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 
- Peak incidence: 30–39 years 
- 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. 
Epidemiological data refers to the US, unless otherwise specified.
- The exact pathophysiology is unclear. 
- Genetic predisposition
- Potential triggers
- The pathophysiology of migraine is not fully understood.
- Various factors are thought to contribute to the development and severity of migraines.
Activation of meningeal nociceptors
- Dilatation of intracranial blood vessels → activation of meningeal nociceptors
- Activation of the trigeminovascular pathway: activation of trigeminal neurons → release of vasoactive neuropeptides such as substance P or calcitonin gene-related peptide (CGRP) → vasodilatation and release of proinflammatory molecules (histamine, bradykinin, serotonin, prostaglandins) → neurogenic inflammation → activation of meningeal nociceptors 
- Cortical spreading depression: excitation and inhibition of the cerebral cortex → changes in cortical enzymatic activity (proinflammatory molecules) → neurogenic inflammation → activation of meningeal nociceptors 
- Dysregulation of pain sensitization in the trigeminal system (CN V): cortical spreading depression → dysregulation of trigeminovascular neurons → neurogenic inflammation → hypersensitization → nausea, loss of appetite, yawning, fatigue, anxiety, depression 
- Genetic predisposition: in individuals with migraine, the brain does not have the ability to habituate itself to external stimuli (e.g., stress, hormonal changes) → hyperexcitable brain 
- Activation of the autonomic nervous system; : external physiological and emotional stimulation (e.g., hormonal changes, stress) → hypothalamic response to the change in homeostasis → hypothalamic neurons influence the autonomic nervous system → shift toward a parasympathetic tone → constriction and dilatation of intracranial, especially the meningeal, blood vessels 
- Activation of meningeal nociceptors
Vasodilatation is now considered an epiphenomenon rather than the primary cause of migraine headache. 
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
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
- Atypical aura
- 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.
Subtypes and variants
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 
- 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 ).
Hemiplegic migraine 
- 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, 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) 
- 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 a ≥ 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|| || |
Avoid in patients with known migraines and pursue a in patients with .
- Not routinely indicated
- Consider a urine pregnancy test to guide pharmacotherapy choices in women of childbearing age.
Neurological imaging is not routinely indicated for uncomplicated migraine.
- Clinical features suggest a secondary headache (see “ ” and “ ”).
- Migraine with the following characteristics: 
- MRI is preferred over CT (except in emergency settings if there is suspicion of a vascular hemorrhagic event).
- See “ .”
- Typically normal
- Nonspecific white-matter changes may be seen 
- See “.”
- Medication overuse headache
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. 
Abortive therapy 
- Limit stimuli (i.e., light, loud noises) and activity.
- Start abortive treatment as soon as possible. 
- Treat , if present.
Mild to moderate headache 
- First-line treatment: consists of NSAIDs, acetaminophen, acetylsalicylic acid, or combinations including caffeine.
- Second-line: Treat as “Moderate to severe headache.”
- Children: ibuprofen and family counseling
Moderate to severe headache 
Trial a parenteral antidopaminergic agent OR start a migraine-specific agent.
- Parenteral antidopaminergics
Migraine-specific agents: triptans (e.g., sumatriptan) OR ergotamine; do not combine these agents! 
- First-line: oral or parenteral triptans
- Second-line: consider a parenteral ergotamine (e.g., dihydroergotamine )
- Short-term recurrence prevention: Consider IV dexamethasone. 
- Refractory headache: See “Status migrainosus.”
In the emergency department, consider IV dexamethasone to reduce the risk of recurrent migraine after discharge. 
Overview of migraine-specific agents
|Agents|| || |
|Mechanism of action|
|Side effects|| || |
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.
A SUMo wrestler TRIPs ANd falls on his head: SUMaTRIPtANs are used for headaches (cluster and migraine).
Prophylactic therapy of 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
Status migrainosus 
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 
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 the above 
- Most patients with migraines can be managed as outpatients.
- Consider hospitalization in the following cases:
- Consider referral to neurology or a specialized headache clinic.
- If discharging from the emergency department, provide patient counseling and consider appropriate prescription of abortive and prophylactic medications.
- See also “Disposition” in “Headache.”
Special patient groups
Management of migraine in pregnancy 
- First-line: acetaminophen (either alone or in combination with caffeine)
- Second-line: NSAIDs (safe to use until the end of the 2nd trimester of pregnancy)
- Ergot derivatives are contraindicated because they induce uterine contractions.
- Control of nausea/vomiting: the following medications are safe to use in pregnancy
- One-Minute Telegram 29-2021-3/3: Eptinezumab shows promise in the treatment of migraine attacks
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