GP · neurological-presentations
Migraine
Also known as Migraine headache · Migraine with aura · Sick headache
GP-fellowship guide to migraine: the ICHD-3 diagnostic framework (attack features, aura timing, five-attack threshold), the SNOOP red flags and TAC differential, the acute ladder from simple analgesia plus antiemetic to triptans (BMJ network meta-analysis rankings, early-intake evidence, NSAID-plus-triptan combination) and gepants, triptan contraindications, prophylaxis indications and the propranolol/topiramate/amitriptyline/CGRP mAb ladder with trial numbers, medication-overuse headache definitions and management, menstrual migraine, and the aura-contraception interaction.
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Red flags
- Thunderclap headache (maximal within a minute), fever with neck stiffness, papilloedema, new neurological deficit or a first headache after age 50 is not migraine until proven otherwise — image, do not re-prescribe analgesics
- Migraine with aura plus combined hormonal contraception multiplies ischemic stroke risk — switch to progestogen-only or non-hormonal methods; document the conversation
- Any patient taking acute headache medicines on 10 or more days a month (15 or more for simple analgesics) has medication-overuse headache until proven otherwise — withdrawal, then prophylaxis
- Triptans are contraindicated in coronary disease, previous stroke/TIA, hemiplegic migraine, basilar-type aura and uncontrolled hypertension — ask before the first script
Overview
Migraine is the leading neurological cause of disability worldwide. In GBD 2023, 2.9 billion people were affected by headache disorders and migraine alone contributed a YLD rate of about 488 per 100,000 — the largest single headache contribution; female rates run more than twice male rates, peaking through the reproductive decades.[2] Most of that burden sits in general practice, where diagnosis is clinical, treatment is stratified, and the biggest avoidable harms are under-treated attacks and medication overuse: medication-overuse headache alone contributes up to 58.9% of the disability attributed to tension-type headache and up to 22.6% of that attributed to migraine in men.[2]
References21ShowHide
- [1]Headache Classification Committee of the International Headache Society (IHS) Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 2018.PMID 29368949
- [2]GBD 2023 Headache Collaborators Global, regional, and national burden of headache disorders, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet Neurol, 2025.PMID 41240916
- [3]Karlsson WK, Ostinelli EG, Zhuang ZA, Kokoti L, Christensen RH, et al. Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis. BMJ, 2024.PMID 39293828
- [4]Law S, Derry S, Moore RA Sumatriptan plus naproxen for the treatment of acute migraine attacks in adults. Cochrane Database Syst Rev, 2016.PMID 27096438
- [5]Goadsby PJ, Reuter U, Hallström Y, Broessner G, Bonner JH, et al. One-year sustained efficacy of erenumab in episodic migraine: Results of the STRIVE study. Neurology, 2020.PMID 32636324
- [6]Ashina M, Mitsikostas DD, Ramirez Campos V, Barash S, Ning X, Diener HC Numbers needed to treat or harm and likelihood of being helped versus harmed for fremanezumab in patients who had prior inadequate response to two to four classes of migraine preventive medications: A post hoc analysis. Headache, 2023.PMID 37955395
- [7]Frank F, Ulmer H, Sidoroff V, Broessner G CGRP-antibodies, topiramate and botulinum toxin type A in episodic and chronic migraine: A systematic review and meta-analysis. Cephalalgia, 2021.PMID 34130525
- [8]Linde K, Rossnagel K Propranolol for migraine prophylaxis. Cochrane Database Syst Rev, 2004.PMID 15106196
- [9]Brandes JL, Saper JR, Diamond M, Couch JR, Lewis DW, et al. Topiramate for migraine prevention: a randomized controlled trial. JAMA, 2004.PMID 14982912
- [10]Srinivasan AV, Bhanu K A Comparative Systematic Review and Meta-analysis of Amitriptyline with Propranolol and Flunarizine for the Prophylaxis of Migraine Headache. J Assoc Physicians India, 2025.PMID 40553594
- [11]Hutchinson S, Dodick DW, Treppendahl C, Bennett NL, Yu SY, et al. Ubrogepant for the Acute Treatment of Migraine: Pooled Efficacy, Safety, and Tolerability From the ACHIEVE I and ACHIEVE II Phase 3 Randomized Trials. Neurol Ther, 2021.PMID 33608814
- [12]Istoc M, Chaudhry BA, Christensen RH, Al-Khazali HM, Ashina M, et al. Rimegepant for the acute treatment of migraine: a systematic review and meta-analysis. J Headache Pain, 2026.PMID 42143245
- [13]Puledda F, Younis S, Huessler EM, Haghdoost F, Lisicki M, et al. Efficacy, safety and indirect comparisons of lasmiditan, rimegepant, and ubrogepant for the acute treatment of migraine: A systematic review and network meta-analysis of the literature. Cephalalgia, 2023.PMID 36786357
- [14]Irimia P, Santos-Lasaosa S, Pozo-Rosich P, Leira R, Pascual J, Láinez JM Eptinezumab for the preventive treatment of episodic and chronic migraine: a narrative review. Front Neurol, 2024.PMID 38523607
- [15]Carlsen LN, Munksgaard SB, Nielsen M, Engelstoft IMS, Westergaard ML, et al. Comparison of 3 Treatment Strategies for Medication Overuse Headache: A Randomized Clinical Trial. JAMA Neurol, 2020.PMID 32453406
- [16]Ornello R, Canonico M, Merki-Feld GS, Kurth T, Lidegaard Ø, et al. Migraine, low-dose combined hormonal contraceptives, and ischemic stroke in young women: a systematic review and suggestions for future research. Expert Rev Neurother, 2020.PMID 32056462
- [17]Kurth T, Gaziano JM, Cook NR, Logroscino G, Diener HC, Buring JE Migraine and risk of cardiovascular disease in women. JAMA, 2006.PMID 16849661
- [18]Chen YS, Lee HF, Tsai CH, Hsu YY, Fang CJ, et al. Effect of Vitamin B2 supplementation on migraine prophylaxis: a systematic review and meta-analysis. Nutr Neurosci, 2022.PMID 33779525
- [19]Okoli GN, Rabbani R, Kashani HH, Wierzbowski AK, Neilson C, et al. Vitamins and Minerals for Migraine Prophylaxis: A Systematic Review and Meta-analysis. Can J Neurol Sci, 2019.PMID 30764890
- [20]Afridi SK Migraine: navigating the hormonal minefield. Pract Neurol, 2020.PMID 31753858
- [21]Steiner TJ, Buse DC, Al Jumah M, Westergaard ML, Jensen RH, et al. The headache under-response to treatment (HURT) questionnaire, an outcome measure to guide follow-up in primary care: development, psychometric evaluation and assessment of utility. J Headache Pain, 2018.PMID 29445880