Migraine Clinical Features and Acute Treatment
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Direct answer
Migraine is a recurrent primary headache disorder with unilateral, pulsating pain, nausea, and photophobia or phonophobia, often preceded by a reversible aura. Acute treatment begins with an NSAID or paracetamol, plus an antiemetic, and triptans are added for moderate to severe attacks. Triptans are contraindicated in ischaemic heart disease, uncontrolled hypertension and hemiplegic or basilar migraine. Gepants such as rimegepant and ubrogepant are CGRP antagonists used when triptans are unsuitable.
What you must remember
- Aura: fully reversible visual, sensory or speech symptoms that spread gradually over at least five minutes, each lasting 5 to 60 minutes, with headache usually following within an hour.
- Attack phases: prodrome lasting hours to days, aura, headache lasting 4 to 72 hours if untreated, and postdrome with tiredness and poor concentration.
- Aura and hormones: combined oral contraceptives raise ischaemic stroke risk in women with aura, so progestogen-only or non-hormonal methods are preferred.
- First-line acute drugs: NSAIDs such as ibuprofen or paracetamol for mild attacks, with metoclopramide or domperidone to treat nausea and improve absorption.
- Triptans: 5-HT1B/1D agonists such as sumatriptan and rizatriptan, which work best when taken early in the headache phase.
- Triptan contraindications: ischaemic heart disease, prior stroke or TIA, uncontrolled hypertension, peripheral vascular disease, hemiplegic or basilar migraine, and recent ergot or MAO inhibitor use.
- Gepants and lasmiditan: rimegepant and ubrogepant are CGRP antagonists, while lasmiditan is a 5-HT1F agonist without vasoconstriction that causes sedation and advice against driving afterwards.
A stepwise plan for an acute attack
A 28-year-old woman with throbbing right-sided headache, nausea and photophobia for six hours presents to the emergency department. The steps below sequence the decisions that the exam expects you to make in order.
- Exclude red flags: a thunderclap onset, focal deficit, papilloedema, fever with neck stiffness or a first severe headache after the age of 50 must prompt imaging before migraine is accepted.
- Start simple analgesia: give an oral NSAID or paracetamol early, and add metoclopramide or domperidone for nausea.
- Check triptan eligibility: ask about ischaemic heart disease, uncontrolled hypertension, prior stroke and aura type, since a hemiplegic or brainstem aura excludes triptans.
- Give a triptan if eligible: sumatriptan or rizatriptan, ideally early in the headache, and reassess the response after about two hours.
- Switch to a gepant or lasmiditan: if triptans are contraindicated or fail, rimegepant or ubrogepant, or lasmiditan, provides the alternative.
- Review frequency: frequent attacks, commonly four or more a month, or attacks causing significant disability call for prophylaxis.
- Choose prophylaxis: propranolol, topiramate, amitriptyline or a CGRP-targeted agent, with sodium valproate avoided in women of childbearing potential.
Where migraine questions mislead
Most errors in migraine questions come from confusing the aura type with drug eligibility.
- Trap: picking sumatriptan for a patient with hemiplegic migraine Correct: hemiplegic and brainstem migraine are contraindications to triptans, so the aura type decides the answer.
- Trap: prescribing a combined oral contraceptive to a woman with aura Correct: oestrogen raises ischaemic stroke risk in migraine with aura, so progestogen-only options are preferred.
- Trap: labelling a sudden thunderclap headache as migraine Correct: thunderclap onset is a red flag for subarachnoid haemorrhage and needs urgent imaging.
- Trap: using valproate freely in women of reproductive age Correct: valproate is teratogenic, so it is avoided unless no alternative exists.
Frequently asked questions
Which aura features make a migraine diagnosis typical?
Typical migraine aura consists of fully reversible visual phenomena such as zigzag lines or scotomas, or unilateral paraesthesia and dysphasia. Each symptom develops gradually and lasts about five to sixty minutes, with headache following within an hour.
Which drugs are contraindicated in hemiplegic migraine?
Triptans and ergot derivatives are contraindicated in hemiplegic migraine because the aura includes motor weakness and vasoconstrictors are considered unsafe. Acute treatment relies on NSAIDs, paracetamol and antiemetics, with specialist input for prophylaxis.
Why are combined oral contraceptives avoided in migraine with aura?
Combined oral contraceptives containing oestrogen increase the risk of ischaemic stroke in women with migraine with aura. Progestogen-only methods or non-hormonal options are therefore preferred for contraception in these patients.
Which migraine prophylactic drug is avoided in women of childbearing potential?
Sodium valproate is avoided in women of childbearing potential because it is teratogenic and carries a risk of neural tube defects and reduced cognitive outcomes in the offspring. Propranolol or amitriptyline are commonly preferred, with contraception counselling for any drug with teratogenic risk.
What is status migrainosus and how is it managed?
Status migrainosus is a migraine attack lasting longer than 72 hours. It usually needs admission for intravenous fluids, antiemetics and an intravenous antidopaminergic, with prophylaxis considered once the attack resolves.