AKT · Neurology/Headache & facial pain

Migraine

Primary headache — cortical spreading depression + trigeminovascular activation

Overview

A common primary headache disorder of recurrent moderate–severe headaches, classically unilateral, pulsatile, with nausea, photophobia/phonophobia and aggravation by activity, ± aura. The exam tests acute vs preventive treatment and the COCP/aura interaction.

Recognise

Unilateral, pulsatile, moderate–severe, 4–72h, worse with activity; nausea, photophobia, phonophobia
Aura (~25%): visual scintillations/scotoma, sensory symptoms — gradual march over minutes
Triggers: stress, menstruation, sleep, foods; chronic = ≥15 days/month

Red flags

Aura + COCP (stroke risk → COCP is UKMEC 4); thunderclap or new focal/systemic features → exclude secondary causes (see Headache red flags)

Differentials & how to tell them apart

Tension headachebilateral tight-band, mild–moderate, no nausea/aura, not worsened by activity

Cluster headachesevere unilateral periorbital pain with autonomic features, restless, short attacks

Medication-overuse headacheanalgesics ≥10–15 days/month, rebound on withdrawal

Subarachnoid haemorrhagethunderclap, instantly maximal — emergency

Investigations

Clinical diagnosis; image only if red flags. A headache diary helps identify pattern/triggers.

Management

Acute: triptan + NSAID/paracetamol (± antiemetic); prophylaxis: propranolol or topiramate

1Acute attack: oral triptan + NSAID or paracetamol, ± antiemetic. Avoid opioids.Gate: Migraine WITH AURA is an absolute contraindication to the combined pill (UKMEC 4 — ischaemic stroke risk) → use a progestogen-only method
2≥4 attacks/month or disabling → prophylaxis: propranolol (preferred in women of childbearing potential) or topiramate (teratogenic, reduces COCP efficacy) or amitriptyline. Riboflavin/menstrual strategies as adjuncts.

Triptan + NSAID/paracetamol — acute first-line (e.g. sumatriptan); add antiemetic (metoclopramide/prochlorperazine)

Propranolol or topiramate — prophylaxis (topiramate teratogenic + reduces COCP efficacy → avoid in women of childbearing potential)

Amitriptyline — prophylaxis alternative

Key points

Topiramate is teratogenic AND an enzyme effect reduces COCP efficacy — propranolol is safer in women who might conceive. Watch for medication-overuse headache from triptan/analgesic overuse.

Monitor & prognosis

Headache-diary frequency, treatment response, medication-overuse.

Often improves with age; prophylaxis reduces frequency.

Source: NICE CKS Migraine; NICE NG (headaches)