Migraine headache in adults

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 7 Aug 2025

Last updated: 07 Mar 2025

Migraine is a chronic, episodic, neurologic disorder that has a strong genetic component and usually presents in early-to-mid life. It can have a severe effect on quality of life, but it is often under-diagnosed and under-treated.

Patients report intermittent headache and associated symptoms, such as visual disturbance, nausea, vomiting, and sensitivity to light or noise (photophobia and phonophobia).

Some women experience menstrual migraine, which is most likely to occur in the 2 days leading up to a period and in the first 3 days of a period.

Diagnosis is based on history and physical exam. No laboratory or imaging tests are essential for diagnosis.

Treatment approaches should be individualized, taking into account patient characteristics, preferences, and goals. Management involves identifying and avoiding trigger factors, and the use of medication and nonpharmacologic therapies to treat the acute attack and to prevent future attacks.

Migraine-specific treatments such as triptans, lasmiditan, and calcitonin gene-related peptide (CGRP) antagonists, are preferred over nonspecific treatments. Noninvasive neuromodulation is a newer treatment for acute moderate to severe symptoms.

Preventive therapies with established efficacy include anticonvulsants, beta-blockers, CGRP antagonists, and botulinum toxin.

Definition

Migraine is a chronic, episodic neurologic disorder that has a strong genetic component and usually presents in early-to-mid life. Key features in the history that support a diagnosis of migraine are nausea, photophobia, and reduced ability to function, along with headache. Typical migraine aura (a complex of reversible visual, sensory, or speech symptoms), which precedes or occurs during headache, is pathognomonic of migraine but occurs only in 15% to 30% of patients.[1][2]

History and exam

Key diagnostic factors

prolonged headache
nausea and/or vomiting
decreased ability to function
headache worse with activity
sensitivity to light
sensitivity to noise
unilateral
throbbing sensation
aura

Full details

Risk factors

family history of migraine
female sex
obesity
stressful life events
medication overuse
sleep disorders
low socioeconomic status
allergies or asthma
hypothyroidism

Full details

Diagnostic investigations

1st investigations to order

clinical diagnosis

Full details

Investigations to consider

erythrocyte sedimentation rate (ESR)
c-reactive protein (CRP)
lumbar puncture (LP)
cerebrospinal fluid (CSF) culture
MRI brain
CT head
angiography

Full details

Treatment algorithm

INITIAL

presenting to the emergency department with persistent migraine

ACUTE

mild symptoms: nonpregnant

moderate to severe symptoms: nonpregnant

pregnant

ONGOING

frequent recurring severe/disabling symptoms not linked to menstrual cycle: nonpregnant

frequent recurring severe/disabling symptoms linked to menstrual cycle: nonpregnant

frequent recurring severe/disabling symptoms: pregnant

Contributors

Authors

Timothy A. Collins, MD

Associate Professor of Neurology

Chief

Headache Division

Department of Neurology

Duke University Medical Center

Durham

Disclosures

TAC provides expert testimony for legal cases regarding headache disorders and treatment (approximately one or two cases per year). TAC is an author of several references cited in this topic.

Acknowledgements

Dr Timothy Collins would like to gratefully acknowledge Dr Ann Donnelly, the previous contributor to this topic.

Disclosures

AD declares that she has no competing interests.

Peer reviewers

Anne Walling, MD

Professor

Family and Community Medicine

University of Kansas School of Medicine

Wichita

Disclosures

AW declares that she has no competing interests.

Marc S. Husid, MD

Director

Walton Headache Center

Augusta

Disclosures

MSH declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Ailani J, Burch RC, Robbins MS, et al. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache. 2021 Jul;61(7):1021-39.Full text Abstract

Eigenbrodt AK, Ashina H, Khan S, et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol. 2021 Aug;17(8):501-14.Full text Abstract

Becker WJ, Findlay T, Moga C, et al. Guideline for primary care management of headache in adults. Can Fam Physician. 2015 Aug;61(8):670-9.Full text Abstract

Worthington I, Pringsheim T, Gawel MJ, et al. Canadian Headache Society Guideline: acute drug therapy for migraine headache. Can J Neurol Sci. 2013 Sep;40(5 suppl 3):S1-80.Full text Abstract

VanderPluym JH, Halker Singh RB, Urtecho M, et al. Acute treatments for episodic migraine in adults: a systematic review and meta-analysis. JAMA. 2021 Jun 15;325(23):2357-69.Full text Abstract

Orr SL, Friedman BW, Christie SC, et al. Management of adults with acute migraine in the emergency department: the American Headache Society evidence assessment of parenteral pharmacotherapies. Headache. 2016 Jun;56(6):911-40.Full text Abstract

Silberstein SD, Holland S, Freitag F, et al; Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1337-45.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Tension-type headache (TTH)
- Cluster headache
- Medication overuse headache
More Differentials
Guidelines
- Prevention of episodic migraine headache using pharmacologic treatments in outpatient settings: a clinical guideline from the American College of Physicians
- The international classification of headache disorders, 3rd edition
More Guidelines
Patient information
Migraine
Migraines: questions to ask your doctor
More Patient information
Videos
Diagnostic lumbar puncture in adults: animated demonstration
Peripheral intravascular catheter: animated demonstration
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Migraine headache in adults

Summary

Definition

History and exam

Key diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

presenting to the emergency department with persistent migraine

mild symptoms: nonpregnant

moderate to severe symptoms: nonpregnant

pregnant

frequent recurring severe/disabling symptoms not linked to menstrual cycle: nonpregnant

frequent recurring severe/disabling symptoms linked to menstrual cycle: nonpregnant

frequent recurring severe/disabling symptoms: pregnant

Contributors

Authors

Timothy A. Collins, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Anne Walling, MD

Disclosures

Marc S. Husid, MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice