Migraine headache in adults

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

Last reviewed: 18 Aug 2025

Last updated: 07 Mar 2025

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 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 examination. No laboratory or imaging tests are essential for diagnosis.

Treatment approaches should be individualised, taking into account patient characteristics, preferences, and goals. Management involves identifying and avoiding trigger factors, and the use of medication and non-pharmacological 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 non-specific treatments. Non-invasive 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 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.[1][2]

History and exam

Key diagnostic factors

presence of risk 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 socio-economic 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: non-pregnant

moderate to severe symptoms: non-pregnant

pregnant

ONGOING

frequent recurring severe/disabling symptoms not linked to menstrual cycle: non-pregnant

frequent recurring severe/disabling symptoms linked to menstrual cycle: non-pregnant

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

利益声明

AW declares that she has no competing interests.

Marc S. Husid, MD

Director

Walton Headache Center

Augusta

利益声明

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.

参考文献

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.

关键文献

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.全文摘要

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.全文摘要

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.全文摘要

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-S80.全文摘要

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.全文摘要

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.全文摘要

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. Neurology. 2012 Apr 24;78(17):1337-45.全文摘要

参考文献

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

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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: non-pregnant

moderate to severe symptoms: non-pregnant

pregnant

frequent recurring severe/disabling symptoms not linked to menstrual cycle: non-pregnant

frequent recurring severe/disabling symptoms linked to menstrual cycle: non-pregnant

frequent recurring severe/disabling symptoms: pregnant

Contributors

Authors

Timothy A. Collins, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Anne Walling, MD

利益声明

Marc S. Husid, MD

利益声明

Peer reviewer acknowledgements

Disclosures

参考文献

关键文献

参考文献

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

鉴别诊断

指南

患者教育信息

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