Migraine is a chronic, episodic, neurological 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 complain of 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 examination. No laboratory or imaging tests are essential for diagnosis.
Treatment approaches involve identifying and avoiding trigger factors, and the use of medication to treat the acute attack and to prevent future attacks. Triptans are preferred over non-specific treatments.
Migraine is a chronic, episodic neurological 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. 
History and exam
Key diagnostic factors
- presence of risk factors
- prolonged headache
- decreased ability to function
- headache worse with activity
- sensitivity to light
- sensitivity to noise
Other diagnostic factors
- throbbing sensation
- family history of migraine
- female sex
- stressful life events
- medication overuse
- sleep disorders
- low socio-economic status
- allergies or asthma
1st investigations to order
- clinical diagnosis
Investigations to consider
- erythrocyte sedimentation rate (ESR)
- lumbar puncture (LP)
- cerebrospinal fluid (CSF) culture
- MRI brain
- CT head
patient presenting to the emergency department with persistent migraine
mild to moderate symptoms: non-pregnant
severe symptoms: non-pregnant
frequent recurring severe/disabling symptoms: non-pregnant
frequent recurring severe/disabling symptoms: pregnant
Timothy A. Collins, MD
Associate Professor of Neurology
Department of Neurology
Duke University Medical Center
TAC served as a paid consultant for Alphasights (a global healthcare consulting organization) in 2017 and 2018 regarding migraine headache diagnosis and treatment. He provides expert testimony for legal cases regarding headache disorders and treatment (approximately one case per year). TAC is an author of several references cited in this topic.
Dr Timothy Collins would like to gratefully acknowledge Dr Ann Donnelly, the previous contributor to this topic.
AD declares that she has no competing interests.
Anne Walling, MD
Family and Community Medicine
University of Kansas School of Medicine
AW declares that she has no competing interests.
Marc S. Husid, MD
Walton Headache Center
MSH declares that he has no competing interests.
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