neurology

Migraine

Recurrent moderate-to-severe headache, often unilateral and throbbing, with nausea, photophobia or phonophobia, sometimes preceded by aura. Diagnosis rests on a previous consistent pattern — which is why the whole on-call teaching is the boundary…

Is this their usual headache? If not, image before you treat

The pathway

1 · Ask the only question that matters first

"Is this your usual headache?"
A patient who says yes, with a pattern going back years, is describing a migraine — a starting point, not the whole assessment, because the red flags below are still asked
A patient who hesitates, or says it is different, is describing something that needs working up
Known migraineurs get subarachnoid haemorrhages, and that is the trap this step exists for

2 · Red flags — any one means this is not a migraine yet

Thunderclap: maximal within seconds to a minute
First or worst headache, or a clear change in character
Fever, neck stiffness, rash
New focal neurology, seizure, or reduced consciousness
Worse lying flat, on waking, or with coughing and straining
New headache over 50, immunosuppression, cancer, anticoagulation, pregnancy or postpartum
Jaw claudication or scalp tenderness over 50 — think giant cell arteritis

3 · Recognise a real migraine

4 to 72 hours, unilateral, pulsating, moderate to severe
Worse with movement, and the patient wants a dark quiet room
Nausea or vomiting, photophobia or phonophobia
Aura: visual, sensory or speech symptoms developing over 5 to 20 minutes and lasting under an hour, usually BEFORE the headache
A previous identical pattern is the strongest single feature

4 · Treat it properly and early

Simple analgesia at an adequate dose, taken EARLY — aspirin or an NSAID, or paracetamol
A triptan, alone or with an NSAID, where simple analgesia fails
An antiemetic — it treats the nausea and helps absorption
Avoid opioids. They work poorly, cause rebound, and are the route into medication-overuse headache
Dark, quiet, fluids, and let them sleep

5 · Status migrainosus and medication overuse

Status migrainosus — a disabling attack beyond 72 hours. Consider IV fluids, an IV antiemetic, and senior or neurology advice
Medication-overuse headache — a daily or near-daily headache in someone taking analgesia on most days, particularly codeine or a triptan
The treatment is withdrawal of the overused drug, which is an outpatient plan with warning that it worsens first
Do not add another analgesic to a medication-overuse headache

6 · Prescribing points that are actually decisions

Migraine WITH AURA is a contraindication to the combined oral contraceptive — an absolute one, on stroke risk
Triptans are contraindicated in uncontrolled hypertension and in ischaemic heart or cerebrovascular disease
Pregnancy: paracetamol first line; involve obstetrics, and remember pre-eclampsia in any new headache after 20 weeks
Prophylaxis is a GP or neurology decision, not a discharge prescription

Drugs

Drug	Dose	Route	Notes
Aspirin or NSAID	Per BNF, adequate dose, taken early	PO	Early and adequate beats late and cautious. Check contraindications.
Triptan	Per BNF	PO / SC / Nasal	Contraindicated in ischaemic heart disease, cerebrovascular disease and uncontrolled hypertension.
Antiemetic	Per BNF	PO / IV / IM	Treats the nausea and improves absorption of the analgesic.
Opioids	Avoid	—	Poorly effective, cause rebound, and are the commonest route into medication-overuse headache.

When to escalate

Thunderclap headache — subarachnoid haemorrhage pathway, CT then LP timing per that pathway,Fever with headache and neck stiffness — meningitis pathway, antibiotics without waiting for imaging,New headache over 50 with jaw claudication or scalp tenderness — giant cell arteritis, treat and refer same day,New headache after 20 weeks of pregnancy — check the blood pressure and urine; think pre-eclampsia

Reference: NICE CG150 headaches in over-12s; NICE CKS migraine; MHRA and FSRH guidance on combined hormonal contraception in migraine with aura.

This page is the reference half

The app adds what a web page cannot: a VINDICATE differential builder, worked on-call scenarios with full A–E findings, recall practice, and all of it offline.