Migraine: how to prevent and treat attacks

Migraine is one of the most under-diagnosed and under-treated conditions I see in general practice. It is not just a bad headache.

A typical attack combines severe, often one-sided throbbing pain with nausea, light and sound sensitivity, and, in about a third of sufferers, preceding visual or sensory aura.

Around one in seven people in the UK live with migraine, women roughly three times more often than men.

With the right combination of acute treatment, preventive medication and sensible lifestyle work, most people can bring their monthly migraine-day count into single figures, if not zero.

What is a migraine, in plain terms?

Migraine is a neurological disorder, not a vascular one, in which waves of cortical excitation and inhibition spread across the brain, activating the trigeminovascular system and releasing inflammatory neuropeptides such as calcitonin gene-related peptide, known as CGRP. The NHS migraine page and the charity Migraine Trust both offer patient-friendly explanations.

The diagnosis is clinical.

Four or more attacks lasting 4 to 72 hours, with at least two of unilateral location, pulsating quality, moderate or severe intensity and aggravation by routine activity, plus at least one of nausea, vomiting, photophobia or phonophobia, meets the International Classification of Headache Disorders criteria.

Neuroimaging is not routinely needed; the key tasks are to rule out red flags and to open the conversation about prevention.

Red flags that need urgent review

Most headaches are benign, but a small minority signal something serious.

Call 999 or attend A and E for the first or worst headache of your life of sudden onset, headache with fever and stiff neck, new neurological symptoms that do not resolve, headache after significant head injury, or headache with visual loss in one eye.

Also seek same-day review for headache that always wakes you at night, worsens with coughing or lying flat, or starts for the first time after age 50.

Acute treatment: stop the attack

The cardinal rule is to treat early and treat hard. Once central sensitisation sets in, oral medicines absorb poorly and work less well. The stepped approach used by most UK GPs, aligned with the BNF migraine summary, is the following.

Step one: simple analgesia plus an antiemetic

At the very first sign, take a soluble formulation of aspirin 900 mg or ibuprofen 400 to 600 mg with an antiemetic such as prochlorperazine or domperidone. For patients who cannot tolerate NSAIDs, high-dose paracetamol is a fallback. Add naproxen 500 mg, particularly for menstrual migraine, where a short course covering the perimenstrual days prevents or limits attacks.

Step two: triptans

Triptans are selective 5-HT1B/1D receptor agonists and remain the workhorse of acute migraine therapy. They are effective in around two thirds of patients when taken early enough, and come in several flavours with different speeds of onset and recurrence rates. Sumatriptan 50 or 100 mg orally is the usual starting point, with a nasal or subcutaneous formulation if tablets are vomited out. Rizatriptan acts a little faster; zolmitriptan is available as an orodispersible wafer useful when nausea is severe; and naratriptan is slower but longer-acting with a lower recurrence rate, which suits patients whose headaches relapse at 12 to 24 hours.

Triptans are contraindicated in uncontrolled hypertension, ischaemic heart disease, previous stroke, hemiplegic or basilar migraine, and peripheral vascular disease. Side effects include chest pressure, flushing and paraesthesiae, which are usually short-lived and not cardiac in origin in otherwise healthy patients.

Step three: combination and rescue

Combining a triptan with an NSAID or with an antiemetic often works when either alone has failed. Cross-titration through at least two triptans before concluding the class does not suit you is good practice. Opioids and barbiturate-containing combinations should be avoided in migraine; they worsen medication-overuse headache and are not recommended. A wider context sits in our migraine treatment guide.

Medication-overuse headache: the commonest trap

Using acute painkillers, including over-the-counter codeine combinations, on more than 10 days per month, or triptans on more than 10 days per month, risks converting episodic migraine into chronic daily headache.

If you are reaching for painkillers most days, speak to your GP. The paradoxical treatment is to withdraw the overused analgesic, usually with preventive medication started in parallel.

Preventive treatment: change the baseline

I offer preventive treatment to anyone with four or more migraine days per month, or fewer if each attack is severely disabling.

Prevention does not abolish migraine; the realistic aim is to halve attack frequency, shorten attacks, and improve response to acute treatment.

First-line oral preventers

• Beta blockers. Propranolol 80 to 160 mg daily, usually as the modified-release preparation, is my most frequent first-line choice in patients without asthma. Metoprolol is an alternative.
• Amitriptyline 10 to 75 mg at night is particularly useful when sleep is poor or tension-type headache coexists.
• Topiramate 50 to 100 mg daily is effective but needs careful counselling about cognitive effects, weight loss, paraesthesiae and the absolute contraindication in pregnancy and in women of childbearing age without robust contraception.
• Candesartan 16 mg daily is a well-tolerated angiotensin receptor blocker with good evidence in migraine prevention.

Specialist options

For patients who fail three preventive classes, NHS specialist headache clinics offer onabotulinumtoxinA injections for chronic migraine, and the newer CGRP monoclonal antibodies, erenumab, galcanezumab and fremanezumab, delivered as monthly self-injections. Greater occipital nerve blocks are a useful bridging option. The Migraine Trust maintains an up-to-date overview of treatments that I share with patients.

Lifestyle and trigger work that actually helps

Triggers are individual, and spending time identifying yours is one of the highest-yield things a migraine patient can do.

A three-month migraine diary, either on paper or in an app, noting headache days, sleep, meals, menstrual cycle and obvious exposures, will often reveal patterns.

• Regular sleep with consistent wake times, including at weekends, matters more than total hours.
• Do not skip meals. Hypoglycaemia is a powerful trigger.
• Limit caffeine to under 200 mg a day and do not binge then withdraw.
• Hydrate. Dehydration lowers migraine threshold.
• Regular aerobic exercise reduces attack frequency in randomised trials; aim for 30 minutes, three times a week.
• Manage stress with cognitive behavioural therapy, mindfulness or relaxation training where available.
• For women, explore menstrual migraine with perimenstrual NSAIDs or triptans.

Migraine in pregnancy, children and older adults

Migraine frequency often falls in the second and third trimesters. Paracetamol is first line acutely, with metoclopramide as antiemetic; triptans are used cautiously when benefit justifies, with sumatriptan having the most safety data. NSAIDs should be avoided in the third trimester. In children, ibuprofen plus rest in a dark room is the starting point; nasal sumatriptan has a licence from age 12. In patients over 50, sudden-onset headache, new visual disturbance or scalp tenderness warrants urgent review for giant cell arteritis. Our broader pain relief treatment hub covers analgesic choice across age groups.

Frequently asked questions

Are triptans safe for long-term use?

Yes, for episodic migraine used on fewer than 10 days per month and in patients without the cardiovascular contraindications listed above. Annual review of blood pressure and risk factors is sensible.

Why is the first triptan I tried no use?

Individual response varies more than most people expect. Roughly 20 percent of patients who do not respond to one triptan respond well to another.

Cross-titration through at least two agents, in both oral and alternative formulations where nausea is severe, is standard.

Can I take propranolol if I have asthma?

No. Non-selective beta blockers are contraindicated in asthma. Candesartan, amitriptyline or topiramate are safer first-line preventers in asthmatic patients.

Do CGRP antibodies work better than tablets?

For appropriately selected chronic migraine patients, randomised trials show meaningful extra reductions in monthly migraine days on top of existing treatment. Access on the NHS requires failure of at least three oral preventers and is handled by specialist headache clinics.

Is there a cure for migraine?

No definitive cure, but migraine frequency and severity can be reduced dramatically with combined preventive and acute treatment. Many patients move from weekly attacks to occasional manageable ones.

Aura, hemiplegic migraine and the basilar variant

About a third of people with migraine experience aura: reversible neurological symptoms that usually precede the headache by 5 to 60 minutes, though they can also occur during or after the pain.

Visual aura is commonest, typically a slowly expanding zigzag scintillating scotoma across part of the visual field.

Sensory aura, such as tingling or numbness spreading up one arm and into the face, and speech aura with temporary word-finding difficulty, are also recognised.

Aura itself is not dangerous, but migraine with aura roughly doubles baseline ischaemic stroke risk, particularly in younger women who smoke or use combined hormonal contraception.

For this reason, the combined oral contraceptive pill is contraindicated in migraine with aura, and a progestogen-only method, copper coil or the hormonal intrauterine system is preferred.

Hemiplegic migraine, which causes genuine one-sided weakness during aura, and basilar-type migraine, with vertigo, ataxia, double vision or altered consciousness, are rare variants that must never be treated with triptans or ergotamines because of cerebral vasoconstriction risk.

A first episode of any of these should prompt urgent neurological assessment to exclude stroke or transient ischaemic attack.

Hormonal factors and menstrual migraine

Menstrual migraine, defined as attacks occurring between two days before and three days after the first day of menses in at least two of three consecutive cycles, affects a substantial minority of women with migraine. Attacks tend to be longer, more severe and more resistant to acute treatment. Strategies include a short perimenstrual course of naproxen, a longer-acting triptan such as naratriptan taken twice daily from two days before expected menses, and, for women on combined hormonal contraception, tailored continuous or tricycling regimens that reduce the number of hormone-withdrawal weeks per year.

Pregnancy often brings welcome relief, particularly in the second and third trimesters, though postpartum and early perimenopause are both common relapse points.

Hormone replacement therapy, usually transdermal oestradiol combined with a progestogen, is compatible with migraine without aura and does not worsen most patients' headaches; oral combined HRT is sometimes less well tolerated.

Migraine, mental health and sleep

Migraine and mood disorders share genetic and neurochemical pathways, and depression, anxiety and migraine frequently travel together.

Undertreated depression worsens migraine outcomes, so an honest conversation with your GP about mood is a clinical priority, not an add-on.

Sleep apnoea, restless legs syndrome and insomnia all lower the migraine threshold.

Snoring with witnessed apnoeas, daytime somnolence and morning headache as the first symptom of the day should prompt sleep-disorder assessment; treating obstructive sleep apnoea reduces migraine frequency meaningfully in affected patients.

Conclusion

Treat attacks early with a triptan plus an NSAID, keep acute medication days under 10 a month, and start prevention once you reach four migraine days a month or earlier if attacks are disabling.

Keep a diary, work on sleep, meals and hydration, and do not hesitate to ask your GP about specialist review if standard preventers are not enough.

Modern migraine care is far better than it was a decade ago.

This article is for information only and does not replace individualised medical advice. Always read the patient information leaflet and speak to a pharmacist or GP if in doubt.