Migraine Headache

A patient with established, typical migraine, a normal neurologic examination, and no red-flag or atypical features generally does not need brain imaging. The American College of Radiology and American Headache Society recommend against routine neuroimaging in this setting; estimated tumor yield in a patient without malignancy history and uncomplicated headache is less than 0.1%. ccjmccjmWhen is brain MRI with and without contrast indicated for evaluation of headache? | Cleveland Clinic Journal of medicine

Escalate beyond a primary-migraine pathway for abrupt or progressive change in headache pattern, abnormal neurologic findings, systemic illness, immunocompromise, cancer history, pregnancy-related concern, trauma, positional headache, papilledema, or features suggesting vascular disease, infection, inflammation, mass lesion, or abnormal intracranial pressure. Medication overuse is itself a common secondary headache cause and should be assessed at every acute-care and preventive-treatment visit. ccjmccjmWhen is brain MRI with and without contrast indicated for evaluation of headache? | Cleveland Clinic Journal of medicine

For suspected idiopathic intracranial hypertension, obtain neuroimaging before lumbar puncture to exclude a space-occupying lesion and evaluate secondary causes; a cerebrospinal fluid opening pressure of at least 25 cm H2O is a diagnostic criterion. ccjmccjmWhen is brain MRI with and without contrast indicated for evaluation of headache? | Cleveland Clinic Journal of medicine

Migraine is diagnosed primarily from history. In adults, attacks typically last 4 to 72 hours and are accompanied by nausea, vomiting, photophobia, and/or phonophobia; aura may produce reversible visual, sensory, or speech symptoms. WHO+1WHOMigraine and other headache disordersnice org ukHeadaches in over 12s: diagnosis and management In children and adolescents, attacks may last 2 to 72 hours, are often bilateral, and may have prominent gastrointestinal symptoms. NatureNatureDiagnosis and management of migraine in ten steps

Document whether aura is typical versus atypical. Typical aura may be visual positive or negative phenomena, sensory positive or negative symptoms, or speech disturbance; atypical symptoms should shift management toward investigation rather than routine migraine escalation. nice org uknice org ukHeadaches in over 12s: diagnosis and management

Identify menstrual association with a diary spanning at least two cycles. Suspect menstrual-related migraine when attacks occur predominantly from 2 days before through 3 days after menstruation begins in at least 2 of 3 consecutive cycles. nice org uknice org ukHeadaches in over 12s: diagnosis and management This pattern permits consideration of short-term perimenstrual prevention with frovatriptan, naratriptan, or zolmitriptan started several days before the anticipated menstrual onset and continued for 5 to 6 days. PubMedPubMedMigraine Prophylaxis - StatPearls - NCBI Bookshelf - NIH

For mild migraine attacks, use an analgesic or NSAID early in the attack; for moderate or severe attacks, use a triptan when there is no contraindication. NatureNatureMigraine | Nature Reviews Disease Primers Acute migraine therapies should be selected with cardiovascular safety, prior efficacy, and tolerability in mind; vascular safety concerns are a key limitation of triptans and other vasoconstrictive therapies. NatureNatureMigraine | Nature Reviews Disease Primers

Avoid opioids as first-line treatment for acute migraine. Guidelines recommend against opioid-first approaches for migraine and other primary headaches, and the 2025 American Headache Society emergency evidence assessment states that IV hydromorphone must not be offered to eligible adults presenting with migraine requiring parenteral therapy. Nature+1NatureCharacteristics of Patients Referred To A Specialized Headache Clinic | Scientific ReportsPubMed2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies - PubMed

For pregnancy, offer paracetamol for acute migraine. A triptan or NSAID may be considered only after discussing the treatment need and risks. nice org uknice org ukHeadaches in over 12s: diagnosis and management For children and adolescents, bed rest may suffice for some attacks; otherwise, ibuprofen is recommended for acute treatment. NatureNatureDiagnosis and management of migraine in ten steps

For adults in the emergency department with migraine requiring parenteral therapy, IV prochlorperazine and greater occipital nerve block should be offered when no contraindication is present. Ketorolac IV, metoclopramide IV, subcutaneous sumatriptan, and supraorbital nerve block should be offered when appropriate. PubMedPubMed2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies - PubMed

Chlorpromazine IV, dexamethasone IV, and valproate IV may be offered, reflecting lower-certainty support than the therapies that should or must be offered. IV paracetamol should not be offered for this indication. PubMedPubMed2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies - PubMed Treatment failure should prompt reassessment for diagnostic error, medication overuse, and a secondary headache process rather than opioid rescue. PubMed+1PubMed2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies - PubMedccjmWhen is brain MRI with and without contrast indicated for evaluation of headache? | Cleveland Clinic Journal of medicine

Initiate preventive treatment when a patient has 4 or more migraine days per month, or 2 or more migraine days per month with disabling attacks despite acute treatment. acpjournalsacpjournals2023 U.S. Department of Veterans Affairs and ... Before selecting an agent, quantify monthly migraine days, acute-medication days, disability, prior preventive trials, pregnancy potential, blood pressure and cardiovascular history, psychiatric comorbidity, epilepsy, and treatment preference.

Medication options for episodic migraine prevention include angiotensin-receptor blockers, lisinopril, magnesium, topiramate, valproate, and memantine. acpjournalsacpjournalsclinical guideline In children and adolescents, propranolol, amitriptyline, or topiramate are prevention options. NatureNatureDiagnosis and management of migraine in ten steps Use the headache diary to assess baseline burden and response rather than judging efficacy from recollection alone. PubMedPubMedMigraine Prophylaxis - StatPearls - NCBI Bookshelf - NIH

CGRP-targeting options include oral atogepant, IV eptinezumab, and subcutaneous fremanezumab, erenumab, and galcanezumab. PubMedPubMedHeadaches in over 12s: diagnosis and management - NCBI Bookshelf For episodic migraine, rimegepant is an oral CGRP inhibitor option for adults with 4 to fewer than 15 migraine attacks per month in the cited guidance after at least 3 preventive medicines have failed, are not tolerated, or are unsuitable; this access framework is not a U.S. coverage standard. PubMedPubMedHeadaches in over 12s: diagnosis and management - NCBI Bookshelf

For menstrual-predominant attacks, a short-term triptan strategy can supplement or replace continuous prevention when the diary demonstrates predictable timing: start frovatriptan, naratriptan, or zolmitriptan several days before expected menses and continue for 5 to 6 days. PubMedPubMedMigraine Prophylaxis - StatPearls - NCBI Bookshelf - NIH

Diagnose suspected medication-overuse headache from the pattern of worsening or newly developed headache during frequent acute-medication use for 3 months or more. The exposure threshold is 10 or more days per month for triptans, opioids, ergots, and combination analgesics, and 15 or more days per month for acetaminophen, aspirin, or NSAIDs. ema europa eu+2ema europa euAssessment report - Vyepti - European Medicines Agencynice org ukHeadaches in over 12s: diagnosis and managementcks nice org ukScenario: Adults | Management | Migraine - CKS - NICE

The practical response is to reconcile all prescribed and over-the-counter acute agents, identify the specific overused class, reduce or eliminate the overused medication, and establish preventive treatment when attack burden meets criteria. acpjournals+2acpjournals2023 U.S. Department of Veterans Affairs and ...ema europa euAssessment report - Vyepti - European Medicines Agencynice org ukHeadaches in over 12s: diagnosis and management Continue diary tracking because a falling acute-medication-day count is as clinically important as a reduction in headache days.

At follow-up, re-evaluate any apparent treatment failure for a changed phenotype, atypical aura, new red flags, and medication overuse before simply adding rescue drugs. This is especially important in late-onset presentations and in older adults, in whom secondary headache and medication adverse effects are more consequential. Nature+1NatureDiagnosis and management of migraine in ten stepsccjmWhen is brain MRI with and without contrast indicated for evaluation of headache? | Cleveland Clinic Journal of medicine