Contents discussed in this post
What migraine is
Symptoms and types: with aura and without aura
Why migraine happens
Common triggers and how to monitor them
Diagnosis and when to order tests
Acute treatment: what works
Prevention: medications, habits, and supplements with evidence
Special situations: pregnancy, lactation, and contraceptives
Medication overuse headache
When to seek urgent care
Quick FAQ
Important notice (health disclaimer)
References and recommended reading
What migraine is
Migraine is a neurological disorder with recurrent headache, usually pulsating, moderate to severe, worse with routine physical activity, and often accompanied by nausea, vomiting, light and sound sensitivity, and in some people, aura. Without treatment, attacks typically last 4 to 72 hours. It is not “just stress.” There is a well-described biological basis with genetic predisposition.
Symptoms and types: with aura and without aura
Without aura: often unilateral, throbbing pain that worsens with activity, sensitivity to light and noise, nausea or vomiting.
With aura: transient neurological symptoms before or during pain. Most are visual (flashing lights, zigzag lines, scotomas). Tingling or brief speech difficulty can occur. Aura usually develops over 5 to 60 minutes and fully resolves.
Chronic migraine: headache on 15 or more days per month for over 3 months, with migraine features on at least 8 of those days.
Why migraine happens
Migraine involves nervous system hypersensitivity and a neurogenic inflammatory cascade. CGRP is a central mediator. In predisposed people, changes in sleep, hormones, diet, and stress modulate brain excitability. It is not caused by clogged arteries. Understanding this biology led to targeted CGRP-based therapies.
Common triggers and how to monitor them
Triggers vary. Frequent ones include irregular sleep, fasting or highly processed foods, dehydration, alcohol, too much or abrupt withdrawal of caffeine, hormonal fluctuations around menses, stress and the “let-down” after stress, strong odors, bright lights, and weather shifts.
A simple headache diary helps: record date, duration, intensity, meds, sleep, menstrual cycle, and potential triggers. After 4 to 8 weeks, patterns often emerge.
Diagnosis and when to order tests
Diagnosis is clinical with a normal neurological exam between attacks. Imaging is not routine and is reserved for red flags or major pattern changes.
Red flags that warrant evaluation and possible imaging (SNOOP):
Systemic symptoms or Signs like fever or weight loss
Neurologic deficits that persist, confusion, seizures
Onset sudden, thunderclap headache
Older age at onset, after 50
Pattern change, progressive course, “worst headache ever”
Other concerns: exertional or Valsalva-triggered pain, post-trauma headache, anticoagulant use, immunosuppression, pregnancy or postpartum.
Acute treatment: what works
Goals: rapid relief, reduce nausea, and return to function.
Initial measures: quiet, dark room, hydration, brief sleep if possible. Consider an antiemetic early if nausea is present.
Medications for attacks:
Analgesics and NSAIDs: acetaminophen (paracetamol), ibuprofen, naproxen, ketoprofen, diclofenac. Use a full dose early in the attack. Metamizole/dipyrone may be used where available.
Triptans: sumatriptan, rizatriptan, eletriptan, zolmitriptan. Migraine-specific and most effective when taken early. Avoid in coronary disease, prior stroke, and vasculopathies.
Gepants for acute use: ubrogepant, rimegepant, zavegepant nasal in some countries, for those who cannot take or do not respond to triptans.
Ditans: lasmiditan acts at 5-HT1F without vasoconstriction; may cause sedation.
In emergency settings, parenteral NSAIDs and antiemetics are common. Routine opioid use is not recommended.
Have a Plan A and Plan B agreed with your clinician for tougher days.
Prevention: medications, habits, and evidence-based supplements
Consider prevention if you have 4 or more migraine days per month, prolonged attacks, or major life impact.
Classic preventives:
Beta-blockers: propranolol, metoprolol
Anticonvulsants: topiramate and valproate (valproate has restrictions for women of childbearing potential)
Tricyclics: low-dose amitriptyline, useful with insomnia or comorbid pain
Flunarizine and candesartan are options with supporting evidence where available
Modern options:
Anti-CGRP monoclonal antibodies or receptor blockers: erenumab, fremanezumab, galcanezumab, eptinezumab. Monthly or quarterly dosing with generally favorable tolerability.
Preventive gepants: atogepant, and rimegepant on specific intermittent schedules depending on local approvals.
OnabotulinumtoxinA: for chronic migraine using standardized PREEMPT protocols.
Helpful habits: regular sleep, meals, and hydration; aerobic plus strength training 2 to 4 times weekly; reduce excessive caffeine and avoid long fasts; stress-management strategies and CBT for chronic pain.
Supplements with some evidence: magnesium (citrate or glycerophosphate 300–400 mg per day), riboflavin 400 mg per day, coenzyme Q10 100–300 mg per day, and melatonin when insomnia is present. Discuss dosing and interactions with your clinician.
Menstrual migraine: options include short courses of NSAIDs or triptans around menses and contraceptive adjustments with gynecology when appropriate.
Special situations: pregnancy, lactation, and contraceptives
Pregnancy: prefer non-pharmacologic measures first. Acetaminophen is first line. NSAIDs have trimester-specific restrictions. Triptans can be considered in selected cases with specialist guidance.
Lactation: several options are compatible, including ibuprofen and some triptans.
Migraine with aura and combined hormonal contraceptives: increased ischemic stroke risk. Non-estrogen methods or very low-dose regimens are generally preferred after individualized risk assessment.
Medication overuse headache
Frequent use of acute meds can perpetuate headache. Warning signs: simple analgesics on 15 or more days per month, or triptans on 10 or more days per month, for over 3 months. Management involves tapering overuse, starting a preventive, and using rescue meds more selectively.
When to seek urgent care
Sudden, maximal headache unlike any before
Headache with high fever, neck stiffness, confusion, seizure, or fainting
Focal deficits that do not resolve within 60 minutes
Progressive worsening of your usual pattern, especially after age 50
Headache after trauma or while on anticoagulants
Quick FAQ
Is migraine lifelong?
It tends to fluctuate. With treatment and habits, many people reduce frequency and intensity substantially.
Is coffee good or bad?
It depends on dose and the individual. Excess can worsen headaches and abrupt withdrawal can trigger them. Moderation and consistency help.
Are most “sinus headaches” actually sinusitis?
No. Many are migraine with nasal symptoms. True sinusitis usually has fever, purulent discharge, and facial tenderness.
I have aura. Can I drive?
Avoid driving during aura and at the start of an attack. Wait until vision and attention are normal.
Does topiramate cause weight gain or loss?
It is more often associated with mild weight loss, but can cause tingling and attention issues in some people.
Important notice (health disclaimer)
This content is educational and does not replace medical care. Migraine plans should consider history, comorbidities, current medications, pregnancy, and personal preferences. Seek immediate care if red flags are present.
References and recommended reading
American Headache Society (AHS). Evidence-based guidelines for acute and preventive treatment of migraine.
European Academy of Neurology (EAN) / EFNS. European guidelines on the management of episodic and chronic migraine.
NICE. Migraine: diagnosis and management.
Cochrane Reviews. Triptans, NSAIDs, topiramate, and onabotulinumtoxinA efficacy.
The Lancet Neurology / JAMA / NEJM. Trials and reviews on anti-CGRP therapies, gepants, and ditans.
National neurology and headache societies. Preventive protocols and life-stage recommendations.
