QuestionSBA
QuestionChoice
Given that the most likely cause here is a migraine it would be unnecessary to perform a MRI. A CT head would often be performed acutely to exclude an intercranial haemorrhage but this would not be a likely diagnosis given the overall clinical picture.
10015768
c
MRI head
QuestionChoice
There is no evidence that this patient is experiencing an infective meningitis, given the lack of fever and meningism.
10015770
e
IV cefuroxime
QuestionChoice
The history and examination findings are consistent with the diagnosis of a migraine. High dose NSAIDs + paracetamol should be used in the first instance. According to NICE guidelines, the first line treatment for acute attacks of migraine include Ibuprofen 400mg, Aspirin 900mg or Paracetamol 1g. 
10015766
a
Ibuprofen 400mg
QuestionChoice
NSAIDs should be tried in the first instance, following the WHO pain ladder. Opioids should not routinely be used in migraines. Overuse of weak opioids (e.g. codeine) can contribute to medication overuse headaches.
10015769
d
Morphine sulphate (oral)
QuestionChoice
There is no evidence that this patient is experiencing an infective meningitis or subarachnoid haemorrhage. A lumbar puncture is not yet indicated.
10015767
b
Lumbar puncture
QuestionComment
When would you use sumatriptan over NSAIDs for migraine?
33005
QuestionComment
If they have a CI including gastric ulcers/ bleeding or if it's not well controlled with NSAID/Paracetamol then GP will consider using sumatriptan along with paracetamol/NSAID to terminate an attack 
33889
User
subscriber
Haemolytic antibody
User
subscriber
Rhinoplasty Myopathy
QuestionComment
it sounds like a cluster headache  fromt he description , did anyone else think that  ?
35919
QuestionComment
nausea makes migraine more likely
36741
User
subscriber
charlotte
QuestionComment
where's the cluster at g
44919
User
subscriber
Viral Myopathy
User
subscriber
Amy
QuestionComment
nah definitely go with triptans over NSAIDs
45054
QuestionComment
First line is NSAIDS according to NICE
45164
User
subscriber
test123
User
subscriber
Gastro Complement
QuestionComment
Imagine someone tells you they're having the worst headache of their life and you whack out some ibuprofen lol
52247
User
subscriber
drevnisolone
QuestionComment
Anyone that's ever had a migraine is screaming right now
52685
User
subscriber
Contusion Migraine
QuestionComment
Would you not want to rule out meningitis and SAH?
56570
User
subscriber
Chill Pill
QuestionComment
"worst headache of his life" and hyperacute presentation, is this not more indicative for SAH?
58303
QuestionComment
no meningism 
59745
User
subscriber
Migraine Biopsy
User
subscriber
KMH
QuestionComment
but it says no photophobia on exam? surely sudden 10/10 headache + nausea is more consistent with cluster?
60227
User
subscriber
Sydney Sweeney
QuestionComment
You would always rule out a SAH in this scenario before assuming its anything less sinister
60909
User
subscriber
Nightshift Bradykinin
Concept
Chapter
# Summary

Migraine is a common neurological disorder characterised by recurrent, unilateral, throbbing headaches often preceded by an aura such as visual or sensory symptoms. Migraines can last between 4-72 hours and often result in photophobia and phonophobia. Key signs and symptoms include a unilateral headache, a pulsating character, impairment or worsened by daily activities, and presence of nausea,  vomiting or photophobia. Diagnosis is often based on clinical history, focusing on the presence of an aura. Management strategies include avoidance of triggers, prophylaxis with medications such as Propranolol, Topiramate or Amitriptyline, and managing acute attacks with oral triptans alongside Paracetamol or an NSAID.

# Definition

Migraine is a primary headache disorder characterised by intense episodes of debilitating headaches, usually unilateral and pulsating in nature. Symptoms may be preceded by an 'aura' which manifests as visual disturbances or sensory changes. The pain usually lasts from 4-72 hours and can be accompanied by nausea, vomiting, photophobia, and phonophobia.

# Epidemiology

Migraines are one of the most prevalent neurological disorders worldwide, affecting roughly 12% of the global population. It is more common in women, with a male to female ratio of approximately 1:3, likely related to hormonal influences. The peak incidence occurs between the ages of 30-39.

# Aetiology

The exact cause of migraines is not fully understood, but it is likely a combination of genetic and environmental factors. 

The triggering factors are variable and can include certain foods, changes in weather, stress, hormonal changes, and certain medications such as oral contraceptives.

# Signs and Symptoms

- Aura (usually visual or sensory symptoms preceding the headache)
- Unilateral throbbing headache
- Photophobia and phonophobia
- Nausea and/or vomiting

The International Headache Society criteria for migraine without aura:

| Criteria | Description                                                  |
| -------- | ------------------------------------------------------------ |
| A        | At least five attacks fulfilling criteria B-D                |
| B        | Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) |
| C        | Headache has at least two of the following four characteristics: <br>1. Unilateral location <br>2. Pulsating quality <br>3. Moderate to severe pain intensity <br>4. Aggravation by or causing avoidance of routine physical activity |
| D        | During headache, at least one of the following: <br>1. Nausea and/or vomiting <br>2. Photophobia and phonophobia |
| E        | Not better accounted for by another ICHD-3 diagnosis         |

# Differential Diagnosis

Migraines must be differentiated from other conditions that present with severe headache. Some of these include:

- Tension-type headache: Bilateral, band-like pressure or tightness, not worsened with physical activity, no associated nausea or vomiting.
- Cluster headache: Severe, unilateral, orbital, supraorbital and/or temporal pain lasting 15-180 minutes, occurring up to 8 times a day, associated with autonomic symptoms like ptosis, miosis, lacrimation.
- Subarachnoid hemorrhage: Sudden-onset severe headache, often described as "the worst headache of my life", associated with nausea, vomiting, and possible loss of consciousness.
- Giant cell arteritis: New headache in a person over 50 years, scalp tenderness, jaw claudication, visual disturbances, elevated ESR and CRP.

# Investigations

Diagnosis is primarily clinical, based on the history and examination. 

A headache diary is important to help identify triggers and response to treatment.

If secondary causes of headaches are suspected, further investigations may be warranted, such as neuroimaging (MRI or CT) or blood tests (ESR, CRP for giant cell arteritis).

# Acute Management

- **Avoidance of triggers**: 
  - Identify and avoid potential triggers like certain foods, stress, and poor sleep.
- **Medications for acute attacks**: 
  - **Triptans** (e.g., Sumatriptan) – avoid in patients with ischaemic heart disease.
  - **Paracetamol** or an **NSAID** (e.g., Ibuprofen) can be used in combination with triptans.
  - **Anti-emetics** (e.g., Metoclopramide)
- **Special considerations**:
  - Female patients with migraine with aura should avoid the **combined oral contraceptive pill** due to increased risk of ischaemic stroke.

# Prophylaxis

- Medications:
  - **Propranolol** (contraindicated in asthma).
  - **Topiramate**.
  - **Amitriptyline**.
  - **Candesartan**.
- Injections:
	- Greater Occipital Nerve Block
	- Botulinum Toxin Injection 
- **Newer treatments**:
  - **Rimegepant** (per NICE guidance, May 2023):
    - Used for preventing episodic migraine.
    - Suitable when at least 3 preventive treatments have failed.
    - Indicated for adults with 4-15 migraine attacks per month.

Regular use of acute migraine medications (e.g., triptans, NSAIDs) more than 10-15 days per month can lead to **medication overuse headache (MOH)**.

Patients should be counseled on limiting the use of acute treatments to prevent MOH.

## References

[Click here for NICE Clinical Knowledge Summaries on Migraines](https://cks.nice.org.uk/topics/migraine/)
2024
183
Migraine
Topic
34
Neurology
Video
Concept
183
Migraine
614
ZMAGtgf
images/videos/cardiology.png
Quesmed Tutorial: General Practice
Video
Concept
183
Migraine
226
DBYQXUo
images/videos/neurology.png
Migraine
Video
Concept
183
Migraine
304
XBigS3j
images/videos/neurology.png
Quesmed Tutorial: Advanced Neurology
Video
Concept
183
Migraine
678
hnAQ5W4
images/videos/neurology.png
Migraine 2
Condition
431
Migraine
UkmlaTopic
12
General practice and primary healthcare
Condition
432
Migraine
UkmlaTopic
17
Neurosciences
15697
In acute migraine attacks, Ibuprofen 400mg is an effective first-line treatment as per NICE guidelines.
Presentation
304
Headache
UkmlaTopic
1
Acute and emergency
Presentation
305
Headache
UkmlaTopic
3
Cancer
Presentation
307
Headache
UkmlaTopic
12
General practice and primary healthcare
Presentation
308
Headache
UkmlaTopic
17
Neurosciences
Presentation
309
Headache
UkmlaTopic
18
Obstetrics and gynaecology
A 19-year-old man is referred to the emergency department by his GP after he experiences 'one of the worst headaches of his life'. He describes a throbbing pain above his right eye, accompanied by severe nausea and light intolerance.

Observations show:
* Temperature 37.2 degrees celsius
* Heart rate 76 beats/minute
* Blood pressure 124/85mmHg
* Respiratory rate 14 breaths/minute

On examination, he looks well although is obviously in pain. There are no focal neurological deficits, nuchal rigidity, or photophobia.

Given the most likely diagnosis, what is the most appropriate management?
a