Author: Dr David PB Watson, GPwER Headache, Department of Neurology, Aberdeen Royal Infirmary AB25 2ZN – david.watson2@nhs.scot
Overview
Learning objectives
By the end of this CPD module, readers should be able to:
- Recognise migraine as the most common cause of disabling recurrent headache presenting to primary care
- Confidently diagnose migraine and differentiate it from other primary headache disorders and secondary headache causes
- Implement evidence-based acute and preventive treatments including target therapies (Gepants)
- Counsel patients about medication overuse headache and lifestyle modifications
- Know when and how to escalate care or refer appropriately
60 Second Summary
Migraine is a complex neurological condition affecting one in seven people yet remains underdiagnosed and undertreated in primary care. The PIN diagnostic tool offers a simple, validated approach to diagnosis. Modern treatment approaches recognise the importance of early, adequate acute treatment and appropriate use of prevention. Recent advances, particularly CGRP-targeted therapies, provide new options for patients who don’t respond to traditional treatments. The key to successful migraine management lies in accurate diagnosis, individualised treatment plans, and understanding when to escalate care. With proper recognition and treatment, the vast majority of people with migraine can be managed in Primary Care and can achieve significant improvement in their quality of life and functional capacity. This CPD module aligns with SIGN 155 (v4.1, 2026), The NHS Scotland’s National Headache Pathways and BASH Guidelines
Introduction:
Why Migraine Matters
Migraine affects approximately one in seven people globally and is the most common cause of disabling episodic headache seen in primary care. Migraine impacts patients’ home, work and family lives. Data from the Landmark study demonstrate that around 94% of patients presenting to GPs with disabling episodic headache and a normal examination meet criteria for migraine, even when they are initially labelled with alternative diagnoses such as tension-type headache or ‘sinus’ headache. Despite this, migraine remains underdiagnosed and undertreated. This matters: The WHO rates migraine as a leading cause of years lived with disability in working-age adults, and effective treatment can transform daily functioning, reduce repeat consultations and improve patient confidence in primary care management.
Key take-home message: in patients with recurrent, disabling headache and a normal neurological examination, think migraine first.
Case Study: Sarah’s Story Sarah, a 32-year-old teacher, presents to her GP with a 4-year history of “persistent headaches” on the right side of her face. She was initially suspected of having trigeminal neuralgia and tried amitriptyline, nortriptyline and carbamazepine without effect. Antibiotics and nasal sprays were given for presumed “sinus” headache but did not help. The headaches were a lot better during pregnancy but returned postnatally. She now wakes with headache and experiences facial numbness, causing her GP to refer her urgently due to concern about a secondary headache. She gets 12 headache days a month. She has well controlled asthma and used a Mirena coil for contraception. She has no plans for further family.
On detailed history taking, Sarah describes:
• Right-sided headache affecting V1, V2, and V3 distribution, occasionally bilateral
• Severe light sensitivity – she wears sunglasses all year round
• Noise sensitivity
• Complete headache freedom during pregnancy
• Sensory aura affecting right arm and cheek occurring twice monthly
Diagnosis: Episodic Migraine with aura
This case illustrates several real- world thinking errors:
- Trigeminal neuralgia and “sinus” headache being considered due to facial pain. Acute sinusitis can cause headache but recurrent facial pain without clear signs of infection is rarely due to sinus problems.
- Sensory symptoms and waking from sleep raising concern about secondary pathology. Migraine aura symptoms occur in about one in three migraine patients. Visual aura is the most common but can also be sensory and motor. Migraine commonly develops during sleep.
- Improvement during pregnancy being overlooked as a diagnostic clue. Note: not all migraine gets better in pregnancy.
- Secondary headache is less likely if there are headache free days.
A structured headache history reframes this clearly as migraine and avoids unnecessary referral or imaging.
Top Tip: Aura symptoms are usually both positive and negative and are usually progressive and are fully reversible. Aura is due to a change in electric activity in the brain that moves across the brain in waves. eg getting flashing lights and then tunnel vision that progresses across the visual field, pins and needles then numbness that can spread distally or proximally. Transient ischaemic attacks are sudden vascular events that tend to be immediate and have negative symptoms. Eg power loss, sensory loss.
Diagnosing migraine: keeping it simple and recognise the pattern
Migraine is a clinical diagnosis, based on history taking. In patients under 50 years with recurrent disabling headache and a normal examination, migraine should be the default diagnosis unless red flags are present. The Landmark study showed that 94% of this group of patients will have migraine or probable migraine. In the short time constraints of a Primary Care consultation a useful and validated screening tool is the three-question Migraine ID (PIN) screener:( See box 1) Headache diaries can also be helpful.
Box 1
• P – Photophobia: “Does light bother you during headaches?”
• I – Impaired function: “Have headaches limited your activities for a day or more?”
• N – Nausea: “Do you feel sick or nauseated during headaches?”
Answering “yes” to two or more supports a diagnosis of migraine with high sensitivity and positive predictive value. (sensitivity 81%, specificity 75%).
Key features supporting migraine
• Migraine is a long duration headache with episodic attacks lasting 4–72 hours if untreated which has 4 stages though patients don’t get every stage. See Diagram below. Ask about crystal clear days between attacks. Forty percent of patients can get bilateral headache and most patients don’t get aura.
• Moderate-to-severe pain with functional impairment. Tension headache is a featureless headache, and the majority of patients self-manage and don’t present to Primary Care.
- Associated symptoms: nausea, photophobia, phonophobia, dizziness, cognitive symptoms, fatigue
- Trigger sensitivity. The migraine brain is boring and sensitive to change. Common triggers are sleep disturbance, stress, hormonal change missing meals and weather pressure changes
- A positive family history of migraine is found in two thirds of patients.
- Neck stiffness, yawning and fatigue are often reported as prodromal symptoms warning patients before the headache starts.
- Top Tip: Ask the patient about previous headache. Patients often mention having had “normal” headache which are usually migraine. Examples are “it was normal to get a headache with my period” (menstrually associated migraine) , “it was normal to get a headache even after one drink”(undeserved hangover is usually migraine) ,” it was normal to get a headache at the weekend after a busy week” ( let down migraine)
Diagram: Migraine stages on a timeline
Top Tip: Ask the patient what they would want to do (if they could) when they get a headache. A patient with migraine would prefer to stop activities and keep still, a patient with tension headache may go for a walk and get some fresh air, a patient with cluster headache would feel agitated and restless and would want to move, maybe bang their head on a wall or sit and rock.
Top Tip: A headache diary can be helpful to confirm a diagnosis, quantify headache and migraine days, identify medication overuse and provide a baseline for assessing treatment response (available at migrainetrust.org)
Excluding secondary headache: red flags that change management
Both patients and Primary Care clinicians worry about secondary causes for headache. The Scottish Headache Pathways highlight the most consistent indicators of serious underlying pathology:
• Sudden onset “thunderclap” headache
• New focal neurological deficit
• Systemic features (fever, weight loss, jaw claudication)
• New or progressive headache in those aged >50 years
• Headache triggered by posture or Valsalva manoeuvre
Patients with these features require urgent assessment or referral. In their absence, neuroimaging is not routinely required in migraine. Any patient with these features requires urgent assessment, often in secondary care.
Top Tip: Explain to the patient that the brain itself has no pain fibres and that pain is referred from the structures around the brain. This means that brain tumours usually present with a disturbance of the part of the brain where the tumour is eg a new epileptic seizure, a permanent loss of parts of the vision, neurological symptoms that don’t resolve. To find a brain tumour in a patient with just headache alone would require 1,111 patients to be scanned
Understanding migraine: a brief overview
It is important for Primary Care Clinicians to have an understanding of migraine pathophysiology so they can explain to their patients why they get a variety of symptoms and why the targeted treatments against CGRP are migraine specific medications rather than repurposed medications. Migraine is a complex brain disorder of sensory processing, not just a headache. Patients often find it helpful when clinicians explain that the migraine brain is unusually sensitive to normal life stimuli.
Key concepts that support patient understanding: (Diagram below)
• Migraine involves activation of the trigeminovascular system with the trigeminal nerve innervating pain sensitive structures including cranial blood vessels and the dura.
• The neuropeptide CGRP (calcitonin gene-related peptide), by causing vasodilation and neurogenic inflammation, plays a key role in pain signalling and sensitisation
• Attacks evolve through phases (prodrome, aura, headache, postdrome), which may overlap or be absent entirely
This framework makes sense of why:
• Symptoms extend beyond pain (fatigue, cognitive symptoms, neck pain)
• targeted therapies that block the effects of CGRP can help many patients with migraine
The foundation of management: education and lifestyle
All patients with migraine benefit from simple, consistent advice:
• Regular meals, hydration and sleep
• Avoidance of identified triggers where practical
• Normalisation of exercise
• Stress management strategies
Sign Post patients to the Irish Patient Headache Association or the Migraine Trust
Acute treatment: getting it right early
Core principles
• Treat early, while pain is mild using adequate doses remembering that triptans don’t help aura and only work once headache starts
• Avoid opioids and limit acute medication to no more than 2 days per week on average to avoid potential medication overuse headache
- Treatment options include Aspirin 900 mg, Ibuprofen 400–600 mg or a Triptan. If one triptan fails, trial another triptan before abandoning the class.
- Rimegepant, an oral CGRP receptor antagonist, should be considered for patients who have an inadequate response to at least two triptans, or have contraindications or intolerance to triptans
Top Tip: For patients with significant nausea, very fast onset or severe attacks or are early vomiters consider either nasal zolmitriptan (more nasal absorption than sumatriptan nasal) or subcutaneous sumatriptan. All melt in the mouth triptans are gastrically absorbed. Of the oraltriptans Eletriptan has the best NNT data. Adding an antiemetic such as Metoclopramide 10 mg or Prochlorperazine 10 mg can helptreat nausea and have independent analgesic effect. Triple therapy of triptan + antiemetic + a long acting NSAID such as Naproxen can be helpful. A useful metaphorfor patients is that we are trying to put out the fire in the corner of the room before the whole rroom is on fire ie treat early with all available treatments.
Diagram: The role of CGRP and the trigeminal system in migraine pathophysiology
Top Tip: Sumatriptan is safe to use in pregnancy
Medication-overuse headache (MOH)
All patients with migraine are at risk of developing MOH. About two thirds of patients with chronic migraine have medication overuse. Suspect the possibility of MOH when Triptans, opioids or combination analgesics are used on ≥10 days/month or simple analgesics are used on ≥15 days/month. Triptan overuse can result in a daily migraine like headache, whereas overuse of other analgesia can give a daily headache with features of both migraine and tension headache.
Key management principles include educating patients early and clearly when starting acute therapy, avoiding opioids, individualise withdrawal strategy and introduce or optimise preventive therapy at the same time as withdrawing overused medications. Warn patients that headache often gets worse in the first 2 weeks of withdrawal. The BASH guidelines give clear guidance on how to manage MOH.
Top Tip: Migraine is often co- morbid with other chronic pain conditions. Ask the patient which of their pains is the worse. Very often it is the migraine, and this allows negotiation to withdraw or reduce analgesia used for the other pain conditions.
Preventive treatment: reducing migraine burden
The decision to start preventive treatment should be a joint decision with the patient and should be individualised based on the patient’s preference, current clinical situation, co- morbidities and their future plans (e.g. pregnancy or contraception). In Primary Care the recommended first line preventives are candesartan, propranolol and amitriptyline/nortriptyline.
Topiramate is now a specialist only medication due to the change in the licensing laws around women of childbearing age. Medications should be started a low dose and titrated every 1-2 weeks aiming for a target dose. Assess effectiveness after 8 weeks at the target dose aiming for a 50% reduction in migraine frequency. Move on to the next medication if either lack of effectiveness or poor tolerability. If effective reassess the need for the medication at 12 months. If first line therapies don’t work or are not tolerated or are contra-indicated then consider targeted preventive therapies (see table) based on local protocols.
Reasons to start preventive therapy
• Migraine impacts on quality of life regardless of frequency
• ≥4 headache days per month as a general guide
• If frequent acute medication use (>10 days/month)
• If migraine attacks respond poorly to acute treatment
- Patient preference to reduce attack frequency
First Line Preventives in Primary Care
1. Candesartan 16mg daily: start on 2-4 mg. Well tolerated, few interactions, established effectiveness, avoid in pregnancy/breastfeeding
2. Propranolol 80-160mg daily: start on 10-120 mg twice a day, established effectiveness, avoid in asthma, note interaction with rizatriptan (maximum 5mg dose), safe at low dose in pregnancy
3. Amitriptyline 25-150mg at night: start at 10 mg, note anticholinergic side effects, safe at low dose in pregnancy.
Targeted preventive therapies
Oral CGRP Antagonists (Gepants)
Atogepant 60mg daily: Licensed for 4 or more migraine days a month, well tolerated (constipation, nausea, somnolence and slight weight loss are main side effects) Rimegepant 75 mg every other day: Licensed for 4-14 migraine days a month, well tolerated (nausea)
CGRP Monoclonal Antibodies
For specialist use in patients with chronic migraine or frequent episodic migraine who have failed multiple oral preventives:
• Erenumab (targets CGRP receptor)
• Fremanezumab, galcanezumab, eptinezumab (target CGRP ligand)
• Monthly or quarterly subcutaneous injections
• Require specialist initiation
Botulinum Toxin A Reserved for chronic migraine (≥15 headache days/month with ≥8 migraine days) where ≥3 oral preventives have failed. Specialist administration required.
Top Tip: Three preventives need to be considered before starting targeted therapy. However a contraindication eg propranolol and asthma would count as considering one preventive.
Top Tip: When using targeted therapy advise the patient that some patients can start to respond n 1-2 weeks but for others it may take 3 months. Organise a review at 3 months. A diary may be helpful for assessment.
Our Case: Sarah
Over the counter analgesia has not helped her migraine so she was started on a triptan and advised to use only two days a week. As she has 12 headache days a month and a tricyclic had not helped and propranolol contra-indicated dueto asthma she was started on candesartan. This initially made her dizzy but this settled after 2 weeks and she was able to increase the dose to 16 mg. Aftertaking this dose for 8 weeks her migraine frequency fell to 8 days a month and her triptan worked for 3 out of 4 migraine to resolve the attack within 2 hours. As she still had more than 4 migraine days a month a Gepant was added as a preventer, After 3 months her migraine days had fallen to 3. She was keen to continue with both preventers and will be reviewed at12 months.
When to refer
Referral to neurology or a headache service should be considered if:
- Diagnostic uncertainty remains
- Red flags for secondary headache are present
- Preventive therapies available in Primary Care have failed and specialist treatments (Botox or CGRP mAbs) are required
Local referral pathways should be consulted
Key Practical Points for Daily Practice .
Think migraine first – 94% of patients presenting in Primary Care with episodic disabling headaches with a normal neurological examination will have migraine 2. Use PIN diagnostic tool – simple, quick, validated 3. Treat early and adequately – effectiveness diminishes once “brain wind-up” occurs 4. Consider combination therapy – triptan + NSAID + anti-emetic often more effective 5. Address medication overuse – common cause of treatment failure 6. Prevention is underused – consider earlier, especially if >4 headache days/month 7. New options available – Gepants offer additional acute and preventive choices
References available on request
