One-liner#

Migraine management centers on early acute treatment (triptans first-line, gepants for triptan-contraindicated), preventive therapy when ≥4 headache days/month (propranolol, topiramate, or amitriptyline based on comorbidities), and strict limits on acute medication use (≤10 days/month) to prevent medication-overuse headache.

Quick nav#

• Definition and epidemiology
• Pathophysiology
• Clinical presentation
• Diagnostic workup
• Treatment
• Patient education
• Prognosis and monitoring
• Special populations
• When to refer
• Smartphrase snippets
• Related pages

Definition and epidemiology#

Diagnostic criteria#

ICHD-3 criteria for Migraine without Aura:

A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) C. Headache has at least 2 of the following:

• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine physical activity D. During headache, at least 1 of the following:
• Nausea and/or vomiting
• Photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis

ICHD-3 criteria for Migraine with Aura:

A. At least 2 attacks fulfilling criteria B and C B. One or more fully reversible aura symptoms:

• Visual (most common): scotoma, zigzag lines, flashing lights
• Sensory: numbness, tingling (typically unilateral face/arm)
• Speech/language: dysphasia
• Motor: weakness (hemiplegic migraine—rare)
• Brainstem: vertigo, tinnitus, diplopia, ataxia
• Retinal: monocular visual symptoms C. At least 3 of the following:
• At least 1 aura symptom spreads gradually over ≥5 minutes
• Two or more aura symptoms occur in succession
• Each individual aura symptom lasts 5-60 minutes
• At least 1 aura symptom is unilateral
• At least 1 aura symptom is positive (scintillations, pins/needles)
• Aura accompanied or followed within 60 minutes by headache D. Not better accounted for by another diagnosis

Chronic migraine: ≥15 headache days/month for >3 months, with migraine features on ≥8 days/month.

Episodic migraine: <15 headache days/month.

Epidemiology#

Prevalence is 12% overall (18% women, 6% men). Peak prevalence is ages 25-55. Migraine is the second leading cause of disability worldwide. 90% of migraineurs have family history. Annual cost in US exceeds $20 billion in direct and indirect costs.

Risk factors for progression to chronic migraine:

• High attack frequency (>4/month)
• Medication overuse (most important modifiable factor)
• Obesity
• Depression/anxiety
• Sleep disorders
• Caffeine overuse
• Stressful life events

Pathophysiology#

Mechanism (clinical understanding)#

Migraine is a neurovascular disorder involving cortical hyperexcitability, trigeminovascular activation, and central sensitization.

Cortical spreading depression (CSD): A wave of neuronal depolarization spreads across the cortex at 3-5 mm/min, followed by prolonged suppression. CSD is the physiologic basis of aura—visual aura corresponds to CSD spreading across visual cortex. CSD also activates trigeminal afferents, triggering the headache phase.

Trigeminovascular system activation: Trigeminal nerve fibers innervating meningeal blood vessels release vasoactive neuropeptides (CGRP, substance P, neurokinin A). CGRP (calcitonin gene-related peptide) is the key mediator—causes vasodilation, neurogenic inflammation, and pain signal transmission. This explains why CGRP-targeted therapies (gepants, anti-CGRP monoclonal antibodies) are effective.

Central sensitization: Repeated migraine attacks lead to sensitization of central pain pathways. Clinically manifests as cutaneous allodynia (scalp tenderness, discomfort wearing glasses/earrings). Once central sensitization occurs, triptans are less effective—treat early before allodynia develops.

Serotonin (5-HT) involvement: Serotonin levels drop during migraine attacks. Triptans are 5-HT1B/1D agonists—they constrict dilated meningeal vessels and inhibit trigeminal nerve activation. This explains triptan efficacy and why they’re contraindicated in vascular disease.

Clinical relevance:

• Treat early (before central sensitization/allodynia)
• CGRP pathway is a validated target (gepants, monoclonal antibodies)
• Triptans work via serotonin receptors (vascular contraindications)
• Preventive therapy reduces cortical hyperexcitability

How to explain to patients#

Migraine is not just a bad headache—it’s a brain condition where your brain is extra sensitive to certain triggers.

Think of your brain like a smoke detector. In migraine, the smoke detector is set too sensitive—it goes off with things that shouldn’t trigger an alarm, like bright lights, certain foods, or changes in sleep. When the alarm goes off, it triggers a cascade of events: blood vessels in your head dilate, nerves get irritated, and you feel pain, nausea, and sensitivity to light and sound.

The good news is we can turn down the sensitivity of that smoke detector with preventive medications. And when an attack starts, we can stop the cascade early with the right treatment—but it works best if you take it at the first sign of a headache, not after it’s severe.

Some people get warning signs before the headache called “aura”—usually visual changes like zigzag lines or blind spots. This is caused by a wave of electrical activity spreading across your brain. It’s not dangerous, but it tells you a headache is coming and it’s time to take your medication.

Clinical presentation#

Characteristic symptoms#

Prodrome (hours to days before headache):

• Mood changes (irritability, depression, euphoria)
• Food cravings (especially sweets)
• Yawning
• Neck stiffness
• Fatigue
• Increased urination

Aura (5-60 minutes before or during headache):

• Visual (90% of auras): scintillating scotoma, fortification spectra (zigzag lines), photopsia (flashing lights), visual field defects
• Sensory (30%): paresthesias spreading from hand to face over minutes
• Language (10%): word-finding difficulty, dysarthria
• Motor (rare): unilateral weakness (hemiplegic migraine—refer to neurology)

Headache phase (4-72 hours):

• Location: unilateral (60%), bilateral (40%); often frontotemporal
• Quality: pulsating/throbbing (classic) or pressure
• Intensity: moderate to severe; interferes with activity
• Aggravated by: physical activity, bending over, coughing
• Associated: nausea (80%), vomiting (30%), photophobia (90%), phonophobia (80%), osmophobia (smell sensitivity)

Postdrome (hours to days after headache):

• Fatigue, “washed out” feeling
• Cognitive difficulty (“brain fog”)
• Mood changes
• Neck stiffness

Common triggers:

• Sleep: too little or too much; irregular schedule
• Stress: during or after (weekend migraine)
• Hormonal: menstruation (60% of women), oral contraceptives
• Dietary: alcohol (especially red wine), aged cheese, processed meats, MSG, artificial sweeteners, skipped meals, dehydration
• Environmental: bright/flickering lights, strong odors, weather changes, altitude
• Medications: vasodilators (nitrates, PDE5 inhibitors), hormone therapy

Physical exam findings#

During attack:

• Appears uncomfortable, may prefer dark/quiet room
• Pallor, diaphoresis
• Unilateral conjunctival injection or tearing (if autonomic features)
• Scalp tenderness (allodynia)
• Neck muscle tenderness

Neurologic exam (should be normal):

• Mental status: normal (may be slow to respond due to pain)
• Cranial nerves: normal (no pupil asymmetry, no facial weakness)
• Motor: normal strength
• Sensory: normal (except allodynia during attack)
• Reflexes: symmetric
• Gait: normal

If abnormal neuro exam: Consider secondary headache; imaging indicated.

Red flags#

Require urgent evaluation/imaging:

• Thunderclap onset (peak <1 minute)—rule out SAH
• New headache >50 years—rule out GCA, mass
• Fever + headache—rule out meningitis
• Papilledema—rule out increased ICP
• Focal neurologic deficits persisting beyond aura
• Change in established headache pattern
• Headache worse with Valsalva, positional
• Immunocompromised patient with new headache
• Cancer history with new headache
• Anticoagulated patient with new headache

Aura red flags (refer to neurology):

• Motor weakness (hemiplegic migraine)
• Brainstem symptoms (basilar migraine)
• Aura lasting >60 minutes
• Aura without subsequent headache (first occurrence)
• Aura symptoms that don’t spread gradually

Diagnostic workup#

Initial evaluation#

Migraine is a clinical diagnosis. No test confirms migraine; diagnosis is based on history meeting ICHD-3 criteria with normal neurologic exam.

Required assessment:

• Detailed headache history (frequency, duration, quality, associated symptoms)
• Headache diary: track frequency, triggers, medication use, disability
• Screen for medication overuse: how many days/month using acute medications?
• Screen for depression/anxiety (PHQ-2, GAD-2)—common comorbidities affecting treatment
• Assess disability: MIDAS (Migraine Disability Assessment) or HIT-6 (Headache Impact Test)

No routine labs needed for typical migraine with normal exam.

Consider labs if:

• Anemia suspected (fatigue, pallor): CBC
• Thyroid dysfunction suspected: TSH
• Starting topiramate: BMP (baseline bicarbonate)
• Starting valproate: CBC, LFTs

Confirmatory testing#

Neuroimaging is NOT routinely indicated for migraine with typical features and normal neurologic exam.

MRI brain (without contrast) indicated if:

• Atypical headache features (thunderclap, positional, exertional)
• Abnormal neurologic exam
• New headache >50 years
• Change in established headache pattern
• First or worst headache
• Headache with fever (also consider LP)
• Aura with atypical features (prolonged, motor, brainstem)
• Treatment-refractory headache (to reassure patient and clinician)

MRI preferred over CT for headache evaluation (better sensitivity for posterior fossa, white matter lesions).

When imaging is normal: Reassure patient that migraine is the diagnosis; normal imaging does not mean “nothing is wrong”—migraine is a real neurologic condition.

When to refer for specialist workup#

• Diagnostic uncertainty (is it migraine vs other primary headache vs secondary cause?)
• Hemiplegic migraine or migraine with brainstem aura
• Aura without headache (first occurrence, especially >40 years)
• Chronic migraine (≥15 days/month)
• Failed 2-3 preventive medications
• Medication-overuse headache not responding to withdrawal
• Considering CGRP monoclonal antibodies or other specialist-initiated therapies
• Pregnancy planning in woman on teratogenic preventive

What NOT to order#

• Routine neuroimaging for typical migraine with normal exam—low yield, high cost, incidental findings cause anxiety
• CT head as first-line (MRI preferred; CT only if MRI contraindicated or emergent)
• EEG unless seizure suspected (aura is not a seizure)
• Cervical spine imaging unless cervicogenic component suspected
• Extensive blood work (ANA, Lyme, etc.) without specific clinical indication
• Lumbar puncture unless meningitis, SAH, or idiopathic intracranial hypertension suspected

Treatment#

Goals of therapy#

Acute treatment goals:

• Rapid, complete pain relief within 2 hours
• No recurrence within 24 hours
• Minimal side effects
• Restored function (able to return to activities)

Preventive treatment goals:

• Reduce headache frequency by ≥50%
• Reduce headache severity and duration
• Improve response to acute treatment
• Reduce disability (MIDAS score)
• Prevent progression to chronic migraine

Treatment targets:

Non-pharmacologic management#

Trigger identification and avoidance:

• Keep headache diary for 2-3 months to identify patterns
• Common modifiable triggers: irregular sleep, skipped meals, dehydration, alcohol, stress
• Avoid trigger stacking (multiple minor triggers can summate)

Lifestyle modifications (evidence-based):

• Regular sleep schedule: same bedtime/wake time daily, including weekends
• Regular meals: don’t skip meals; avoid prolonged fasting
• Hydration: 8 glasses water daily; more in heat/exercise
• Regular aerobic exercise: 30-40 minutes, 3-5 times/week (reduces frequency by 40-50%)
• Stress management: relaxation techniques, biofeedback, CBT

Behavioral therapies:

• Biofeedback: teaches control of physiologic responses; NNT ~3 for ≥50% improvement
• Cognitive behavioral therapy (CBT): addresses pain catastrophizing, stress
• Relaxation training: progressive muscle relaxation, guided imagery
• Mindfulness-based stress reduction

Supplements with evidence:

• Magnesium oxide 400-500 mg daily: modest benefit; safe; may cause diarrhea
• Riboflavin (B2) 400 mg daily: takes 3 months for effect; very safe
• CoQ10 100 mg TID: limited evidence; safe
• Feverfew: inconsistent evidence; avoid in pregnancy

Devices (FDA-cleared):

• Cefaly (external trigeminal nerve stimulation): for prevention and acute treatment
• SpringTMS (single-pulse transcranial magnetic stimulation): for acute treatment with aura
• gammaCore (vagus nerve stimulation): for acute and preventive treatment

Pharmacologic management#

Acute treatment—First-line:

Acute treatment—Gepants (CGRP receptor antagonists):

Acute treatment—Adjunctive:

Triptan selection guidance:

• First-line: sumatriptan (most data, cheapest) or rizatriptan (fast onset)
• Recurrence problem: eletriptan (longest half-life) or naratriptan
• Menstrual migraine: naratriptan or frovatriptan (long half-life for scheduled use)
• Nausea/vomiting: sumatriptan nasal or SC; add antiemetic
• Triptan non-responder: try different triptan (30% respond to second triptan after first failure)
• CV disease or multiple risk factors: use gepant instead

Preventive treatment—First-line:

Preventive treatment—Second-line/alternatives:

CGRP monoclonal antibodies (specialist-initiated):

When to consider CGRP monoclonal antibodies:

• Failed ≥2 oral preventives
• Intolerance to oral preventives
• Contraindications to oral preventives
• Patient preference for monthly injection over daily pill
• Refer to neurology or headache specialist for initiation

Preventive selection by comorbidity:

• Hypertension: prefer propranolol, candesartan
• Depression/anxiety: prefer venlafaxine, amitriptyline; avoid propranolol (may worsen depression)
• Insomnia: prefer amitriptyline; avoid topiramate (may worsen)
• Obesity: prefer topiramate; avoid amitriptyline, valproate (weight gain)
• Epilepsy: prefer topiramate, valproate
• Tremor: prefer propranolol
• Asthma: prefer venlafaxine, amitriptyline, topiramate; avoid propranolol (contraindicated)
• Pregnancy planning: stop all preventives; consider magnesium, riboflavin; avoid topiramate, valproate (teratogenic)
• Elderly: prefer magnesium, riboflavin, candesartan; avoid topiramate (cognitive), amitriptyline (anticholinergic)
• CKD: prefer propranolol, amitriptyline (no renal adjustment); avoid topiramate (kidney stones), high-dose magnesium

Medication-overuse headache (MOH) prevention and treatment:

MOH occurs when acute medications are used ≥10-15 days/month, leading to chronic daily headache. It’s the most common cause of chronic migraine transformation.

Thresholds for MOH:

• Triptans, ergots, opioids, combination analgesics: ≥10 days/month
• Simple analgesics (NSAIDs, acetaminophen): ≥15 days/month

Prevention:

• Educate ALL migraine patients about MOH risk at first visit
• Limit acute medication use to ≤2 days/week (≤10 days/month)
• Start preventive therapy if approaching these limits
• Track medication use in headache diary

Treatment of established MOH:

• Abrupt withdrawal (preferred) or gradual taper over 2-4 weeks
• Bridge therapy during withdrawal: naproxen 500 mg BID scheduled x 2-4 weeks, or prednisone 60 mg x 5 days then taper
• Start or optimize preventive therapy simultaneously
• Warn patient: headaches will worsen for 1-2 weeks before improving
• Close follow-up (weekly) during withdrawal period
• Consider neurology referral if multiple failed attempts

Patient counseling points#

When starting acute treatment:

• “Take your migraine medication at the first sign of headache—don’t wait until it’s severe. Early treatment works much better.”
• “If the first dose doesn’t work after 2 hours, you can take a second dose. But don’t take more than the maximum daily dose.”
• “Limit your migraine medication to no more than 10 days per month. Using it more often can actually cause more headaches.”

When starting preventive treatment:

• “This medication is taken every day to reduce how often you get migraines. It doesn’t work immediately—give it 8-12 weeks to see the full effect.”
• “We’re aiming to cut your headache days in half. It may not eliminate migraines completely, but should make them less frequent and less severe.”
• “Don’t stop this medication suddenly, even if you feel better. We’ll taper it slowly when the time is right.”

About triptans:

• “Triptans work by narrowing blood vessels in your brain and blocking pain signals. They’re very effective but shouldn’t be used if you have heart disease.”
• “Common side effects include tingling, warmth, tightness in the chest or throat. These are usually harmless but tell me if they’re severe.”

About side effects:

• Propranolol: “You may feel tired or notice your heart rate is slower. Don’t stop suddenly—we need to taper.”
• Topiramate: “You may notice tingling in your hands/feet, difficulty finding words, or carbonated drinks tasting flat. These often improve with time.”
• Amitriptyline: “Take it at bedtime—it causes drowsiness. You may have dry mouth and constipation.”

Monitoring and follow-up#

Initial treatment phase:

Maintenance phase:

• Every 3-6 months once stable
• Review headache diary at every visit
• Monitor for medication overuse
• Reassess need for preventive after 6-12 months of good control

What to track:

• Headache days per month
• Acute medication days per month
• Headache severity (0-10 scale)
• Disability (MIDAS or HIT-6 periodically)
• Side effects
• Triggers identified

Patient education#

What is this condition?#

Migraine is a brain condition that causes severe headaches along with other symptoms like nausea and sensitivity to light and sound. It’s not just a bad headache—it’s a medical condition that affects how your brain processes signals.

About 1 in 8 people get migraines. They’re more common in women than men. Migraines often run in families, so if your parents had them, you’re more likely to get them too.

During a migraine, your brain becomes extra sensitive. Blood vessels in your head widen, nerves get irritated, and this causes the throbbing pain you feel. The nausea and sensitivity to light happen because your brain is overwhelmed by normal signals.

Migraines are not dangerous, but they can really affect your quality of life. The good news is that with the right treatment, most people can get their migraines under much better control.

What you can do#

Keep a headache diary. Write down when you get headaches, what you ate, how you slept, and what was happening in your life. This helps identify your triggers.

Take your migraine medicine early. At the first sign of a headache, take your medication. Waiting until the pain is severe makes it harder to treat.

Limit how often you use pain medicine. Using migraine medicine more than 10 days a month can actually cause more headaches. This is called medication-overuse headache.

Stick to a regular schedule. Go to bed and wake up at the same time every day. Eat regular meals. Don’t skip breakfast.

Stay hydrated. Drink at least 8 glasses of water a day. Dehydration is a common trigger.

Exercise regularly. Aim for 30 minutes of moderate exercise most days. Exercise can help prevent migraines.

Manage stress. Try relaxation techniques like deep breathing or meditation. Stress is one of the most common triggers.

When to seek care#

Call your doctor’s office if:

• Your headaches are getting more frequent
• Your usual treatment isn’t working anymore
• You’re using migraine medicine more than 10 days a month
• You have new symptoms with your headaches
• Your headaches are affecting your work or daily life

Go to the emergency room if:

• You have the worst headache of your life that came on suddenly
• You have a headache with fever and stiff neck
• You have a headache with confusion, weakness, numbness, or trouble speaking
• You have a headache with vision changes that don’t go away
• You have a headache after a head injury

Questions to ask your doctor#

• What type of migraine do I have?
• What are my triggers, and how can I avoid them?
• Should I be on a daily preventive medication?
• How often is it safe to use my acute medication?
• Are there any foods or activities I should avoid?
• When should I come back for a follow-up?
• Should I see a headache specialist?
• Are there any new treatments I should know about?

Prognosis and monitoring#

Expected course#

Natural history:

• Migraine is a chronic condition with episodic attacks
• Frequency varies widely: some have rare attacks, others have multiple per week
• ~3% of episodic migraineurs progress to chronic migraine annually
• Migraines often improve with age, especially after menopause in women
• Complete remission occurs in ~40% over decades

With treatment:

• 50-70% achieve ≥50% reduction in headache frequency with appropriate preventive
• Acute treatment provides pain freedom at 2 hours in 30-50% (triptans)
• Combination of preventive + optimized acute treatment provides best outcomes
• Most patients can achieve good control with available treatments

Factors predicting better outcome:

• Lower baseline headache frequency
• Shorter duration of chronic migraine
• No medication overuse
• No psychiatric comorbidity
• Good response to initial preventive trial
• Adherence to lifestyle modifications

Factors predicting worse outcome:

• High baseline frequency (>8 days/month)
• Medication overuse
• Comorbid depression/anxiety
• Obesity
• Sleep disorders
• Allodynia (cutaneous hypersensitivity)
• Multiple failed preventive trials

Monitoring parameters#

Complications to watch for#

Disease-related:

• Chronic migraine: progression to ≥15 headache days/month
• Medication-overuse headache: from frequent acute medication use
• Status migrainosus: migraine lasting >72 hours (may need IV treatment)
• Migrainous infarction: rare; stroke during migraine with aura
• Persistent aura without infarction: aura symptoms lasting >1 week

Treatment-related:

• Medication-overuse headache (most common)
• Triptan overuse: can cause rebound; chest tightness (usually benign)
• Propranolol: bradycardia, fatigue, depression, bronchospasm
• Topiramate: cognitive impairment, kidney stones, metabolic acidosis, teratogenicity
• Amitriptyline: weight gain, sedation, anticholinergic effects, cardiac conduction
• Valproate: weight gain, tremor, hair loss, hepatotoxicity, teratogenicity

Comorbidities to monitor:

• Depression and anxiety (screen annually; treat if present)
• Sleep disorders (screen for OSA if snoring, obesity)
• Cardiovascular risk (migraine with aura associated with increased stroke risk)

Special populations#

Elderly/geriatric#

Presentation differences:

• New-onset migraine rare after age 50—consider secondary causes
• Aura may occur without headache (“acephalgic migraine”)—must rule out TIA
• May present with less typical features

Treatment considerations:

• Avoid triptans if CAD, uncontrolled HTN, or multiple CV risk factors—use gepants instead
• Avoid topiramate: cognitive side effects, kidney stones
• Use amitriptyline cautiously: anticholinergic burden, falls, cardiac conduction (Beers criteria)
• Avoid valproate: cognitive effects, drug interactions
• Preferred preventives: magnesium, riboflavin, candesartan, low-dose propranolol (if no bradycardia)
• Start all medications at lower doses; titrate slowly
• Gepants (ubrogepant, rimegepant) are good acute options—no CV contraindications

Polypharmacy concerns:

• Triptans: serotonin syndrome risk with SSRIs/SNRIs (rare but monitor)
• Propranolol: interactions with other rate-lowering drugs
• Topiramate: reduces efficacy of oral contraceptives (less relevant in elderly)
• Valproate: multiple drug interactions

Chronic kidney disease#

Acute treatment:

• NSAIDs: avoid if eGFR <30; use cautiously if eGFR 30-60
• Triptans: no dose adjustment needed; safe in CKD
• Gepants: ubrogepant—avoid if eGFR <30; rimegepant—avoid in severe renal impairment
• Acetaminophen: safe; preferred simple analgesic in CKD

Preventive treatment:

• Propranolol: no dose adjustment needed
• Amitriptyline: no dose adjustment needed; anticholinergic effects may be more problematic
• Topiramate: reduce dose if eGFR <70; avoid if eGFR <30; increases kidney stone risk
• Valproate: no dose adjustment but monitor closely
• Magnesium: reduce dose or avoid if eGFR <30 (accumulation risk)
• Candesartan: use cautiously; monitor K and Cr
• CGRP monoclonal antibodies: limited data; likely safe

Other populations#

Women of childbearing potential:

• Topiramate and valproate are teratogenic—require reliable contraception
• Topiramate reduces efficacy of hormonal contraceptives—use alternative method
• Discuss pregnancy planning; switch to safer preventives before conception
• Safe preventives in pregnancy: magnesium, riboflavin, propranolol (taper before delivery)
• Triptans: limited data but no clear teratogenicity; use if benefit outweighs risk

Menstrual migraine:

• Defined as migraine occurring -2 to +3 days of menstruation
• Short-term prevention: naratriptan 1 mg BID or frovatriptan 2.5 mg BID starting 2 days before expected menses through day 3
• Alternative: naproxen 500 mg BID during menstrual window
• Continuous hormonal contraception (skip placebo week) may help

Migraine with aura and contraception:

• Combined hormonal contraceptives (estrogen-containing) are contraindicated—increased stroke risk
• Progestin-only methods are safe
• Counsel on stroke risk; document discussion

Cardiovascular disease:

• Triptans contraindicated in CAD, prior stroke/TIA, uncontrolled HTN, peripheral vascular disease
• Gepants are safe—no vasoconstrictor effect
• NSAIDs: use cautiously; avoid in HF
• Propranolol: good choice if no decompensated HF or severe bradycardia

When to refer#

Specialist referral criteria#

Refer to neurology/headache specialist:

• Diagnostic uncertainty (atypical features, concern for secondary cause)
• Hemiplegic migraine or migraine with brainstem aura
• Chronic migraine (≥15 days/month)
• Failed 2-3 adequate preventive trials
• Medication-overuse headache not responding to withdrawal
• Considering CGRP monoclonal antibodies or Botox
• Aura without headache (first occurrence, especially age >40)
• Prolonged aura (>60 minutes)
• Pregnancy planning in woman on teratogenic preventive
• Significant disability despite treatment (MIDAS >20)

Refer to emergency department:

• Thunderclap headache (sudden severe onset)
• Headache with fever and neck stiffness
• Headache with focal neurologic deficits
• Headache with altered mental status
• Status migrainosus not responding to outpatient treatment
• First or worst headache of life

Urgency levels#

Routine (weeks):

• Chronic migraine for preventive optimization
• Failed 2+ preventives for specialist input
• Consideration of CGRP monoclonal antibodies
• Medication-overuse headache for structured withdrawal program

Urgent (days):

• New aura without headache in patient >40 (rule out TIA)
• Significant change in established headache pattern
• Status migrainosus (migraine >72 hours)
• Suspected GCA (age >50, jaw claudication, vision symptoms)

Emergent (immediate/ED):

• Thunderclap headache
• Headache with fever and meningismus
• Headache with focal neurologic deficits
• Headache with papilledema
• Worst headache of life

Smartphrase snippets#

Episodic migraine, stable: Episodic migraine with [X] headache days/month, well-controlled on current regimen with acute medication use ≤10 days/month. Neuro exam normal, no red flags. Continue current preventive and acute treatment; f/u 3-6 months.

Episodic migraine, starting preventive: Episodic migraine with [X] headache days/month, meeting criteria for preventive therapy. Starting [medication] [dose], will titrate over [timeframe]; expect 8-12 weeks for full effect. F/u 6-8 weeks to assess response.

Chronic migraine/medication overuse: Chronic migraine with medication-overuse headache (acute medications [X] days/month). Plan: structured withdrawal with bridge therapy, starting/optimizing preventive with [medication]. Close f/u in 2 weeks; neurology referral if not improving.

Migraine, new diagnosis: New diagnosis of migraine without aura; no red flags, neuro exam normal, imaging not indicated. Prescribed [sumatriptan 50 mg] for acute treatment, limit to ≤10 days/month. Discussed triggers and warning signs; f/u 4-6 weeks.

Related pages#

Complaint pages#

• Headache — symptom-based approach to headache differential, including migraine acute management
• Dizziness/Vertigo — vestibular migraine evaluation
• Neck Pain — cervicogenic headache overlap

Problem pages#

• Major Depressive Disorder — common comorbidity; shared preventive options
• Generalized Anxiety Disorder — common comorbidity; shared preventive options
• Chronic Insomnia — sleep disorders worsen migraine