Migraine headache in adults

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

Evidence last reviewed: 11 Mar 2026

Topic last updated: 18 Mar 2026

Migraine is a chronic, episodic, neurologic disorder that 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 drugs and nonpharmacologic therapies to treat the acute attack and to prevent future attacks.

Mild symptoms are often managed with nonsteroidal anti-inflammatory drugs (NSAIDs) and other analgesics. Migraine-specific treatments such as triptans and calcitonin gene-related peptide (CGRP) antagonists, are preferred over nonspecific treatments for moderate to severe symptoms. Noninvasive neuromodulation is a newer treatment which may be considered as an option 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 tests

1st tests to order

clinical diagnosis

Full details

Tests 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

Declarações

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.

Agradecimentos

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

Declarações

AD declares that she has no competing interests.

Revisores

Anne Walling, MD

Professor

Family and Community Medicine

University of Kansas School of Medicine

Wichita

Declarações

AW declares that she has no competing interests.

Marc S. Husid, MD

Director

Walton Headache Center

Augusta

Declarações

MSH declares that he has no competing interests.

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Referências

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Principais artigos

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.Texto completo Resumo

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.Texto completo Resumo

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.Texto completo Resumo

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. Resumo

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.Texto completo Resumo

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.Texto completo Resumo

American Academy of Neurology. Update: pharmacologic treatment for episodic migraine prevention in adults. Apr 2012 [internet publication].Texto completo

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais
- Tension-type headache (TTH)
- Cluster headache
- Medication overuse headache
Mais Diagnósticos diferenciais
Guidelines
- International Headache Society evidence-based guidelines on the use of non-invasive neuromodulation devices for the acute and preventive treatment of migraine
- The international classification of headache disorders, 3rd edition
Mais Guidelines
Patient information
Migraine
Migraines: questions to ask your doctor
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Migraine headache in adults

Summary

Definition

History and exam

Key diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests 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

Declarações

Agradecimentos

Declarações

Revisores

Anne Walling, MD

Declarações

Marc S. Husid, MD

Declarações

Créditos aos pareceristas

Declarações

Referências

Principais artigos

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais

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