About migraine and headache
Migraine is a neurological condition, not simply a bad headache. Attacks typically bring a one-sided throbbing headache with sensitivity to light and sound, nausea, and sometimes an aura of visual or sensory symptoms beforehand. When headache occurs on 15 or more days a month for more than three months, with migraine features on at least eight, it is called chronic migraine and needs a different treatment approach.
Other headache disorders seen in the clinic include tension-type headache, cluster headache (severe one-sided attacks around the eye in bouts), medication overuse headache (a daily headache driven by frequent painkiller use), and the small number of headaches that signal another condition and need urgent investigation.
Symptoms we assess
Reasons to be assessed include:
- Headaches on more than four days a month, or that are getting more frequent
- Headaches that stop you working, studying or caring for others
- Visual disturbance, numbness or speech difficulty before or during a headache
- Painkillers taken on ten or more days a month
- A new headache after 50, or a change in a long-standing pattern
- Headache with fever, neck stiffness, weakness, confusion or a sudden very severe onset (seek urgent care)
- Severe attacks around one eye with a watering eye or blocked nose
How we diagnose it
Headache diagnosis rests on the history, so the consultant spends most of the first appointment on it: what the pain is like, how often it comes, what triggers it, what you take for it and what else happens during an attack. A headache diary kept for a few weeks before the visit is enormously useful. The neurological examination is normal in migraine; its purpose is to rule out other causes.
Most patients with a typical migraine history do not need a brain scan. MRI is arranged when the pattern is unusual, when there are warning features, or when examination is abnormal. Blood tests are occasionally needed.
Treatment and follow-up
Treatment has two parts. Acute treatment stops an attack once it starts: simple painkillers taken early and at the right dose, triptans, and the newer gepant medicines for those who cannot take triptans. Preventive treatment reduces how often attacks happen and is offered when headache days are frequent or attacks are severe. Options include several classes of daily tablet, the CGRP monoclonal antibody injections given monthly, and botulinum toxin (Botox) injections for chronic migraine.
Medication overuse headache is treated by planned withdrawal of the overused painkiller with a preventive in place, and improves within weeks. Cluster headache has its own effective treatments, including high-flow oxygen and injectable sumatriptan for attacks and verapamil for prevention.
Lifestyle factors matter: regular sleep and meals, hydration, managing stress and known triggers. The consultant writes the plan up for your GP, who can continue prescribing, and reviews you until the plan is working.
When to see a GP, and when to see a consultant
Your GP can treat occasional migraine. Ask for a neurology referral when attacks are frequent or disabling, when two or more preventives have not worked, when painkiller use is frequent, when the diagnosis is uncertain, or when you want to discuss CGRP treatments or Botox. A sudden, extremely severe headache, or headache with weakness, confusion, fever or rash, needs emergency care the same day.
