Call your local emergency number or go to an emergency department for a sudden, explosive headache that reaches full strength within minutes, the worst headache of your life, or a headache with weakness, slurred speech, loss of vision, confusion, drowsiness, fever with a stiff neck, or after a head injury.
Key points
- Migraine is a common, often lifelong condition. Attacks of moderate to severe, usually throbbing pain last 4 to 72 hours in adults, with nausea or sensitivity to light and sound, and get worse with routine activity.
- Some people with migraine have aura: reversible visual, sensory or speech symptoms that build up over at least 5 minutes and last 5 to 60 minutes.
- A headache that peaks within 5 minutes, comes with new neurological symptoms or fever, follows head injury, or is new after age 50 needs urgent assessment, not a migraine label.
- Taking triptans, opioids or combination painkillers on 10 or more days a month, or paracetamol, aspirin or NSAIDs on 15 or more days a month, for 3 months or longer can cause medication-overuse headache.
- NICE advises a triptan combined with an NSAID or paracetamol for acute migraine, and does not recommend opioids or ergots.
What migraine is and who gets it
WHO estimates that headache disorders affect about 40% of the world's population (3.1 billion people in 2021), and that migraine is the third highest cause of disability-adjusted life years worldwide, after stroke and neonatal encephalopathy. Migraine often begins around puberty, is most common between ages 35 and 45, and affects women more than men, probably because of hormonal influences. In children, attacks are usually shorter and abdominal symptoms more prominent.
The NINDS describes four possible phases:
- Prodrome: hours to days before the pain, with food cravings, mood changes, repeated yawning or passing urine more often.
- Aura (only some people): usually visual, such as dots, zigzags, flashing lights or partial loss of vision, but also pins and needles, numbness or difficulty speaking.
- Headache: usually one-sided and throbbing, building up gradually, with nausea, vomiting and sensitivity to light, sound or smell.
- Postdrome: exhaustion, poor concentration, dizziness or mood change for up to 2 days.
NICE calls migraine chronic when headache occurs on 15 or more days a month for more than 3 months, with migraine features on at least 8 of those days. Menstrual-related migraine is suspected when attacks mainly start between 2 days before and 3 days after a period begins, in at least 2 of 3 cycles.
How migraine differs from other primary headaches
- Tension-type headache: pressing or tight, on both sides, mild to moderate, not worsened by routine activity and without nausea or aura.
- Cluster headache: severe pain on one side, around or above the eye, lasting 15 to 180 minutes. It comes with restlessness and a red or watery eye, runny or blocked nostril, drooping eyelid or small pupil on the same side.
- Migraine: one- or both-sided, pulsating, moderate to severe, worsened by activity, with nausea or light and sound sensitivity.
Common triggers
Triggers vary between people. NINDS and WHO list:
- too much or too little sleep, or a change in routine
- emotional stress (some people have attacks at weekends after a stressful week)
- hormonal changes, especially around periods or in pregnancy
- alcohol and certain foods or drinks
- sudden changes in weather or environment, and loud or sudden noise
A headache diary helps. NICE suggests recording, for at least 8 weeks, how often headaches occur and how long and severe they are, other symptoms, every medicine taken (including over-the-counter ones), possible triggers, and any link to periods. Regular sleep and meals, enough fluids, exercise and limiting alcohol help many people.
Red flags / when to get urgent help
NICE advises clinicians to evaluate, and consider investigation or referral for, headache with any of these features:
- sudden-onset headache reaching maximum intensity within 5 minutes (thunderclap). MedlinePlus lists bleeding in or around the brain among the emergency causes of headache
- worsening headache with fever
- new weakness, numbness, loss of vision, speech problems, confusion or memory loss, a change in personality, or reduced consciousness
- head injury, typically within the past 3 months
- headache triggered by coughing, straining, sneezing or exercise
- headache that changes with posture (for example, worse on standing or lying down)
- symptoms of giant cell arteritis: headache with visual disturbance or jaw pain on chewing
- symptoms of acute angle-closure glaucoma: headache with a painful red eye, misty vision or haloes
- a substantial change in the usual pattern of headaches
- new headache in someone with weakened immunity (such as HIV or immunosuppressive drugs), a cancer that can spread to the brain, or vomiting without another clear cause
MedlinePlus adds: the first severe headache of your life, a headache described as "the worst ever" even in someone who has migraine, one that worsens over 24 hours, fever with a stiff neck and vomiting, and new headaches after age 50.
Aura that is not typical also needs assessment: weakness of an arm or leg, double vision, visual loss in one eye only, poor balance, or reduced consciousness. Do not assume these are migraine, especially at a first episode: MedlinePlus lists stroke among the emergency causes of headache with these symptoms.
Medication-overuse headache
WHO describes medication-overuse headache as the most common secondary headache disorder, affecting up to 5% of some populations. It is present on more days than not and is often worst on waking. NICE advises suspecting it when headache has developed or worsened in someone taking, for 3 months or more:
- triptans, opioids, ergots or combination painkillers on 10 or more days a month, or
- paracetamol, aspirin or an NSAID, alone or in any combination, on 15 or more days a month.
Treatment is to stop all overused acute medicines for at least 1 month. NICE advises stopping abruptly rather than gradually, except for opioids, where withdrawal needs specific guidance. Headaches usually get worse before they improve, so close follow-up and support help. A preventive treatment for the underlying migraine may be started at the same time.
How migraine is treated (NICE CG150)
- Acute treatment: a triptan combined with an NSAID or paracetamol, or one of these alone (a triptan, an NSAID, aspirin 900 mg or paracetamol). Take it early in the attack. For people aged 12 to 17, a nasal triptan is preferred. Aspirin should not be given to children under 16 because of the risk of Reye's syndrome. An anti-sickness medicine can be added. Opioids and ergots are not recommended.
- When triptans fail: NICE recommends an oral CGRP-blocking medicine (gepant) for adults in whom at least 2 triptans did not work well enough, or in whom triptans were unsuitable and NSAIDs and paracetamol did not work well enough.
- Prevention: propranolol, topiramate or amitriptyline, after discussing benefits and risks. Topiramate must not be used for prevention in pregnancy, or in women who could become pregnant unless they meet pregnancy-prevention conditions including highly effective contraception. Riboflavin 400 mg daily may help some people. CGRP medicines, rimegepant and botulinum toxin (for chronic migraine) are options after 3 preventives have failed. Preventive treatment should be reviewed 3 to 6 months after starting.
- Pregnancy: paracetamol is first choice for an attack. A triptan or NSAID can be considered after discussing the risks. Seek specialist advice if prevention is needed.
- Contraception: NICE advises against routinely offering combined hormonal contraceptives to women and girls who have migraine with aura.
Rules on which medicines are licensed or available differ between countries. Sumatriptan, for example, is not available everywhere (WHO).
Frequently asked questions
Do I need a brain scan for migraine?
Usually not. NICE advises against scanning people with a typical migraine diagnosis solely for reassurance. A scan or urgent referral is needed when red-flag features are present.
Can migraine aura look like a stroke?
It can. Typical aura spreads gradually over at least 5 minutes and fully resolves within an hour. Sudden weakness, loss of vision in one eye, double vision, poor balance or confusion, especially for the first time, need emergency assessment.
How often can I take painkillers for headaches?
Keep triptans, opioids and combination painkillers to fewer than 10 days a month, and simple painkillers to fewer than 15 days a month. If you need them more often, ask about preventive treatment.
Is caffeine good or bad for migraine?
NINDS notes that small amounts of caffeine may help early in an attack. Record caffeine in your headache diary alongside other food and drink, as NINDS suggests, to see whether it plays a part for you.
Sources
- NICE. Headaches in over 12s: diagnosis and management (CG150), last updated June 2025. nice.org.uk/guidance/cg150
- US National Institute of Neurological Disorders and Stroke. Migraine. ninds.nih.gov
- World Health Organization. Migraine and other headache disorders, fact sheet. who.int
- MedlinePlus. Headaches: danger signs. medlineplus.gov
This article is for education and does not replace advice from a doctor or pharmacist who knows the person's history. A new or changed headache should be assessed by a clinician.
