Migraine

You won't cure it, and there are three things you can do that matter.

Illness script in one line: unilateral throbbing headache lasting 4 to 72 hours, moderate to severe, made worse by routine physical activity, with nausea and both light and sound sensitivity, sometimes preceded by aura.

Caseload frequency: you will see migraineurs constantly, usually presenting for something else. Read further: prevalence, disease burden and the need for preventive therapy [1], prevalence and burden [2].

The three things this page is actually for

1. Recognise it, so you don't treat it as a neck. Every row of the migraine picture is the opposite of tension-type headache [3].

2. Know that migraine with aura and cervical artery dissection have been studied together [4]. It changes what you do before you touch a neck.

3. Know that exercise is a preventive intervention, not just kindness. Read further: network meta-analysis of exercise interventions [5].

Everything else — triptans, CGRP therapies, prophylaxis — you refer.

MAIN PROBLEM

"I get migraines." Take that word seriously and then check it — plenty of people call any bad headache a migraine, and plenty of true migraineurs have been told for years they have sinus headaches or neck headaches.

BODY CHART

• Unilateral, and it can swap sides between attacks. Always the exact same side, every time, is a flag.
• Frontotemporal, retro-orbital, sometimes occipital.
• ± neck and shoulder symptoms — common, and part of the attack.

BEHAVIOUR — the criteria

• Aggs: movement, light, sound, smells, exertion.
• Eases: dark, quiet, sleep, lying still. They want to be still — the opposite of cluster headache, where they can't stay still.

HISTORY — six things

1. Aura: present, and what kind? Typical visual aura, gradual onset over minutes, 5 to 60 minutes, fully reversible. Motor weakness, aura over 60 minutes, always the same side, or a first-ever aura over 50 — medical review, not physiotherapy.
2. Attack frequency, and the trend.
3. Analgesic and triptan days per month. Medication overuse headache [6] is as relevant here as in tension-type headache. Ask it as a number.
4. Hormonal pattern. The usual line is "triggered by hormones" — give it its name: menstrual migraine, which has its own acute and preventive treatment literature [7].
5. Sleep. Read further: migraine and sleep disorders [8]. Clinical pearl: stress and sleep regulation are the key modifiable factors.
6. Dizziness or vertigo with attacks. See below. This is the addition that will change a real patient's care.

The one that gets missed: vestibular migraine

Read further: diagnostic criteria for vestibular migraine [9], prevalence and functional implications of vestibular symptoms in migraine [10], an update on the condition [11].

Why it matters to you: dizziness gets sent to physiotherapy. A migraineur with episodic vertigo is routinely worked up as cervicogenic dizziness and treated for months. Ask every dizzy patient about headache history.

SPECIAL / SCREENING QUESTIONS

The full SNNOOP10 secondary headache screen [12] — thunderclap, new or changed headache over 50, progressive, positional, fever, neurological deficit, cancer or immunosuppression, papilloedema, trauma, pregnancy, painful eye with autonomic features.

Plus the CAD/VBI screen — the 5 D's and 3 N's — and read the next section before you do anything cervical.

Top three, and the one feature that separates each

Also on the list

The overlap that costs students most

Migraine and cervicogenic headache coexist, and a migraineur will usually have a stiff, tender neck. That is not the same as the neck causing the headache. Clinical pearl: screen for cervicogenic overlap and treat the mechanical component if present. Treat the component. Don't claim the headache.