Migraine is a common primary headache disorder with repeated attacks of moderate to severe throbbing pain, often with nausea and sensitivity to light. Some patients have an aura, usually visual, that comes before or with the headache.
Key symptoms
- One-sided, throbbing headache lasting 4 to 72 hours
- Pain worse with routine activity
- Nausea or vomiting
- Sensitivity to light and sound
- Aura: zigzag lines, blind spots or tingling that spread over minutes
What you find on exam
- Vital signs, including blood pressure and temperature
- Full neurological exam, normal between attacks
- Fundoscopy to look for papilledema
- Neck stiffness and temporal artery tenderness to look for other causes
Tests
- Diagnosis is clinical; no test needed with typical features and a normal exam
- CT or MRI only with red flags or an atypical pattern
- Headache diary to find triggers and track frequency
Treatment basics
- Mild attacks: an NSAID such as ibuprofen or naproxen, or acetaminophen
- Moderate to severe: a triptan such as sumatriptan, early in the attack
- Nausea: an antiemetic such as metoclopramide or prochlorperazine
- Limit acute medicines to avoid medication overuse headache
- Frequent attacks: prevention with propranolol, topiramate, amitriptyline or a CGRP medicine
Red flags
- Sudden, worst headache of life that peaks within a minute
- Fever, stiff neck, new neuro deficit or confusion
- New headache after age 50, in pregnancy or with cancer
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.