Migraine / Chronic Headache

Introduction

Migraine and other chronic headache disorders are among the most common reasons people see a neurologist. If you are reading this, you likely already know how disruptive the condition can be — the missed work and school days, the cancelled plans, the careful avoidance of bright lights or strong smells, the worry that the next attack is never far away.

The good news is that the medical understanding of migraine has changed significantly in the past decade. It is now recognised as a complex neurological disorder rather than “just a bad headache,” and several new classes of treatment have become available. With the right combination of acute medication, preventive therapy, and lifestyle adjustments, most people can reduce how often attacks happen and how severe they are when they do.

This article is written for people who have already been diagnosed with migraine or chronic headache, or who are in the process of being evaluated. It explains what is happening in the brain during an attack, the different headache types, how diagnosis is made, and the full range of treatment options — from over-the-counter medications to the newer CGRP-targeted therapies, neuromodulation devices, and behavioural approaches. It also covers what to do when headaches change in pattern, and when urgent evaluation is needed.

What Is Migraine?

Migraine is a neurological disorder characterised by recurring attacks of head pain that are typically moderate to severe, often one-sided, and frequently accompanied by other symptoms such as nausea, vomiting, and sensitivity to light, sound, or smell. An attack can last anywhere from four hours to three days if untreated.

During a migraine, changes happen in the brain that involve the trigeminal nerve system, the brain’s pain pathways, and inflammatory molecules including a peptide called CGRP (calcitonin gene-related peptide). These changes can also affect blood vessels, but migraine is now understood primarily as a brain disorder rather than a blood vessel disorder, which was the older view.

Migraine often runs in families. About two-thirds of people with migraine have a close relative who also has it. Women are affected roughly three times more often than men, and hormonal changes around menstruation, pregnancy, and menopause frequently influence attack patterns.

The phases of a migraine attack

• Prodrome — hours or even a day or two before the pain begins, some people notice subtle changes: yawning, mood shifts, food cravings, neck stiffness, increased thirst, or difficulty concentrating.
• Aura — about a quarter of people with migraine experience an aura. This is usually a visual disturbance (flashing lights, zigzag lines, blind spots) but can also involve tingling, numbness, or speech difficulty. Aura usually lasts 20 to 60 minutes.
• Headache — the pain itself, often throbbing, often one-sided, often worsened by movement, and frequently accompanied by nausea and sensitivity to light, sound, or smell.
• Postdrome — the “migraine hangover.” After the pain eases, many people feel drained, foggy, sore, or emotionally flat for a day or more.

Recognising these phases can help you act earlier with acute treatment, which often works better when taken at the first sign of an attack.

Types of Migraine and Chronic Headache

Migraine without aura

The most common form. Attacks of moderate to severe pain, often one-sided and throbbing, lasting hours to days, with nausea or light and sound sensitivity, but without the neurological aura.

Migraine with aura

Attacks preceded or accompanied by reversible neurological symptoms — most often visual, but sometimes involving sensation, language, or coordination. The aura typically resolves before or as the headache begins.

Chronic migraine

Defined as headache occurring on 15 or more days per month for at least three months, with at least eight of those days having migraine features. People with chronic migraine often started with episodic migraine that gradually became more frequent. Chronic migraine has its own treatment considerations, including some preventive medications that are specifically approved for it.

Tension-type headache

A different headache disorder that causes a pressing or tightening pain, usually on both sides of the head, without the throbbing or severe nausea of migraine. Many people experience both tension-type headaches and migraines. Chronic tension-type headache is diagnosed when these headaches occur 15 or more days per month over three months.

Cluster headache

A rarer but extremely severe headache disorder, more common in men, in which attacks occur in “clusters” over weeks or months, often with strictly one-sided pain around the eye, accompanied by tearing, nasal congestion, or eyelid drooping on the same side. Cluster headache has its own treatment pathway.

Medication-overuse headache

Also called “rebound headache.” When acute pain medications — including over-the-counter painkillers, combination analgesics, triptans, or opioids — are used too frequently, the headache pattern can worsen and become more difficult to treat. This is a common and often unrecognised cause of headaches becoming chronic. Identifying and addressing medication overuse is a key part of treating chronic headache.

Causes and Triggers

Migraine itself is a biological disorder — it is not caused by lifestyle choices or stress alone. People are born with a brain that is more sensitive to certain stimuli. However, individual attacks are often set off by triggers, and identifying personal triggers is one of the most useful things you can do.

Common triggers

• Stress — and, paradoxically, the relaxation after a stressful period (“weekend migraine”)
• Sleep changes — too little, too much, or irregular sleep
• Hormonal changes — especially the days just before menstruation
• Skipped meals or dehydration
• Specific foods or drinks — commonly aged cheeses, processed meats, red wine, certain food additives. Triggers vary widely between people.
• Caffeine — both excess intake and withdrawal
• Bright or flickering lights, loud noises, strong smells
• Weather changes — especially changes in barometric pressure
• Physical exertion in some people
• Certain medications, including some used for blood pressure or hormonal therapy

Many people find that no single trigger causes an attack, but rather a combination — for example, poor sleep plus stress plus an approaching period. Keeping a headache diary, either on paper or in a smartphone app, helps reveal personal patterns over a few months.

When Headaches Become Chronic

One of the most important issues in headache medicine is the transition from episodic to chronic headache. Several factors increase the risk of this transition:

• Frequent use of acute pain medications (the most common driver of medication-overuse headache)
• Untreated or poorly controlled migraine
• Obesity
• Untreated sleep disorders such as sleep apnoea
• Depression and anxiety
• Persistent high stress
• Caffeine overuse

Recognising and addressing these factors is part of the standard approach to chronic headache. Many people are surprised to learn that the very medications they have been relying on may be making the problem worse. Reducing acute medication use under medical supervision — combined with starting a preventive treatment — is often the turning point.

Diagnosis

There is no blood test or scan that diagnoses migraine. Diagnosis is clinical, based on the pattern of symptoms and a careful history. A neurologist or headache specialist will typically ask about:

• How long you have had headaches and when the current pattern began
• How often attacks occur and how long they last
• Where the pain is located, what it feels like, and how severe it is
• Associated symptoms (nausea, light/sound sensitivity, aura)
• Triggers and patterns (menstrual, stress, sleep)
• Family history of headache
• All current and recent medications, including how often you take pain relievers
• Past treatments tried and how they worked
• Other medical conditions, mood symptoms, and sleep quality

When imaging is needed

For typical migraine in someone with a stable, recognisable pattern and a normal neurological examination, brain scans are usually not necessary. Imaging — usually an MRI — is considered when there are “red flag” features that raise concern about a different, secondary cause of headache.

Red flag features include:

• A sudden, severe headache that reaches peak intensity within seconds to a minute (“thunderclap”)
• A new headache pattern in someone over 50, or in someone with cancer or a weakened immune system
• A headache that is progressively worsening over days or weeks
• A headache with fever, stiff neck, or rash
• A headache with new neurological symptoms such as weakness, persistent vision change, confusion, or seizures
• A headache that begins or significantly worsens with coughing, exertion, or position change
• A headache after a head injury

If any of these features are present, urgent evaluation is important. They do not mean a serious problem is definitely present, but they need to be checked.

Headache diary

Keeping a record of attacks — date, duration, severity, possible triggers, medications taken, and response — is one of the most useful tools in diagnosis and ongoing management. Many specialists ask patients to bring a diary covering one to three months to the first appointment.

Treatment: An Overview

Treatment of migraine and chronic headache is built around two complementary goals: stopping attacks when they happen (acute or “abortive” treatment) and reducing how often they happen (preventive treatment). For many people, both are needed.

Major societies including the American Academy of Neurology, the American Headache Society, and the International Headache Society have published guidelines that describe a stepped approach: starting with simpler treatments where appropriate and moving to more specialised therapies if attacks remain frequent, severe, or disabling.

Acute Treatment: Stopping an Attack

The aim of acute treatment is to relieve pain and associated symptoms as quickly as possible and return you to normal function. Acute treatments work best when taken early in the attack — ideally at the first sign of pain, not after waiting to see if it gets worse.

Over-the-counter pain relievers

For milder attacks, simple analgesics such as ibuprofen, naproxen, aspirin, or paracetamol can be effective. Combination products containing caffeine may work better for some people. These are appropriate as first-line options for many people with episodic migraine, but only when used at low frequency. Using them more than two or three days a week over a long period raises the risk of medication-overuse headache.

Triptans

Triptans are a class of prescription medications developed specifically for migraine. They work by acting on serotonin receptors in the brain. There are several different triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, naratriptan, frovatriptan, almotriptan), available as tablets, dissolving tablets, nasal sprays, or injections. Different triptans have different speeds of onset and durations, and people sometimes respond better to one than another.

Triptans are usually recommended when over-the-counter options are not enough. They are not suitable for everyone — in particular, people with certain heart or blood vessel conditions, uncontrolled high blood pressure, or some types of migraine with prolonged aura may need to avoid them.

Gepants

Gepants (ubrogepant, rimegepant) are a newer class of medication that blocks the CGRP receptor. They work as acute treatment and, importantly, do not appear to cause medication-overuse headache in the way that triptans and analgesics can. They are an option particularly for people who cannot take triptans or who have not responded well to them.

Ditans

Lasmiditan is the first medication in this class, acting on a different serotonin receptor than triptans. It can be used by people who cannot take triptans for cardiovascular reasons, although it does cause drowsiness and is not suitable before driving.

Anti-nausea medications

Nausea and vomiting are often part of a migraine attack and can make it hard to keep tablets down. Anti-nausea medications such as metoclopramide or prochlorperazine, in combination with pain relievers, can help significantly. Sometimes a nasal spray or injection is used instead of tablets when vomiting is a major problem.

What to do when acute treatment fails

If a first dose of acute medication does not work, sometimes a second dose or a different medication class can be tried. For severe attacks that do not respond — sometimes called status migrainosus — a hospital or emergency department visit may be needed for intravenous medications, fluids, and sometimes a short course of steroids.

Preventive Treatment

Preventive treatment is considered when migraine attacks are frequent, disabling, or not adequately controlled by acute treatment alone. Major guidelines suggest considering prevention when attacks happen four or more days per month, when they are severe or prolonged, or when acute treatments are not working well or are contraindicated.

A preventive medication does not stop attacks immediately. Most need to be taken daily for two to three months before their full effect is seen, and they typically reduce attack frequency by about half in people who respond. This means setting realistic expectations is important: prevention is about reducing the burden of the condition, not eliminating it overnight.

Traditional oral preventives

For many years, the mainstays of migraine prevention have been medications originally developed for other conditions:

• Beta-blockers (propranolol, metoprolol) — originally for blood pressure
• Antiepileptic medications (topiramate, valproate) — originally for seizures. Valproate is not used in women who could become pregnant because of significant risks to the foetus.
• Tricyclic antidepressants (amitriptyline) — helpful particularly when sleep problems or tension-type headache features coexist
• Candesartan — a blood pressure medication with growing evidence in migraine
• Venlafaxine — an antidepressant with some evidence in migraine prevention

The choice depends on individual factors, other medical conditions, side-effect profile, and the patient’s preferences. These medications are typically started at a low dose and gradually increased.

CGRP-targeted therapies

Since 2018, a new class of medications has changed the landscape of migraine prevention. These therapies target the CGRP pathway, which plays a central role in migraine biology.

• Monoclonal antibodies — erenumab, fremanezumab, galcanezumab, and eptinezumab. These are given as injections under the skin once a month or once every three months (eptinezumab is given by intravenous infusion). They are specifically developed for migraine prevention and have a generally favourable side-effect profile compared to older oral preventives.
• Oral gepants for prevention — atogepant and rimegepant are taken daily or every other day to prevent migraine.

Major societies including the American Headache Society now describe CGRP-targeted therapies as an option for prevention, particularly for people who have not responded to or cannot tolerate older preventives. Access to these medications varies by country and by individual prescriber.

Botulinum toxin (Botox) for chronic migraine

Standard injection site map used for botulinum toxin treatment in chronic migraine, covering the head, neck, and shoulders.

AI-generated illustration

Neuromodulation devices

Several non-medication devices have been developed to stimulate or modulate nerves involved in migraine. These include devices that deliver electrical stimulation to the forehead, the vagus nerve in the neck, or single-pulse magnetic stimulation to the back of the head. They can be used acutely, preventively, or both, depending on the device. They are an option for people who prefer to avoid medication, who have contraindications, or who want to combine approaches.

Lifestyle and Self-Management

The SEEDS framework summarises five key lifestyle habits that support migraine management: Sleep, Exercise, Eating, Diary, and Stress.

AI-generated illustration

Sleep

Both too little and too much sleep can trigger migraine. Going to bed and waking at consistent times, including on weekends, is one of the most powerful changes many people can make. If you snore heavily or feel tired despite long sleep, consider being assessed for obstructive sleep apnoea, which can worsen headaches when untreated.

Exercise

Regular moderate aerobic exercise — brisk walking, swimming, cycling — three to five times a week has been shown in studies to reduce migraine frequency. Intense exercise can sometimes trigger an attack, so building up gradually and warming up is helpful.

Eating and hydration

Skipping meals and dehydration are common triggers. Eating regularly and drinking enough water throughout the day matters. If certain foods seem to trigger attacks for you, eliminating them is reasonable — but elaborate restrictive diets are not generally helpful and can affect quality of life.

Caffeine

Caffeine has a complicated relationship with migraine. Small, consistent amounts can help with attacks, but large amounts or irregular use can worsen headache patterns. A consistent, moderate daily intake is usually better than wide swings.

Stress management

Stress is one of the most commonly reported triggers. Approaches with research support include:

• Cognitive behavioural therapy (CBT) — particularly helpful when anxiety, low mood, or unhelpful thought patterns coexist
• Biofeedback — learning to influence physical responses such as muscle tension and skin temperature
• Mindfulness-based approaches and relaxation training
• Regular routines that build in recovery time, including on weekends

These approaches can be used alongside medications and are part of the standard treatment landscape recommended by major headache societies.

Identifying and managing triggers

A headache diary kept over a few months helps reveal personal triggers and patterns. The goal is not to avoid everything that ever might trigger an attack — that would make life unmanageable — but to identify a small number of consistent triggers worth modifying.

Monitoring and Specialist Care

Most people with migraine are managed by a general practitioner, with referral to a neurologist or headache specialist if attacks are frequent, severe, complex, or not responding to initial treatments.

Things to look for in a headache specialist or service include relevant neurology training, experience specifically with headache disorders (not all neurologists subspecialise in this), willingness to consider both medication and non-medication approaches, and a clear plan with follow-up. Building a long-term relationship with one clinician who knows your headache history is often more valuable than seeing different practitioners over the years.

Follow-up visits typically review:

• Headache frequency and severity since the last visit
• How well acute treatments are working
• Side effects of any preventive medication
• Acute medication use frequency, to watch for overuse
• Mood, sleep, and stress
• Whether the current plan needs adjustment

Complications and Associated Conditions

Migraine can be associated with several other conditions, and managing them often helps with the headaches:

• Depression and anxiety — substantially more common in people with migraine, particularly chronic migraine. Treating mood symptoms often improves headache outcomes and overall quality of life.
• Sleep disorders — including insomnia and obstructive sleep apnoea.
• Other chronic pain conditions — such as fibromyalgia or temporomandibular joint disorder.
• Cardiovascular considerations — migraine with aura is associated with a modest increase in stroke risk, particularly in women who smoke or use combined hormonal contraception. This is worth discussing with your doctor so the safest contraceptive option can be chosen.

Rare complications of a migraine attack itself include persistent aura without infarction, migrainous infarction (stroke during a migraine with aura), and status migrainosus (an attack lasting more than 72 hours).

Migraine in Children and Adolescents

Migraine is common in children — affecting around one in ten by adolescence — and the pattern can look different from adult migraine. Attacks may be shorter, often two hours or less. Pain may be on both sides of the head rather than one. Nausea, vomiting, and abdominal pain can be very prominent, sometimes overshadowing the headache itself.

Diagnosis in children

Diagnosis is clinical, as in adults, with careful attention to ruling out secondary causes. Sudden changes in behaviour, persistent vomiting, problems with balance or vision, or headache that wakes a child from sleep are signals for thorough evaluation.

Treatment considerations

Treatment in children emphasises healthy routines — consistent sleep, regular meals and hydration, limited screen time, regular physical activity, and stress management. For acute attacks, ibuprofen and paracetamol are commonly used first-line. Certain triptans are approved for adolescents.

For preventive treatment, behavioural approaches such as CBT and biofeedback have strong evidence in children and adolescents and are often tried before or alongside medication. When preventive medication is needed, options are more limited than in adults and depend on the child’s age and other factors. Decisions about preventive medication in children involve careful discussion with a paediatric neurologist or headache specialist.

School and daily life

Frequent headaches can affect school attendance and academic performance. Working with the school to allow flexibility — access to a quiet space, permission to take acute medication, allowance for missed work during attacks — can reduce the impact. Importantly, prolonged absence from school is generally not helpful and can make headaches worse over time; the aim is to manage symptoms while keeping the child engaged in normal life as much as possible.

Migraine, Pregnancy, and Hormones

Hormonal changes strongly influence migraine in many women. Attacks often worsen in the days before menstruation and may improve, worsen, or remain unchanged during pregnancy. Many women experience improvement, particularly in the second and third trimesters, but some have worsening attacks.

Several preventive medications used in migraine are not safe in pregnancy — valproate in particular must not be used by women who could become pregnant unless very specific conditions are met. Treatment during pregnancy generally favours non-medication approaches first, with carefully selected medications when needed. Planning ahead with your doctor before pregnancy is helpful.

Migraine with aura affects contraceptive choices because of the small but real increased stroke risk associated with combined hormonal contraceptives in this group. Progestogen-only options are often preferred.

Preventing Progression to Chronic Headache

• Treat attacks early and effectively, rather than enduring them
• Avoid using acute pain medication more than two or three days per week on average
• Address coexisting conditions such as depression, anxiety, and sleep disorders
• Maintain consistent sleep, meals, hydration, and exercise routines
• Consider preventive treatment when attacks reach a frequency or severity that justifies it
• Stay engaged with follow-up rather than treating headaches in isolation

When to Seek Urgent Care

Most migraines, even severe ones, do not require emergency care. However, some headache patterns do need prompt evaluation. Seek urgent medical attention if:

• You have a sudden, severe headache that reaches its worst within seconds to a minute (“thunderclap”)
• You have a headache with fever, stiff neck, confusion, seizures, or rash
• You have a headache with new weakness, numbness, slurred speech, or vision loss that does not fit your usual aura
• You have a headache after a head injury
• Your headache pattern has changed substantially — new type, new severity, much more frequent
• A migraine attack has lasted more than 72 hours despite usual treatment
• You are pregnant and have a new severe headache

It is reasonable to be cautious. Most evaluations will not find a serious cause, but the conditions being ruled out — bleeding around the brain, infection, stroke — are treatable when caught early.

Living with Migraine

Migraine is a long-term condition for most people who have it. The pattern often changes over a lifetime — attacks may become more frequent during certain phases (puberty, perimenopause, periods of high stress) and improve during others. The goals of care evolve too: in some years the focus is on getting through frequent attacks; in others, it is on keeping a stable plan in place.

Several things help over the long term:

• An honest understanding of what triggers and worsens your attacks
• A clear acute treatment plan you can implement quickly when an attack begins
• Preventive treatment when attack frequency justifies it, with realistic expectations about timing and degree of benefit
• Attention to sleep, mood, and stress as part of the overall plan, not as afterthoughts
• A trusted clinician who knows your history and can adjust the plan as life changes
• Support from family, friends, and colleagues who understand that migraine is a real neurological condition, not something to be pushed through or ignored

Frequently Asked Questions

Is migraine the same as a bad headache?

No. Migraine is a specific neurological disorder with distinct features — throbbing pain that is often one-sided, sensitivity to light and sound, nausea, and often a recognisable pattern of phases. It can be very disabling and is now understood as a brain disorder, not just a headache.

Will my migraines go away?

For some people, migraine becomes less frequent or less severe with age. For others, the pattern is stable, and for some, periods of life bring worsening. Migraine cannot currently be cured, but in most people it can be significantly reduced with the right combination of acute treatment, preventive treatment, and lifestyle approaches.

How long does it take for preventive medication to work?

Most traditional oral preventives take two to three months at an adequate dose to show their full effect. CGRP-targeted injectable therapies often show benefit faster, sometimes within the first month. Patience and consistent use are important — stopping a preventive too early is a common reason people conclude it didn’t work.

How will I know if a preventive medication is helping?

A successful preventive typically reduces the number of headache days per month by around half, makes attacks less severe, or makes acute treatment work better. A headache diary is the most reliable way to see this clearly, since memory often understates improvement.

Are CGRP medications safe long-term?

CGRP-targeted therapies have been in clinical use since 2018, and so far the safety profile has been generally favourable. Long-term data continues to accumulate. Like any newer medication, decisions about starting or staying on them involve discussion with your doctor about the balance of benefits, side effects, and individual circumstances.

Is it dangerous to take painkillers often for migraine?

Taking acute pain medication more than two or three days a week on average over a long period can lead to medication-overuse headache, in which the headache pattern actually worsens. If you are using acute medication frequently, this is important to discuss with your doctor — not as something to feel embarrassed about, but as a common issue that needs addressing as part of treatment.

Can I exercise if I have migraine?

Yes — and regular moderate aerobic exercise is one of the lifestyle changes with the best evidence for reducing migraine frequency. Intense exertion can sometimes trigger an attack in susceptible people, so building up gradually and warming up properly helps.

Should I be worried that my migraines could be a brain tumour?

Migraine itself is not caused by tumours, and most headaches — even severe ones — are not caused by serious underlying disease. The features that raise concern about secondary causes are listed in the “Red flag” section above. If your headache pattern is stable and matches typical migraine, with a normal neurological examination, imaging is usually not necessary.

Does migraine increase stroke risk?

Migraine with aura is associated with a modest increase in stroke risk, particularly in women who smoke or use combined hormonal contraception. The absolute risk for any individual remains low, but this association is worth discussing when choosing contraception and addressing other cardiovascular risk factors.

Can children outgrow migraine?

Many children do experience improvement in puberty or early adulthood, but migraine can also continue into adult life or change in pattern. Establishing good habits and a clear treatment plan in childhood helps regardless of how the pattern evolves.

Conclusion

Migraine and chronic headache are common, biologically based, and often deeply disruptive — but they are also treatable. The past decade has brought new acute medications, new preventive options including CGRP-targeted therapies, established roles for behavioural treatments and neuromodulation devices, and a clearer understanding of the role that sleep, mood, and acute medication use play in shaping the long-term course of the condition.

A practical plan usually combines several elements: identifying personal triggers, having effective acute treatment ready to use early in an attack, considering preventive treatment when attacks are frequent or disabling, and addressing coexisting conditions such as sleep problems, anxiety, and low mood. With a clinician who knows your history and a plan that is reviewed and adjusted over time, most people with migraine can substantially reduce the impact of the condition on their daily life.