Clinical Guides
Migraine
An India-contextualised, clinically focused guide to diagnosing migraine, treating attacks safely, preventing medication overuse and recognising pregnancy or neurological emergencies.
MedNext Academy | 12 min read
Migraine
An India-contextualised, clinically focused guide to diagnosing migraine, treating attacks safely, preventing medication overuse and recognising pregnancy or neurological emergencies.
Summary
Migraine is a recurrent primary headache disorder diagnosed from its characteristic attacks and the exclusion of secondary danger, not from a scan ordered for every headache. Attacks commonly involve unilateral or bilateral pulsating pain, nausea, light or sound sensitivity and worsening with activity. Aura is a fully reversible focal neurological symptom that usually evolves gradually; it must be distinguished from abrupt or persistent deficits. The immediate task is to identify a dangerous alternative before applying a migraine label.
Attack treatment has two goals: restore function early and avoid a pattern in which acute drugs perpetuate headache. Current guidelines supports a triptan, a non-steroidal anti-inflammatory drug, paracetamol, or selected combinations according to individual contraindications and preferences; it advises against opioids and ergots for acute migraine. An anti-emetic may be considered even without reported nausea. The medicine, formulation and dose must be selected from the current local formulary and patient-specific contraindications, not copied from a generic online regimen.
Prevention is considered when attack burden, disability, acute-treatment use or patient preference justifies it. Pregnancy potential, cardiovascular disease, mood, weight, epilepsy and interacting medicines change that decision. A diary of headache days, aura, menstruation, acute-drug days and response is both diagnostic evidence and a safety tool. It also makes unnecessary emergency attendance and unsafe duplicate prescribing easier to identify. [current guidelines, sections 1.1 to 1.3]
How Common Is It?
Migraine is common across primary care, emergency medicine, neurology and obstetrics, but an Indian national prevalence figure should not be invented from a foreign survey or a clinic denominator. Measured frequency changes with the case definition, age range, sex distribution, access to care and whether probable migraine, chronic migraine and medication-overuse headache are counted separately. The educationally important point is not a headline prevalence but the high likelihood that a recurrent headache presentation may be migraine while still requiring a red-flag screen.
Migraine often begins before midlife and is reported more frequently by women, but neither age nor sex proves the diagnosis. Menstrual association may be assessed with a diary over at least two cycles. Chronic daily headache can arise from several primary disorders, secondary causes or frequent acute-drug use; it is not simply severe episodic migraine. Recording days with any headache and days with migraine features prevents conflating attack frequency with analgesic exposure.
In Indian services, apparently low consultation rates may reflect self-treatment, cost, limited neurology access, stigma or long travel rather than low burden. A local audit should report the diagnostic criteria used, red-flag referrals, acute-drug days, pregnancy status where relevant and follow-up outcome. It should not equate medicine sales with a diagnosis. [current guidelines, sections 1.1 and 1.2]
Risk Factors
Risk assessment begins with pattern, not a list of prohibited foods. Ask about family history, puberty, menstruation, pregnancy and postpartum timing, sleep disruption, fasting, dehydration, stress, shift work, head injury and changes in caffeine, alcohol or recreational-drug exposure. These factors can influence attacks but do not establish causation in an individual. A diary can test a suspected relationship more safely than broad dietary restriction that worsens nutrition or anxiety.
Medication review is essential. Frequent triptans, opioids, ergots or combination analgesics on 10 or more days a month for three months, or paracetamol, aspirin or non-steroidal anti-inflammatory drugs on 15 or more days a month for three months, should trigger assessment for medication-overuse headache. Record all sources, including over-the-counter combinations and medicines obtained without a prescription. The count is days of use, not tablet number, and more than one acute medicine on the same day does not reset the count.
Pregnancy potential is a prescribing risk factor. Topiramate is contraindicated for migraine prophylaxis in pregnancy under Pharmaceutical regulators safety measures and may interact with some hormonal contraceptives. Migraine with aura also changes the safety assessment for combined hormonal contraception: FSRH classifies it as UKMEC category 4. These are reasons for specialist contraception and preconception discussion, not for stopping an established medicine without an individual plan. [current guidelines 1.2.7; pharmaceutical regulators (2024); FSRH CHC guideline, table 7]
Diagnosis
History
Establish age at onset, change from the usual pattern, attack duration, pain quality, disability, nausea, sensory sensitivity, autonomic symptoms, aura sequence and recovery. Ask the person to describe any visual, sensory, speech or motor symptom from first onset to full resolution; sudden onset, persistent deficit, a first motor syndrome or reduced consciousness is not routine aura. Record headache days and all acute medicine days, menstruation, pregnancy possibility, vascular risk, cancer, immunosuppression, infection, trauma, anticoagulants and substance exposure.
Examination
Measure observations and perform a focused neurological examination, including mental state, cranial nerves, limbs, coordination, gait and fundoscopy when indicated and feasible. Look for meningism, focal deficit, altered consciousness, fever, hypertension in pregnancy, painful red eye, papilloedema or temporal-artery features in the appropriate clinical context. A normal examination supports but does not independently prove primary headache. Abnormal signs, a new pattern or inability to perform a reliable examination changes the urgency.
Investigations
Diagnose typical migraine clinically when history and examination are reassuring. Do not use imaging simply to reassure a stable person with a typical established syndrome; investigate when red flags, an atypical neurological event or another diagnosis is plausible. Pregnancy adds a broader differential including hypertensive, thrombotic and pituitary disorders, so acute new severe headache requires obstetric assessment. Tests should answer a focused question, not delay emergency care. [current guidelines 1.1.1 to 1.1.4]
Differential Diagnosis
Tension-type headache, cluster headache and other trigeminal autonomic cephalalgias, cervicogenic pain, temporomandibular symptoms and medication-overuse headache may resemble or coexist with migraine. Cluster headache has a different attack pattern with marked unilateral autonomic features and requires its own pathway. Do not call a daily or refractory headache migraine without checking whether frequent acute medicines, sleep disorders, depression, hypertension or a secondary process are contributing.
Secondary causes require active consideration when headache is thunderclap, new after age 50, progressively changing, triggered by exertion or posture, associated with fever, neck stiffness, cancer, immunosuppression, pregnancy/postpartum state, trauma, papilloedema, seizure, altered consciousness or focal neurology. Acute angle-closure glaucoma can present with headache, nausea and a painful red eye. A visual disturbance in one eye alone should not automatically be called aura. These features direct emergency assessment rather than a trial of another triptan.
Transient ischaemic attack or stroke may enter the differential for aura-like symptoms, particularly when onset is abrupt or the symptom is negative and persistent. Functional symptoms, panic and syncope can coexist but must not be assigned before neurological and systemic danger is considered. The safest working diagnosis can be uncertain while urgent assessment proceeds. [current guidelines 1.1.1 and 1.1.2]
Management
Agree an attack plan that is early, practical and written: identify the individual’s effective first option, the anti-emetic strategy if needed, maximum acute-treatment days, what to do when it fails and when to seek urgent help. Current guidelines advises either combination therapy with an oral triptan plus an NSAID or paracetamol, or an oral triptan, NSAID, aspirin or paracetamol alone according to preference, comorbidity and adverse-effect risk. It advises against opioids and ergots for acute migraine. Route selection, renal, gastrointestinal, cardiovascular and pregnancy safety must be checked locally.
Offer preventive treatment through shared decision-making after recording baseline burden and desired outcome. Current guidelines lists propranolol, topiramate and amitriptyline as options after considering comorbidity, risks and patient preference; it advises against gabapentin. Review benefit and harm on a planned schedule and discontinue an ineffective or unsafe preventive rather than accumulating drugs. Specialist pathways are appropriate for chronic migraine, refractory disability, advanced CGRP-targeted therapy or diagnostic uncertainty.
Medication-overuse headache is managed by withdrawing all overused acute headache medicines for at least one month, abruptly rather than gradually under current guidelines guidance, with warning that symptoms may temporarily worsen and with follow-up. Do not use a preventive prescription as a substitute for addressing overuse. [current guidelines 1.3.10 to 1.3.22 and 1.3.42 to 1.3.48]
Prescribing Information
Every prescription should specify the working diagnosis, attack or prevention role, formulation, dose, maximum use, contraindication screen, interaction review and monitoring plan. Acute triptans and NSAIDs are not interchangeable: vascular history, blood pressure, renal function, gastrointestinal bleeding risk, other serotonergic or vasoactive drugs and pregnancy context require an individual check. An anti-emetic choice also needs review for sedation, movement disorders, QT-risk and interactions. Avoid casual repeat dispensing without reviewing the headache and medicine diary.
Topiramate requires particularly strict reproductive safety. Pharmaceutical regulators states that it must not be used for migraine prevention in pregnancy and that people of childbearing potential require the conditions of a Pregnancy Prevention Programme, including highly effective contraception and pregnancy exclusion before starting under the UK programme. It may interact with some hormonal contraceptives. This is UK regulatory guidance, not an Indian programme; in India, use the current local product information and specialist advice rather than assuming the same infrastructure or method availability.
For people with aura, combined hormonal contraception needs a contraception-service assessment because FSRH lists migraine with aura as UKMEC category 4. Do not infer that a progestogen-only or non-hormonal option is appropriate without assessing the person. In pregnancy, seek specialist advice before preventive therapy; do not start, stop or dose-adjust a migraine medicine from this guide. [pharmaceutical regulators (2024); FSRH CHC guideline table 7; current guidelines 1.3.17]
When to Refer
Refer urgently for a first thunderclap headache, focal neurological deficit, seizure, altered consciousness, meningism, papilloedema, painful red eye, head injury concern, systemic illness, new headache in cancer or immunosuppression, or a pregnancy/postpartum headache with concerning features. Emergency assessment is for exclusion and treatment of time-critical causes; it should not wait for diary completion or outpatient migraine response. An established migraine history does not protect against a new secondary event.
Neurology referral is appropriate for diagnostic uncertainty, atypical or prolonged aura, motor, brainstem or retinal symptoms, chronic or disabling migraine despite a reviewed plan, repeated emergency care, suspected medication overuse that has not responded to supported withdrawal, or consideration of specialist preventive treatment. A headache clinic can also support a person whose condition is stable but whose work, education or care responsibilities remain substantially affected.
Pregnancy, pregnancy planning or contraception complexity warrants early coordinated primary-care, obstetric, neurology and contraception input as needed. In India, transfer thresholds should be lower where fundus examination, neuroimaging, obstetric assessment or monitored acute treatment is unavailable. Referral should include the diary, acute-drug days, aura description, examination findings, pregnancy status, all medicines and response to prior interventions. [current guidelines 1.1 and 1.3; pharmaceutical regulators (2024)]
Red Flags
Treat sudden maximal-intensity headache as an emergency until dangerous vascular and other secondary causes have been assessed. New focal weakness, aphasia, persistent visual loss, collapse, seizure, confusion, fever with neck stiffness, severe hypertension in pregnancy, papilloedema or acute painful red eye also needs prompt in-person assessment. A person with known migraine can have a stroke, infection, glaucoma or hypertensive disorder; familiarity with the usual diagnosis must not lower vigilance.
Red flags also arise from a change in treatment safety. Increasing acute-drug days, escalating over-the-counter combination products, opioid use, suspected overuse, new cardiovascular symptoms after an acute treatment, serious adverse effects or a new pregnancy require review rather than automatic renewal. For topiramate used for migraine prevention, a suspected pregnancy requires urgent prescriber contact; Pharmaceutical regulators advises stopping it straight away for migraine and contacting the clinician. The advice is specific to this indication and should not be extrapolated to epilepsy.
Record the time of onset, last known well, pregnancy status, medicine and contraceptive exposure, observations and neurological findings before transfer. A response to a pain medicine does not exclude serious disease. [current guidelines 1.1.1; pharmaceutical regulators (2024)]
Indian Clinical Context
This guide uses current guidelines, Pharmaceutical regulators and FSRH sources because it does not identify a single current India-wide migraine protocol that supplies equivalent detail for all acute, preventive, reproductive-safety and contraception decisions. Those sources are not Indian law, formulary or public-health policy. Indian clinicians must use locally licensed products, current package inserts, hospital pathways and specialist advice; availability of triptans, anti-emetics, contraception methods, imaging and neurology services varies.
Ask about self-purchased analgesics, combination cold remedies, traditional products, fasting, dehydration, work schedules and supply interruption. Counselling should be in a language the person understands and should separate common triggers from blame. A patient who cannot access a headache diary app can use a calendar recording headache days, disability, acute-drug days, menstruation and aura. This low-resource record can safely inform referral without turning the student into a prescriber.
Pregnancy and contraception decisions demand especially cautious local coordination. The pharmaceutical regulators Pregnancy Prevention Programme cannot be presumed to operate in India. Where specialist care, pregnancy testing, imaging or emergency transfer is limited, do not begin a high-risk preventive medicine; arrange review and provide explicit emergency advice. [NMC CBME Curriculum 2024; pharmaceutical regulators (2024)]
NMC Competency Mapping
Migraine integrates neuroanatomy, pain physiology, pharmacology, general medicine, emergency triage, obstetrics and communication. The NMC CBME Curriculum 2024 establishes competency-based undergraduate learning, but this guide does not fabricate a disease-specific code or claim independent prescribing authority. Institutions should map local teaching to their approved curriculum ledger and supervision level.
A learner should take an organised headache history, distinguish an attack pattern from medication overuse, describe aura accurately, screen for secondary-headache red flags and perform a focused neurological examination. They should explain why a diary matters, why acute medicines can worsen a headache pattern when overused and why a pregnancy or contraceptive history changes medicine safety. They should know the difference between acknowledging a probable migraine and dismissing a dangerous new presentation.
Under supervision, students may provide written safety-net information, reconcile medicines and arrange review. They must not independently choose triptan or preventive doses, start topiramate, advise on hormonal contraception, or dismiss focal neurological symptoms as aura. Assessment should reward safe escalation and patient-centred explanation over rote drug lists. [NMC CBME Curriculum 2024, curriculum framework]
Key Exam Pearls for NEET PG
Migraine is primarily clinical. Typical attacks feature episodic headache with nausea or photo-phonophobia and disability; aura is reversible focal neurology that generally evolves gradually. A red flag, first atypical aura, persistent deficit, thunderclap onset or abnormal examination changes the question from migraine treatment to urgent secondary-cause assessment. Do not image a stable, typical presentation only for reassurance.
Medication overuse is tested by drug days over three months: triptans, opioids, ergots or combination analgesics on 10 or more days per month; paracetamol, aspirin or NSAIDs on 15 or more days per month. current guidelines treatment is withdrawal of all overused acute medicines for at least one month, abruptly, with counselling and follow-up. Opioids and ergots are not recommended for acute migraine.
Topiramate is not used for migraine prevention in pregnancy and requires strict reproductive-safety assessment. Migraine with aura changes combined hormonal contraception safety; FSRH lists it as UKMEC category 4. In an India-based answer, distinguish the external recommendation from local product and service rules. [current guidelines; pharmaceutical regulators (2024); FSRH CHC guideline]
Frequently Asked Questions
How can a patient keep an accurate migraine medicine diary?
Use a calendar to record every headache day, migraine-feature day, aura, missed activity and every day on which an acute medicine was used, including over-the-counter combinations. Record the medicine name and response, not merely tablet number. This makes medication-overuse risk visible and lets the clinician compare preventive benefit with a baseline. The diary is evidence for a review, not permission to self-escalate doses.
When should aura be treated as an emergency rather than a usual migraine symptom?
Seek urgent assessment for a first or distinctly different focal neurological event, sudden rather than gradually evolving symptoms, persistent weakness or visual loss, reduced consciousness, seizure or severe headache that reaches maximum intensity immediately. A person with a previous migraine diagnosis can still have stroke, infection or another secondary illness. The safe action is assessment while the diagnosis remains uncertain, rather than taking repeated rescue medicines at home.
Why can frequent painkillers make migraine harder to treat?
Frequent acute medicines can contribute to medication-overuse headache and maintain a near-daily pattern. current guidelines asks clinicians to consider this after three months of triptan, opioid, ergot or combination-analgesic use on at least 10 days per month, or simple analgesic or NSAID use on at least 15 days. Withdrawal needs warning, support and a planned follow-up because headache can worsen briefly before improvement.
What changes if a person using topiramate thinks they might be pregnant?
For migraine prevention, Pharmaceutical regulators safety advice says to stop topiramate straight away and contact the prescriber. Do not apply this instruction to people taking it for epilepsy, because seizure risk changes the balance and urgent specialist advice is required. In India, arrange prompt local obstetric and prescribing review; the UK Pregnancy Prevention Programme is evidence of serious risk, not proof that identical services or product instructions exist locally.
Inside MedNext for this topic
- 411 MedNext-authored chapters
- 80,000+ MCQ bank
- 15 study modes
- a growing library of visual revision sheets
Study modes
- Notes
- MCQ
- Audio
- Video
- Visual
- 3D Anatomy
- Trace
- Flashcards
- Mnemonics
- Image Bank
- Clinical
- Microscopy
- Audio QBank
- Cadaver
- Book Match
Continue reading
Clinical GuidesAll Clinical Guides
Browse all clinical management guides for Indian medical practice.
Test your knowledge
Attempt structured MCQs on this topic to consolidate your understanding and connect the guide to exam-focused practice.
Try MCQs on this topic