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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Migraine lasts 4-72 hours and causes nausea and/or photophobia/phonophobia
- Aura is reversible focal neurological symptoms developing gradually and usually lasting <60 minutes
- Thunderclap headache, fever, papilledema, focal deficit, pregnancy/postpartum, cancer, or age >50 new headache are red flags
- NSAIDs or acetaminophen treat mild attacks; triptans treat moderate-severe attacks when safe
- Prevention includes topiramate, beta-blockers, TCAs/SNRIs, CGRP agents, or botulinum toxin for chronic migraine
Overview
Migraine is a primary headache disorder involving trigeminovascular activation and sensory hypersensitivity. It is diagnosed clinically using ICHD criteria. Aura is typically visual, sensory, or language disturbance with gradual spread and full reversibility.
Epidemiology
Migraine affects a large proportion of adults and is more common in women. Triggers include sleep disruption, fasting, dehydration, stress, menstruation, alcohol, bright light, and medication overuse. Migraine with aura increases ischemic stroke risk, especially with smoking or estrogen-containing contraception.
Clinical Features
Symptoms
Unilateral pulsating moderate-to-severe headache worsened by activity
Nausea, vomiting, photophobia, or phonophobia
Visual aura with scintillating scotoma or zigzag lines
Sensory aura with gradual pins-and-needles spread
Thunderclap onset or persistent neurological deficit is not typical migraine
Signs
Neurological exam is usually normal between attacks
Aura deficits should be fully reversible
Papilledema suggests raised intracranial pressure
Fever or meningismus suggests infection or SAH
Age >50 new headache with jaw claudication suggests giant cell arteritis
Investigations
First-line
Clinical diagnosisRecurrent 4-72 hour attacks with migraine features and no better diagnosis
Pregnancy test when relevantGuides medication choice and secondary headache evaluation
Second-line
MRI brainAbnormal exam, pattern change, cancer, immunosuppression, pregnancy/postpartum red flags, or atypical aura
CT/CTA/LP pathwayThunderclap headache evaluation for SAH
ESR/CRPNew headache after age 50 or symptoms of giant cell arteritis
Specialist
MRVPapilledema, pregnancy/postpartum, hypercoagulability, or venous sinus thrombosis concern
Headache diaryTracks frequency, triggers, rescue medication, and disability
1
Acute therapy
- Mild-moderate: NSAID or acetaminophen
- Moderate-severe: triptan early in attack if no contraindication
- Add metoclopramide or prochlorperazine for prominent nausea
- Avoid routine opioids
2
Contraindications
- Avoid triptans in CAD, prior stroke/TIA, uncontrolled HTN
- Avoid triptans in hemiplegic or brainstem aura
- Use pregnancy-safe options when pregnant
- Screen for medication overuse
3
Prevention
- Topiramate, propranolol/metoprolol, amitriptyline, venlafaxine
- CGRP monoclonal antibodies or gepants for selected patients
- Botulinum toxin for chronic migraine
- Choose based on comorbidities and pregnancy potential
4
Lifestyle
- Regular sleep, hydration, meals, exercise
- Trigger management and caffeine consistency
- Avoid smoking and consider avoiding estrogen contraception in aura
- Treat medication overuse with withdrawal and prevention
Complications
- Status migrainosus: Migraine lasting >72 hours
- Medication overuse headache: Frequent rescue medication use
- Migrainous infarction: Rare stroke during prolonged aura
- Functional impairment: Work and school disability
USMLE Step 2 CK Exam Tips
- 1Aura spreads gradually with positive symptoms; TIA is sudden and often negative
- 2Thunderclap headache = SAH workup
- 3Triptans are contraindicated in CAD, stroke/TIA, uncontrolled HTN
- 4Pregnancy: acetaminophen first-line; avoid valproate/topiramate
- 5Topiramate causes weight loss, kidney stones, cognitive slowing, teratogenicity
- 6Propranolol helps migraine plus essential tremor; avoid asthma
- 7Medication overuse headache = frequent rescue meds
practicetest your knowledge on migraineApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — neurology and beyond.
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