimation, nasal congestion), attacks of 15–180 minutes in clusters.

Key differences at a glance

Item What to look for Why it matters
Aura Visual or sensory symptoms preceding headache (≈30% of migraine cases). Helps confirm migraine and guide prophylaxis; warns of hemiplegic or basilar subtypes.
Red flags Sudden thunderclap onset, new onset after age 50, focal deficits, fever. Mandates evaluation for secondary causes such as hemorrhage or infection.

Work-up snapshot

  • No labs required for typical migraine with a normal neurologic exam.
  • Brain imaging if red-flag symptoms, new neurologic deficits, or change in pattern.
  • Consider secondary causes if systemic illness or atypical features are present.
Red flag: Sudden-onset “worst headache of life” requires emergent evaluation for subarachnoid hemorrhage.

Treatment snapshot

  • Acute: NSAIDs, acetaminophen, triptans; newer options include gepants and ditans.
  • Preventive: beta-blockers, topiramate, valproate, tricyclic antidepressants, CGRP monoclonal antibodies, onabotulinumtoxinA for chronic migraine.
  • Lifestyle: regular sleep, hydration, exercise, and trigger management.
Pearl: Early treatment during mild pain improves triptan effectiveness and reduces recurrence.

References

  1. International Classification of Headache Disorders, 3rd edition (ICHD-3), 2018.
  2. AHS Guidelines for Acute and Preventive Migraine Treatment, 2021.

Educational discussion. Not a substitute for clinical judgment. Consider local protocols and individual factors.