Migraine: typical features and diagnosis
Migraine is typically a one-sided, throbbing headache with untreated attacks in adults lasting 4 to 72 hours, and as a primary headache it is not caused by another disease.
Remember
In adults, an untreated migraine attack typically lasts 4 to 72 hours, with throbbing pain on one side and either nausea or sensitivity to both light and sound.
Memory aid
migraine is a throb on one side of the head that sends you to a dark, quiet room
Picture the throb and the retreat to a dark, quiet room to recall the classic pattern.
Migraine is a primary headache, which means no other disease causes it. People are well between attacks, and the examination between attacks is normal.
Migraine usually presents as a unilateral (one-sided) headache that is often described as throbbing or pulsating. Untreated attacks in adults last from 4 to 72 hours. Light and noise typically aggravate the headache, and patients may report photophobia (sensitivity to light) and phonophobia (sensitivity to sound). Nausea often goes with it. People tend to prefer a dark, quiet room, and sleep often helps.
Some attacks are preceded by an aura, a temporary warning symptom such as flashing lights. An aura is not needed for the diagnosis, because migraine can occur without one.
For migraine without aura, NICE CKS asks for two or more of these: pain on one side, a pulsating quality, moderate or severe pain, and worsening with routine activity. These come with either nausea or both photophobia and phonophobia.
In most people, migraine begins before 30. Women are affected more than men, and the severity tends to fall with age.
Compare tension-type headache, the most common primary headache. Its pain is usually bilateral, pressing or tightening, mild to moderate and not worsened by routine activity, and it usually has no nausea. It is allowed no more than one of photophobia or phonophobia, and it can last 30 minutes to 7 days.
Key facts
- Pain
- usually one-sided and throbbing.
- Duration
- untreated attacks in adults last 4 to 72 hours.
- Light and noise
- Light and noise typically aggravate the headache, and people tend to prefer a dark, quiet room.
- Diagnosis of migraine without aura
- two or more of one-sided pain, a pulsating quality, moderate or severe pain and worsening with routine activity, plus nausea or both photophobia and phonophobia.
- Between attacks
- a normal examination fits a primary headache.
- Tension-type headache
- usually bilateral and pressing, with no more than one of photophobia or phonophobia, and episodes that can last 30 minutes to 7 days.
Exam traps
- A headache that is often worst on waking and eases through the day is linked to raised pressure inside the skull, so it is not a typical migraine feature.
- A thunderclap headache (a sudden, severe pain that reaches maximum intensity within minutes) may indicate subarachnoid haemorrhage (a bleed around the brain), so it is an emergency and not a benign migraine feature.
- Mild or moderate pain that routine activity does not worsen points to tension-type headache rather than migraine, because migraine pain is usually moderate or severe and is aggravated by, or leads the person to avoid, routine activity.
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