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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Migraine without aura: ≥5 attacks lasting 4–72 hours with nausea/vomiting AND photophobia/phonophobia, unilateral pulsating quality
- Migraine with aura: visual (most common), sensory, or speech disturbance lasting 5–60 minutes before headache
- Acute treatment: aspirin/ibuprofen ± oral triptan (sumatriptan 50–100 mg). Add antiemetic (metoclopramide/prochlorperazine)
- Prophylaxis (if ≥4 attacks/month): propranolol, topiramate, or amitriptyline. Consider CGRP inhibitors if 3+ preventatives fail
- Medication-overuse headache: suspect if analgesics/triptans used ≥10–15 days/month
Overview
Migraine is a common primary headache disorder with episodic attacks of moderate-severe headache accompanied by autonomic and neurological features. It is classified into migraine without aura (~70%), migraine with aura (~30%), and chronic migraine (≥15 headache days/month for ≥3 months, of which ≥8 are migraine). The pathophysiology involves cortical spreading depression (aura), activation of the trigeminovascular system, and CGRP release. Migraine is distinct from tension-type headache and cluster headache.
Epidemiology
Migraine affects approximately 15% of the UK population. It is three times more common in women than men (hormonal influence). Onset is usually in adolescence or early adulthood. It is the most common cause of disability in those under 50 worldwide (Global Burden of Disease). Triggers include stress, sleep disturbance, hormonal changes (menstruation, combined oral contraceptive), alcohol (red wine), certain foods, bright lights, and dehydration.
Clinical Features
Symptoms
Unilateral headache (60%), may become bilateral. Pulsating/throbbing quality
Moderate to severe intensity — aggravated by routine physical activity
Duration: 4–72 hours
Nausea ± vomiting
Photophobia and phonophobia (seek dark, quiet room)
Aura: visual (scintillating scotoma, fortification spectra, zigzag lines), sensory (paraesthesiae), or dysphasic. Develops over 5–20 min, lasts <60 min
Prodrome: mood change, yawning, food cravings, neck stiffness — hours before headache
New headache >50 years, thunderclap onset, progressive worsening, fever, focal neurology, papilloedema, personality change
Signs
Usually normal examination between attacks
During attack: pallor, photophobia (avoiding light), tenderness of scalp/temporalis
Focal neurological signs should NOT be present (if present, investigate for secondary cause)
Investigations
First-line
Clinical diagnosisMigraine is a clinical diagnosis based on ICHD-3 criteria. No investigations are needed for typical migraine with normal examination
Second-line
MRI brainOnly if red flags present: new onset >50 years, thunderclap headache, progressive worsening, focal neurology, seizures, personality change, papilloedema
Specialist
Headache diaryUseful for identifying patterns, triggers, frequency, and medication use. Supports prophylaxis decisions
1
Acute treatment
- First-line: oral triptan (sumatriptan 50–100 mg) OR NSAID (ibuprofen 400 mg) OR aspirin 900 mg
- Combination therapy: triptan + NSAID or triptan + paracetamol is more effective than either alone
- Antiemetic: metoclopramide 10 mg or prochlorperazine (also helps with headache absorption)
- Take medications early in the attack for best effect
- Do NOT use opioids or ergotamine routinely for migraine
2
Prophylaxis (if ≥4 attacks/month or significantly disabling)
- First-line: propranolol (40–160 mg/day) or topiramate (25–100 mg/day)
- Topiramate: TERATOGENIC — Pregnancy Prevention Programme applies. Also causes weight loss, paraesthesiae, cognitive slowing
- Amitriptyline 10–75 mg at night — especially if coexistent tension-type headache or insomnia
- Candesartan 8–16 mg/day — alternative if beta-blocker and topiramate not tolerated
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): NICE-approved if ≥3 previous preventatives have failed and ≥4 migraine days/month
3
Medication-overuse headache
- Suspect if analgesics/triptans used ≥10–15 days/month for ≥3 months
- Management: withdraw overused medication (abrupt withdrawal or gradual depending on drug)
- Warn patient headaches will initially worsen before improving
- Specialist referral if unable to withdraw or diagnostic uncertainty
4
Special considerations
- Migraine with aura: avoid combined oral contraceptive (increased stroke risk) — use progesterone-only methods
- Menstrual migraine: frovatriptan or naproxen as mini-prophylaxis perimenstrually
Complications
- Medication-overuse headache: Paradoxical worsening from excessive acute medication use — very common
- Chronic migraine: ≥15 headache days/month — often results from medication overuse or inadequate prophylaxis
- Migrainous infarction: Very rare — ischaemic stroke occurring during migraine with aura
- Status migrainosus: Migraine attack lasting >72 hours despite treatment
- Impact on quality of life: Lost work days, social impairment, depression, anxiety
UKMLA Exam Tips
- 1Migraine without aura: ≥5 attacks, 4–72 hours, unilateral pulsating, nausea/vomiting, photo/phonophobia. With aura: visual/sensory symptoms 5–60 min before headache
- 2Triptan + NSAID combination is more effective than either alone
- 3Propranolol and topiramate are first-line prophylaxis. Topiramate is TERATOGENIC
- 4Migraine with aura = AVOID combined oral contraceptive (increased stroke risk)
- 5Medication-overuse headache: analgesics ≥15 days/month or triptans ≥10 days/month
- 6Red flags for secondary headache: thunderclap, progressive, new >50y, papilloedema, focal signs, fever
- 7CGRP antibodies (erenumab etc) are for patients who have failed ≥3 preventatives (NICE approved)
practicetest your knowledge on migraineApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — neurology and beyond.
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