Migraine

Second leading cause of disability worldwide, and the leading cause of disability in women under 50. See headache for the broader differential.

Presentation

• Migraine without aura, migraine with aura, or chronic migraine (headache ≥15 days/month, migraine on ≥8 of those days).
• Attacks last 4–72 hours — throbbing/pulsating, typically unilateral, moderate–severe, aggravated by physical activity.
• Nausea/vomiting, photophobia and phonophobia are common.
• Aura — gradually developing, fully reversible, typically unilateral neurological disturbance (visual, sensory, speech/language, motor, brainstem or retinal), usually developing over 5–20 minutes and lasting <60 minutes (motor symptoms can rarely persist up to 72 hours); precedes or accompanies the headache.

Management

Lifestyle measures

Regular sleep; regular meals and minimal blood-glucose variation; adequate hydration (1.5–2L/day); limit caffeine (1–2 cups/day); regular exercise (30–40 min, 3–4×/week — walking is a good low-provocation option); good workplace/computer ergonomics with regular breaks; a relaxation technique (meditation, mindfulness, yoga, breathing, progressive muscle relaxation, biofeedback, CBT) especially if stress is a trigger; avoid known triggers (alcohol, MSG, citrus, chocolate, preserved meats, perfume); physiotherapy for postural/neck-tightness contributors. A 3-month trial of magnesium, riboflavin or ubidecarenone (CoQ10) is reasonable given low harm, despite weak evidence.

Non-pharmacological (acute)

Cold packs over the forehead/occiput (supraorbital/greater occipital nerves); hot packs over neck/shoulders; neck stretches/self-mobilisation; rest in a quiet, dark room.

Acute episode

• At onset: NSAID + paracetamol + antiemetic (oral/IM metoclopramide, or oral/rectal prochlorperazine).
• If simple analgesia is ineffective, add or switch to a triptan:
  • Eletriptan 40–80mg PO (max 160mg/24h)
  • Naratriptan 2.5mg PO (max 5mg/24h)
  • Sumatriptan 50–100mg PO (max 300mg/24h) — also available intranasal or IM for significant nausea/vomiting
  • Rizatriptan 10mg PO (max 30mg/24h)
  • Failure of one NSAID/triptan doesn’t preclude response to another.
• Limit nonopioid analgesic use to <15 days/month and triptan/opioid use to <10 days/month — more frequent use risks medication overuse headache.
• If no improvement or worsening, consider ED transfer for IV fluids and parenteral therapy (chlorpromazine infusion, IM droperidol, or IV prochlorperazine).
• Consider preventive treatment for frequent/disabling migraine (below).

Long-term (preventive) management

Offer prophylaxis for ≥2 attacks/month causing ≥3 days’ disability. Trial each agent 8–12 weeks at the maximum tolerated dose before judging efficacy.

First-line:

• Beta blockers — propranolol 20mg nocte, increase by 20mg weekly to max 160mg/day in 2–3 doses (or a beta-1 selective agent — atenolol, metoprolol — if propranolol isn’t tolerated). Avoid in COPD/asthma; watch for hypotension, bradycardia, depression.
• TCAs — useful with comorbid depression, tension-type headache or sleep disturbance. Amitriptyline 10mg nocte, increase by 10mg weekly to max 75mg/day; nortriptyline as an alternative if sedation/dry mouth limit amitriptyline.
• Pizotifen 0.5mg nocte, increase by 0.5mg weekly to max 1.5–3mg/day (weight gain is the main adverse effect — evening dosing reduces this).
• Verapamil SR 90mg daily, increase slowly over 3 weeks to max 240mg/day.
• Candesartan 4mg daily, increase by 4mg weekly to max 32mg/day.

Second-line (first-line per eTG):

• Topiramate 25mg nocte, titrate to max 50mg BD (paraesthesia, word-finding difficulty, teratogenic, may cause weight loss).
• Sodium valproate 200mg nocte, increase by 200mg weekly to max 500mg BD (weight gain, teratogenic — risk highest >1100mg/day).

Other/specialist options: candesartan up to 16mg/day, riboflavin 400mg/day. Refer to neurology for:

• Botulinum toxin — PBS criteria: ≥15 headache days/month with ≥8 migraine days, over ≥6 months, with inadequate response/intolerance/contraindication to ≥3 prophylactic medications; medication overuse headache must be managed first.
• CGRP monoclonal antibodies — galcanezumab, fremanezumab, and eptinezumab (100mg dose) are PBS-listed for chronic migraine under similar failed-prophylaxis criteria to botulinum toxin above; erenumab remains TGA-approved but private-script only. See the guideline update below for detail.

Menstrual migraine

Short-term prophylaxis if cycles are regular and attack timing predictable — start 24–48h before expected menses, continue to the last day of bleeding: naproxen MR 750mg–1g daily for 5–7 days (starting 2–3 days pre-menses); mefenamic acid 500mg TDS; ibuprofen 400mg TDS for 5–7 days; naratriptan 1.25–2.5mg BD for 5–7 days; or transdermal oestradiol (50–100µg patch for up to 7 days, or 0.1% gel 1g daily). Continuous COCP (skipping placebo pills) may help long-term prevention of menstrual migraine without aura. Avoid COCP in migraine with aura (stroke risk) — use progestin-only contraception instead.

Migraine with HRT or COCP

COCP can worsen migraine and is an absolute contraindication in migraine with aura (progestin-only methods are safe). Consider lower-dose oestrogen HRT preparations for migraine without aura, or stopping oestrogen if migraine worsens. If COCP is continued and migraine persists, manage as menstrual migraine.

Migraine in pregnancy/breastfeeding

Migraine often improves in pregnancy. Triptans are contraindicated in pregnancy. Paracetamol is safe in pregnancy/breastfeeding. NSAIDs are safe in the 1st/2nd trimester and breastfeeding. Metoclopramide is safe in pregnancy/ breastfeeding. Eletriptan and sumatriptan are considered safe in breastfeeding. For severe refractory migraine: IV rehydration, short IV magnesium sulfate, or oral prednisolone 50mg daily for 2 days then stop. Propranolol/metoprolol are pregnancy category C with safety not established.

Referral

Non-acute neurology referral if: severe/frequent headaches despite ≥3 preventers and/or ≥4 days/month lost from work or study; prolonged neurological symptoms; sudden deterioration of the usual pattern; acute treatment needed >8–10 days/month without response to prophylaxis; recurrent ED/hospital treatment; isolated aura without headache; diagnostic uncertainty.