More Than Just a Headache
Migraine is frequently dismissed as "just a bad headache" — yet it is a complex neurological disorder that affects over 1 billion people worldwide, making it the second most disabling disease globally.
Migraine causes throbbing, usually one-sided head pain lasting 4–72 hours, often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. For many patients, it means hours or days of lost productivity, missed family moments, and significant impact on mental health.
The Neuroscience of Migraine
Migraine is caused by a cascade of neurological events beginning in the brainstem and cortex. Current understanding involves:
Cortical spreading depression — A wave of electrical activity that sweeps across the brain, followed by suppression. This is responsible for the aura phase.
Trigeminovascular activation — The trigeminal nerve releases inflammatory substances that dilate meningeal blood vessels and generate pain signals.
CGRP (Calcitonin Gene-Related Peptide) — A neuropeptide that plays a central role in migraine pain. The discovery of CGRP's role has led to the most significant advances in migraine treatment in 25 years.
The Four Phases of Migraine
Phase 1: Prodrome (hours to days before)
Many patients experience warning symptoms: mood changes, food cravings, neck stiffness, frequent yawning, or increased urination.
Phase 2: Aura (30–60 minutes, in ~25% of patients)
Reversible neurological symptoms including:
- Visual disturbances (scintillating scotoma, zig-zag lines, blind spots)
- Sensory symptoms (tingling, numbness spreading up an arm or face)
- Speech difficulty
- Rarely: motor weakness (hemiplegic migraine)
Phase 3: Headache (4–72 hours)
Moderate-to-severe throbbing pain, usually one-sided, worsened by movement, accompanied by nausea/vomiting and photophobia/phonophobia.
Phase 4: Postdrome ("migraine hangover")
Fatigue, cognitive fog, and mood changes lasting 24–48 hours after the headache resolves.
Common Triggers
Triggers do not cause migraine but may provoke an attack in susceptible individuals. Common ones include:
Hormonal: Oestrogen fluctuations (menstrual migraine affects 70% of women with migraine)
Dietary: Alcohol (especially red wine), caffeine withdrawal, MSG, processed meats, skipping meals
Sleep: Too much or too little sleep, jet lag, shift work
Environmental: Bright or flickering lights, strong smells, weather changes, high altitude
Stress: Both acute stress and the "let-down" after stress resolves
Medications: Overuse of pain relievers (leading to medication overuse headache)
Keeping a headache diary for 4–8 weeks helps identify your personal triggers.
Treatment: Acute (Abortive) Therapy
First-Line for Mild-Moderate Attacks
- NSAIDs (ibuprofen 400–600 mg, naproxen 500 mg) — most effective when taken early
- Aspirin 1,000 mg + metoclopramide (for nausea)
- Paracetamol (less effective alone but combined with antiemetics)
For Moderate-Severe Attacks: Triptans
Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan) are serotonin agonists that constrict dilated blood vessels and block CGRP release. Effective in 60–70% of patients.
Available as: tablets, nasal sprays (faster onset), and subcutaneous injections (for severe attacks with vomiting).
New: Gepants and Ditans
- Gepants (rimegepant, ubrogepant) — CGRP receptor antagonists. Effective without the cardiovascular restrictions of triptans.
- Lasmiditan — A selective serotonin agonist without vasoconstriction, safe in patients with heart disease.
Treatment: Preventive Therapy
Consider prevention if you have 4+ migraine days/month, attacks significantly impairing function, or medication overuse.
Traditional preventives: Beta-blockers (propranolol, metoprolol), topiramate, amitriptyline, valproate
CGRP-targeted preventives (most significant advance in 25 years):
- Anti-CGRP monoclonal antibodies: Erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality) — monthly or quarterly injections reducing migraine days by 50% in many patients
- Atogepant — Daily oral CGRP antagonist for prevention
When to See a Neurologist Urgently
Seek emergency care if your headache:
- Is the worst headache of your life ("thunderclap")
- Begins after a head injury
- Is accompanied by fever, stiff neck, rash, or confusion
- Progressively worsens over days or weeks
- Is associated with new neurological symptoms (weakness, vision loss, speech problems)
Book a neurology appointment if:
- You have more than 4 headache days per month
- Your pain is not controlled by over-the-counter medications
- Migraine is significantly impacting your quality of life
- You are pregnant or planning pregnancy and need treatment advice
