Recurrent primary headache disorder with unilateral throbbing pain, photophobia, nausea.
Also known as: migraine, migraine with aura, migraine without aura, common migraine, classic migraine
Overview
Primary headache disorder characterized by recurrent attacks of moderate-to-severe headache (usually unilateral and pulsating) lasting 4-72 hours, accompanied by nausea, vomiting, photophobia, and/or phonophobia. May be preceded by aura (visual, sensory, language, or motor symptoms) in ~25% of patients.
Epidemiology
Affects ~12% of adults (18% women, 6% men). Peak prevalence age 25-55. Third most common disease worldwide; second leading cause of disability under age 50.
Try two board-style Migraine questions
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Question 1NeurologyEasy
A 25-year-old woman has a unilateral throbbing headache with nausea and photophobia, preceded by 20 minutes of visual zigzag lines. She has had several similar episodes, and her neurologic examination between attacks is normal. Which of the following is the most appropriate acute abortive therapy?
ATopiramate
BVerapamil
CPropranolol
DSumatriptan
Reveal answer & full explanation
Correct answer: D — Sumatriptan
ATopiramate
BVerapamil
CPropranolol
DSumatriptan✓
Why Sumatriptan is correct
The unilateral throbbing headache with nausea and photophobia preceded by a visual aura is migraine with aura; acute abortive therapy is a triptan (5-HT1B/1D agonist), often combined with an NSAID.
Triptans abort the attack by causing cranial vasoconstriction and inhibiting trigeminal nociceptive transmission.
They are avoided in hemiplegic migraine, migraine with brainstem aura (formerly basilar migraine), and in coronary artery disease or uncontrolled hypertension.
Why the others are wrong
Topiramate — used for migraine prophylaxis when attacks are frequent, not to abort an acute attack (right-diagnosis-wrong-step).
Verapamil — first-line prophylaxis for cluster headache, not an abortive migraine therapy (buzzword-matching headache to the wrong syndrome).
Propranolol — a migraine prophylactic agent, not an abortive therapy (right-diagnosis-wrong-step).
Question 2NeurologyEasy
A 32-year-old woman presents to the office during an acute, severe migraine headache with throbbing unilateral pain, photophobia, and nausea. Her past medical history is unremarkable, she has no cardiovascular disease, and she is not pregnant. Which of the following is the most appropriate agent to abort the current attack?
ATopiramate
BSumatriptan
CAmitriptyline
DPropranolol
Reveal answer & full explanation
Correct answer: B — Sumatriptan
ATopiramate
BSumatriptan✓
CAmitriptyline
DPropranolol
Why Sumatriptan is correct
Sumatriptan is a 5-HT1B/1D receptor agonist used to abort an acute migraine attack
It is the most appropriate agent to treat the active headache described, in a patient with no cardiovascular contraindication
Abortive therapy targets the ongoing attack, distinct from preventive therapy taken daily to reduce attack frequency
Why the others are wrong
Topiramate — an antiepileptic used for migraine PREVENTION, not to abort an acute attack (right-disease-wrong-indication)
Amitriptyline — a tricyclic used for migraine PREVENTION, especially with comorbid tension headache or insomnia; it does not abort an attack (right-disease-wrong-indication)
Propranolol — a beta-blocker used for migraine PREVENTION with strong evidence, but it has no role in aborting an active migraine (right-disease-wrong-indication)
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Trigeminovascular activation with release of CGRP (calcitonin gene-related peptide), substance P, and neurokinin A causes neurogenic inflammation and meningeal vasodilation. Cortical spreading depression — a wave of depolarization followed by suppression across the cortex — is thought to underlie aura. Central sensitization in the trigeminal nucleus caudalis produces allodynia and prolonged pain.
Aura (~25%): visual (scintillating scotoma, fortification spectra, hemianopia), sensory (paresthesias marching up arm to face), language (aphasia) — typically lasts 5-60 min and precedes headache
Headache: unilateral (60%) or bilateral, pulsating/throbbing, moderate-severe, lasting 4-72 hours
ICHD-3 criteria: ≥5 attacks lasting 4-72 hours, with ≥2 of [unilateral, pulsating, moderate-severe, aggravated by activity] AND ≥1 of [nausea/vomiting, photophobia + phonophobia].
Labs
Generally not indicated for typical migraine
ESR/CRP if temporal arteritis suspected (age >50)
CBC, BMP if atypical features
Imaging
Neuroimaging NOT routinely indicated for typical migraine with normal exam
MRI brain indicated for: red flags (SNOOP: Systemic symptoms/Secondary risk factors, Neurologic signs, Onset sudden/thunderclap, Older age >50 with new headache, Pattern change/Progressive/Positional/Precipitated by Valsalva)
Lumbar puncture if SAH or meningitis suspected after negative CT
Triptan — sumatriptan 50-100 mg PO (also 6 mg SC, 20 mg nasal), rizatriptan 10 mg, eletriptan 40 mg — best taken at headache onset; contraindicated with CAD, uncontrolled HTN, prior stroke, hemiplegic/basilar migraine, ergot use within 24 h
Combination (sumatriptan-naproxen) more effective than either alone
Antiemetic — metoclopramide 10 mg, prochlorperazine 10 mg, ondansetron 4-8 mg — adjunct, also has independent abortive effect
Gepant (CGRP receptor antagonist) — ubrogepant 50-100 mg, rimegepant 75 mg — no vasoconstriction, safe in CAD
Status migrainosus (continuous migraine >72 h) — may require IV therapy and brief steroid taper
Medication overuse headache (rebound)
Migrainous infarction (rare — aura symptoms persist >60 min with imaging evidence of stroke)
Increased risk of ischemic stroke in migraine with aura (especially with smoking, OCPs)
Chronic migraine (≥15 days/month for >3 months)
Depression, anxiety, reduced QOL and work productivity
PANCE pearls
Triptans are most effective when taken at the very start of the headache, before central sensitization develops.
Migraine with aura + combined hormonal contraceptive significantly increases ischemic stroke risk — use progestin-only or non-hormonal methods.
Hemiplegic migraine and basilar-type migraine are contraindications to triptans (theoretical risk of vasoconstriction in already-affected vessels).
First or worst-of-life headache, focal deficits outlasting aura duration, or any 'thunderclap' onset = imaging mandatory.
Medication overuse headache: taper offending agent; can transition acute therapy to gepants (no rebound risk).
References
AAN/AHS 2021 — Acute Treatment of Migraine in Adults: AHS Consensus Statement (Ailani et al., Headache 2021)
AHS 2024 — Pharmacologic Treatment for Migraine Prevention in Adults: AHS Position Statement (Charles et al., Headache 2024)
ICHD-3 — International Classification of Headache Disorders, 3rd edition (Headache Classification Committee of the International Headache Society, Cephalalgia 2018)
AAN Imaging — Choosing Wisely: Don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine (American Academy of Neurology)
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