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Migraine

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Migraine

Overview Migraine is a common primary headache disorder affecting roughly 10-20% of the population. It is a heterogeneous condition with a strong genetic component - about 90% of migraine sufferers have a positive family history - and women are affected roughly three times as often as men. Onset can occur in childhood; 4-10% of school-age children have migraines (Textbook of Family Medicine, 9e; Goodman & Gilman's Pharmacological Basis of Therapeutics).

Classification

  • Migraine without aura (common migraine) - the most frequent type.
  • Migraine with aura (classic migraine) - includes subtypes with typical aura, prolonged aura, aura without headache, and acute-onset aura.
  • Other variants: basilar-type migraine (brainstem symptoms - dysarthria, vertigo, tinnitus, diplopia, bilateral paresthesias), retinal migraine (reversible monocular visual disturbance), status migrainosus (attack lasting >72 hours), and migrainous infarction (imaging-confirmed cerebral infarct associated with a migraine attack).

Diagnostic criteria (migraine without aura, per International Headache Society)

At least 5 attacks meeting:
  1. Headache lasting 4-72 hours
  2. At least 2 of: unilateral location, pulsating quality, moderate-severe intensity, aggravation by routine physical activity
  3. At least 1 of: nausea/vomiting, or photophobia and phonophobia during the attack
Aura symptoms (when present) may be visual (zigzag lines, scotomas), sensory (marching numbness/tingling, often starting in an arm or perioral region), motor, or speech-related (mild dysphasia), and a premonitory phase with photophobia, hyperacusis, polyuria, diarrhea, and mood/appetite changes can begin up to 24 hours before pain onset (Goodman & Gilman's Pharmacological Basis of Therapeutics).

Pathophysiology

Migraine involves both neural and vascular mechanisms, with serotonin (5-HT) as a key mediator - plasma/platelet 5-HT levels fluctuate across attack phases, urinary 5-HT metabolites rise during attacks, and 5-HT-releasing agents (e.g., reserpine, fenfluramine) can precipitate attacks. This underlies why 5-HT1B/1D receptor agonists (triptans) are the mainstay of acute treatment - they are thought to cause constriction of intracranial vessels and inhibit trigeminal nociceptive transmission - - Goodman & Gilman's Pharmacological Basis of Therapeutics, p. 3036-3055.

Common triggers

Alcohol, oral contraceptives/hormone replacement, caffeine or caffeine withdrawal, stress, weather changes, strong scents, certain foods (nitrates, aged cheese, chocolate, dairy), and fasting/skipped meals - - Textbook of Family Medicine 9e.

Treatment

Acute (abortive) therapy - choice depends on attack severity:
  • Mild-moderate: analgesics/combination agents (e.g., acetaminophen-isometheptene-dichloralphenazone), NSAIDs
  • Moderate-severe: triptans (sumatriptan, naratriptan, rizatriptan - tablets, nasal spray, or autoinjector), ergotamine/caffeine (Cafergot), or parenteral dihydroergotamine or ketorolac for refractory attacks
  • Adjuncts: antiemetics for associated nausea
Prophylactic therapy is considered based on attack frequency, severity, and disability, and traditionally includes beta-blockers and certain antiepileptic drugs, with newer options such as CGRP-targeted therapies now central to updated guidelines.
Non-pharmacologic management: trigger identification/avoidance, stress management, regular sleep and exercise, and physical therapy - - Textbook of Family Medicine 9e, p. 1216-1217.

Recent evidence update

A 2025 systematic review and practice guideline in Cephalalgia provides updated evidence-based recommendations for pharmacological treatment of migraine (full and summary versions: PMID 40277319, PMID 40277321), and a 2025 systematic review in Frontiers in Neurology (PMID 40901671) evaluates comprehensive preventive treatments for episodic migraine. These are worth checking if you need the most current recommendations, particularly around newer preventive classes (e.g., CGRP monoclonal antibodies/gepants), since textbook prophylaxis lists may not reflect the latest first-line guidance.
If you'd like, I can go deeper into any specific angle - acute drug selection, prophylactic regimens, migraine in pregnancy, migraine-associated vertigo, or differentiating migraine from other headache syndromes.
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