Neurology · Full case

Migraine

NICE CG150CKS 2023ICHD-3

≥5 attacksICHD-3 minimum for migraine without aura diagnosis

4–72 hoursTypical untreated migraine attack duration

≥15 daysMOH threshold: analgesics/NSAIDs per month for 3+ months

≥10 daysMOH threshold: triptans, opioids, ergotamines per month

UKMEC 4Combined OCP + migraine with aura — absolute contraindication

≥50%Minimum attack frequency reduction to define prophylaxis success

3 monthsMinimum trial of each preventive therapy before switching

≥4/monthAttack frequency threshold for considering preventive therapy

📋 Clinical Stem — Worsening Recurrent Headaches with New Aura

A patient with a long history of migraine presenting with new visual symptoms and escalating medication use

Aisha Rahman, a 32-year-old secondary school teacher, attends with a 2-week history of worsening headaches. She has had migraines since age 24 — typically 2–3 per month, unilateral, throbbing, with nausea and light sensitivity, lasting around 18 hours. Over the past 4 months she has noticed new visual zigzag patterns before some headaches (lasting 20–30 minutes). She started Rigevidon (combined oral contraceptive) 4 months ago for contraception and period regulation. She is now taking ibuprofen and codeine-containing tablets on approximately 18 days per month. She has tried sumatriptan (12 uses last month) but "it's barely working any more." She is frustrated and frightened. Her aunt had a stroke aged 42. Aisha is aware there is "some connection" between migraines and the pill but does not know the specifics.

This stem bundles three of the highest-stakes clinical decisions in migraine management: recognising new aura as a change in migraine phenotype; identifying the UKMEC 4 absolute contraindication between combined OCP and migraine with aura; and diagnosing concurrent medication overuse headache (MOH) from analgesic and triptan overuse. The SCA challenge is managing these three urgent issues compassionately while not alarming the patient about stroke risk before explaining the plan.

Scenario A — Migraine Without Aura (Classic Presentation) 28-year-old woman, 4-year history of 3–4 migraines/month, POUND criteria met, no aura, no contraception concerns. First presentation — establish diagnosis, initiate acute treatment (triptan + NSAID + antiemetic), and discuss prophylaxis threshold.

Scenario B — Medication Overuse Headache (MOH) 45-year-old, daily or near-daily headaches for 6 months, takes codeine-paracetamol and triptans on ≥12 days/month. Headaches worse in the morning, present on waking. Explain MOH mechanism; stop overused medications; bridge with naproxen; warn of 2–4-week withdrawal period.

Scenario C — Thunderclap Headache (Red Flag DDx) 38-year-old, sudden-onset "worst headache of my life," maximal intensity in under 60 seconds, with neck stiffness. Not a migraine — subarachnoid haemorrhage until proven otherwise. 999, CT head, LP if CT negative. Do not manage as migraine.

Scenario D — Menstrual Migraine 34-year-old, migraines exclusively 2 days before and on the first 3 days of menstruation, not at other times. Perimenstrual prophylaxis with frovatriptan or short-course naproxen. Combined OCP contraindicated if migraine with aura. POP or non-hormonal contraception.

Scenario E — Migraine in Pregnancy / Breastfeeding 29-year-old, 18 weeks pregnant, severe migraine. Avoid triptans in first trimester (limited evidence; sumatriptan acceptable if benefit outweighs risk). Paracetamol first-line. Aspirin low-dose for migraine in pregnancy is used. Valproate and topiramate are absolutely contraindicated in pregnancy — never use. Propranolol safe for prevention in pregnancy.

Key variables to adapt for Presence or absence of aura, combined OCP use (UKMEC 4 if aura), frequency and number of attacks per month (prophylaxis threshold ≥4/month), analgesic/triptan use frequency (MOH screen), pregnancy and breastfeeding status, and cardiovascular risk factors affecting triptan safety.

Steps:

Step 1

History Taking — Open Question First · Targeted Questions · ICE · Psychosocial Context

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A migraine history has three layers that must be explored simultaneously: confirming the migraine diagnosis (ICHD-3 / POUND criteria), screening for red flags that mandate urgent imaging, and uncovering the medication use pattern that may itself be driving the headache through medication overuse headache (MOH). In a patient on a combined OCP with new visual aura, there is a fourth layer: the UKMEC 4 absolute contraindication that requires the pill to be stopped immediately. Miss any one of these and the consultation has failed — however well-intentioned the management plan.

🎓 Consultation opener — acknowledge the distress before the agenda

"I can see from your notes that you've been dealing with worsening headaches. Before I ask anything specific — can you just tell me, in your own words, what's been happening? Take as much time as you need."

Migraine patients are frequently frustrated, undertreated, and dismissed. Opening with an invitation to tell their story — before clinical interrogation — establishes the rapport needed to uncover the medication use pattern, the contraceptive context, and the family stroke fear that will not emerge in a structured PQRST history.

1A — Start with an open question: let the patient lead, then move to targeted questions

Question to ask	Why it matters clinically	Changes what?
🟢 OPEN QUESTION — always start here"Can you describe what these headaches are like — where they are, what they feel like, and what happens when one comes on?"	The spontaneous narrative reveals the POUND features (Pulsating, One-day duration 4–72h, Unilateral, Nausea/vomiting, Disabling) without leading the patient. 4 out of 5 POUND features has a positive predictive value of 93% for migraine. The patient's own description also reveals features that raise red flags — "worst headache of my life," "came on like a thunderclap," "different from all my previous headaches" — none of which emerge reliably from structured closed questions.In SCA: a candidate who immediately asks "is it one-sided?" has led the diagnostic process in a direction that can falsely confirm or falsely exclude migraine. The unprompted narrative is the most diagnostically valid data source.	POUND criteria + red flag screenAcute vs prophylaxis thresholdMedication overuse pattern
Has anything changed recently?"You said these have been different recently. What's different? New symptoms, new pattern, more frequent, not responding to treatment as well as before?"	A change in headache pattern is a significant clinical signal. New aura is a phenotype change that immediately raises the UKMEC 4 question if the patient is on a combined OCP. "Not responding to treatment" may be MOH — the treatment itself making the headaches worse. Increased frequency in a patient on a combined OCP may be OCP-related. New features in a longstanding headache sufferer are often the most clinically important part of the consultation and are most likely to be underemphasised if not specifically asked about.Migraine can evolve over time — migraine without aura can develop aura; episodic migraine can transform into chronic migraine (≥15 headache days/month for >3 months). Each transformation has specific management implications.	Phenotype change: aura, chronificationUKMEC 4 if new aura + COCNeurology if unusual features
Describe the aura — exactly what happens?"You mentioned flashing lights or zigzag patterns — can you describe exactly what you see, how long it lasts, and what happens to the headache afterwards?"	Typical migraine aura: fully reversible visual, sensory, or speech/language symptoms lasting 5–60 minutes, which precede or accompany headache. Visual aura is most common: a scintillating scotoma (zigzag arc of lights growing towards the periphery), fortification spectra (herringbone pattern), or hemianopia. Aura ≥60 minutes = prolonged aura; motor weakness = hemiplegic migraine — different safety profile for triptans. Aura without headache ("acephalgic migraine" or "silent migraine") is common in older patients. Basilar-type aura (vertigo, tinnitus, diplopia, ataxia) requires specialist review before triptan use.The critical clinical question is: is this reversible aura, or a fixed neurological deficit? Fixed deficit = TIA/stroke until proven otherwise. Duration, complete reversibility, and the march of symptoms (spreading over minutes, not seconds) distinguish migraine aura from focal ischaemia.	Aura type: visual vs hemiplegic vs basilarUKMEC 4 if typical aura + COC; triptan choiceFixed deficit → TIA protocol
POUND criteria — all five"Is it one-sided or all over? Is it throbbing or pressure-like? Does it make you feel sick or vomit? Does light or sound bother you? Can you carry on with what you're doing, or do you need to stop?"	POUND mnemonic (Pulsating, One-day duration 4–72h, Unilateral, Nausea, Disabling): the clinical diagnosis of migraine requires ≥2 of unilateral, pulsating, nausea/vomiting, photophobia/phonophobia, plus moderate-severe pain that worsens with activity. 4/5 POUND features: 93% PPV for migraine. 3/5: 64% PPV. These figures apply to the trained clinician — confirmation by specialist ICHD-3 assessment is higher still. Photophobia + phonophobia during attacks is almost universal in migraine and almost never present in tension-type headache.Osmophobia (sensitivity to smells) is also common in migraine and is highly specific — rarely present in other headache types. Ask if not volunteered.	Migraine vs tension-type vs clusterICHD-3 confirmation for triptan prescribing
Attack frequency and duration — precise numbers"How many of these headaches do you have per month on average? How long does each one last? How many days in the last month did you have a headache of any kind?"	This question defines the prophylaxis threshold and screens for MOH simultaneously. ≥4 migraine attacks per month = NICE CG150 threshold for considering preventive therapy. Headaches on ≥15 days/month for ≥3 months = chronic migraine (suspect MOH if using analgesics/triptans frequently). The total number of headache days per month, regardless of type, gives the clearest picture of the headache burden. Documenting baseline frequency is essential before starting prophylaxis (to measure the ≥50% response).Patients frequently undercount their headache days — they record only migraine attacks, not the lower-grade headaches that are part of MOH. Ask specifically about "any headache, even mild" for accurate count.	Prophylaxis indication if ≥4/monthChronic migraine vs MOHNeurology if ≥15 days/month
Full medication use inventory"What do you take for the headaches — and exactly how many days per month do you take each medication? Have you been told about sumatriptan or other prescription treatments?"	Medication overuse headache (MOH) is the single most common cause of headache transformation from episodic to near-daily. NICE CG150 defines MOH as: regular use of simple analgesics (aspirin/paracetamol/NSAIDs) ≥15 days/month, or triptans/opioids/ergotamines ≥10 days/month, for ≥3 months. The headaches caused by MOH paradoxically worsen with more medication use — creating a treatment trap. MOH affects up to 5% of the general population and is undertreated. The treatment is stopping the overused medication — which causes a 2–4-week withdrawal period before improvement.Patients are often resistant to the diagnosis of MOH because they feel they are "just treating their pain." The analogy of a thermostat stuck in the "on" position — the medication lowers the threshold for the next headache — is the most helpful explanatory frame.	MOH diagnosis (≥10/15 days/month)Withdrawal + bridge therapy required"Am I addicted?" hidden agenda
Contraception and reproductive status"Are you using any hormonal contraception? Which one, and how long have you been on it? Are you planning to become pregnant? Are you breastfeeding?"	This is the single most important safety question in migraine for women of reproductive age. Combined oral contraceptive (oestrogen-containing) + migraine with aura = UKMEC Category 4 (absolute contraindication). The risk is ischaemic stroke — oestrogen + aura increases risk approximately 6-fold compared with oestrogen alone. The combined OCP must be stopped and alternative contraception offered (POP, implant, IUD are all UKMEC 1 or 2 for migraine with aura). This conversation must happen before the end of the consultation — even if the patient is not expecting it.The UKMEC 4 classification (absolute contraindication) means: do not initiate, do not continue. It is a medico-legal obligation. Document the conversation, the decision, and the alternative contraception offered at every consultation where this combination is identified.	UKMEC 4: stop COC immediatelyCOC + aura + smoking: very high stroke riskContraception counselling mandatory
Triggers — identified and trackable?"Have you noticed anything that reliably brings on a migraine? Changes in sleep, missed meals, dehydration, alcohol, stress, hormonal changes, bright light, strong smells, caffeine — including caffeine withdrawal?"	Common migraine triggers: sleep disruption (most potent — both too little and oversleeping on weekends can trigger), dehydration, skipped meals (hypoglycaemia), caffeine withdrawal (the "weekend migraine"), alcohol (especially red wine and beer — histamine, tyramine), stress and stress let-down, hormonal fluctuations (menstrual migraine in 50–60% of women). Trigger identification enables non-pharmacological prevention — often more effective than any drug. A headache diary (paper or app: Migraine Buddy, Healow) allows systematic identification over 4–8 weeks.The "weekend headache" in a coffee-drinker is almost invariably caffeine withdrawal — the headache that seems to undermine all plans for a relaxing Saturday is a recognised migraine trigger. Stable, moderate caffeine intake prevents this more effectively than caffeine cessation, which often causes a worse withdrawal period.	Lifestyle triggers: non-pharmacological preventionSleep, caffeine, meal regularity
Premonitory and postdromal features?"Before the pain starts, do you get warning signs — yawning, food cravings, feeling irritable or 'foggy', neck stiffness? And after the headache — do you feel drained or washed out for a day or two?"	Migraine is a four-phase neurological condition: prodrome (hours to days before — yawning, food craving, mood change, neck stiffness, photosensitivity), aura (visual/sensory/speech), headache phase, and postdrome ("migraine hangover" — fatigue, cognitive fog, nausea for 24–48 hours). Recognising the prodrome allows early treatment — triptan taken at onset of aura or early headache phase is significantly more effective than delayed dosing. Postdromal symptoms significantly extend the total disability burden beyond the headache days.Neck stiffness in the prodrome is commonly mistaken for tension-type headache by both patients and clinicians. It is a prodromal symptom of migraine, not a separate neck problem. Physiotherapy and NSAID-for-neck-pain approaches in this context miss the diagnosis entirely.	Prodrome confirms migraine; excludes tension-typeEarly dosing strategy for triptans
Previous treatments — what has worked, what hasn't?"What have you tried for the headaches — over the counter and prescribed? What has helped? What has made things worse or not helped at all?"	Treatment history guides prescribing directly. Triptan non-response to one triptan does not predict response to all — different triptans have different pharmacokinetics and routes of administration (oral, nasal, subcutaneous). OTC analgesia that has worked in the past at ≤15 days/month is very different from the same treatment that is now overused. Codeine-containing compounds (co-codamol) are specifically linked to the highest rates of MOH and should be specifically screened for.Key prescribing principle in migraine: triptans should be taken at the first sign of headache (not waiting for it to become severe), with an NSAID or antiemetic simultaneously. Late dosing (waiting until the headache is severe) dramatically reduces triptan efficacy because central sensitisation has already occurred.	Triptan choice + combination + timingCodeine/opioid overuse = highest MOH risk
Family history of migraine, stroke, or CVD?"Do migraines run in your family? Has anyone in your family had a stroke, particularly at a young age?"	Migraine has a strong genetic component — 50–60% of patients have a first-degree relative with migraine. A positive family history supports diagnosis and helps explain the condition to the patient. Importantly, family history of stroke in a patient with migraine with aura who is on a combined OCP represents compounded risk — both the aura and the OCP are independent risk factors for ischaemic stroke, and a family history of stroke amplifies this further.CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is a rare genetic condition presenting with migraine with aura, strokes, and cognitive decline — consider in young patients with atypical aura + strong family history of early stroke. MRI white matter hyperintensities are the clue.	CADASIL screen if unusual aura + family strokeCOC absolute CI amplified by stroke FH
Impact on daily life, work, and relationships?"How much are the headaches affecting your work, your time with family, and how you feel about yourself? Have you had to take time off work?"	MIDAS (Migraine Disability Assessment Score) quantifies missed or significantly impaired days across paid work, household work, and non-work activities in the last 3 months. MIDAS Grade I (<6 days) = minimal disability; Grade IV (>21 days) = severe disability. Documenting disability justifies treatment decisions (especially prophylaxis), supports occupational health referrals, and ensures the full burden of migraine — which is invisible to others — is recognised and validated in the clinical record.Migraine is the second leading cause of disability years globally (Global Burden of Disease 2019). In women aged 15–49, migraine is the leading cause of disability years. This clinical impact is routinely underestimated in primary care because patients appear well between attacks.	MIDAS ≥11 → prophylaxis strongly indicatedOccupational impact; psychosocial disabilityOccupational health if significant work impact

1B — Red flags: must not miss · must ask · must act

🚨

Red Flags — act before continuing history

Red flag	Why dangerous	Action
Thunderclap headache — "worst headache of my life," maximal intensity within 60 seconds	Subarachnoid haemorrhage until proven otherwise. SAH presents as a sudden-onset, maximal-intensity headache — often with photophobia, neck stiffness, and nausea. The history alone cannot distinguish severe migraine from SAH. CT head within 6 hours of onset has ~98% sensitivity. If CT negative, LP at 6–12 hours is mandatory (xanthochromia).	999 immediately — CT head urgently
New neurological focal signs with headache — fixed motor, sensory, visual, or speech deficit	A fixed neurological deficit (does not resolve in 60 minutes, or does not follow the typical spreading/marching pattern of migraine aura) = TIA or stroke until proven otherwise. Cerebral venous thrombosis (CVT) can present with progressive headache + focal signs — particularly in women on combined OCP or in the postpartum period. CVT is progressive and life-threatening without anticoagulation.	999 — stroke protocol
Fever + headache + photophobia + neck stiffness (Kernig's / Brudzinski's positive)	Bacterial meningitis or viral encephalitis — photophobia and headache without fever and neck stiffness can resemble migraine. Neck stiffness in meningitis is a cardinal sign. Non-blanching petechial rash = meningococcal disease. Do not delay 999 while performing LP or waiting for CT.	999 — IV benzylpenicillin before transfer if meningococcal suspected
New headache in patients aged ≥50 — particularly temporal, with jaw claudication or scalp tenderness	Giant cell arteritis (GCA / temporal arteritis) — untreated causes irreversible blindness within 24–72 hours of visual symptoms. Urgent ESR + CRP. High-dose prednisolone (40–60mg) must be started immediately without waiting for temporal artery biopsy results if clinical suspicion is high.	Same-day ESR + CRP + prednisolone if suspected GCA
Progressive headache worsening over days/weeks with early morning onset, worse lying down, or associated with vomiting	Raised intracranial pressure from space-occupying lesion (tumour, abscess, subdural haematoma). Classic features: worse in the morning (recumbent position increases ICP overnight), vomiting without preceding nausea, worsened by Valsalva/bending. Papilloedema on fundoscopy = raised ICP until proven otherwise.	Urgent MRI brain / CT head same week
New onset headache in immunocompromised patient (HIV, on steroids, on immunosuppressants) or with systemic features (fever, night sweats, weight loss)	CNS opportunistic infection (cryptococcal meningitis, cerebral toxoplasmosis, CNS lymphoma). Cryptococcal meningitis presents with subacute progressive headache in HIV — may lack classic meningeal signs. In oncology patients: leptomeningeal carcinomatosis or CNS metastases.	Same-day emergency department review

🛡️

Safeguarding Considerations — Consider in Every Consultation

Migraine can mask serious harm and can itself be caused by harm. Recurrent headaches in children or adults may be a somatic manifestation of psychological abuse, domestic violence, or trafficking. Conversely, patients with severe migraine who are prescribed opioids or benzodiazepines may be at risk of medication diversion, misuse, or having their medication controlled by a partner.

🏠 Domestic Abuse & Trauma-Related Headache

Post-traumatic headache (cervicogenic from whiplash or head trauma) may be misdiagnosed as migraine — ask specifically about head or neck injuries and whether they occurred in a safe context
Psychological abuse, coercive control, and chronic stress are potent migraine triggers — a patient with worsening migraine frequency should prompt a brief DASH/SAFE enquiry about home safety
Patients presenting with very frequent headaches requiring strong analgesics may be at risk of medication diversion or inappropriate prescribing relationships — ensure prescriptions are given directly to the patient
Brain injury from repeated physical abuse (repeated head trauma) can cause chronic daily headache that mimics migraine — ensure the history is taken confidentially without the partner present

👴 Older Adults — New Headache Flags

New onset headache in an older adult is GCA, intracranial tumour, or subdural haematoma until proven otherwise — do not attribute to migraine without exclusion of these conditions
Subdural haematoma from a fall (especially in patients on antiplatelets or anticoagulants) may present as a progressive headache weeks after a seemingly minor head injury — ask specifically about falls and head injuries in older adults presenting with new or changed headache
Cognitive impairment prevents accurate symptom reporting — collateral history from carers is essential; "new headache" in a patient with dementia may represent a serious intracranial event
Financial abuse: patients on regular prescription opioids for migraine may have medications taken by family members or carers — explore if medication "runs out" faster than expected

🧒 Children and Young People

Recurrent headache in a child may be a somatic symptom of bullying, emotional abuse, school avoidance, or domestic tension — explore the psychosocial context fully before attributing to migraine
Migraine under 12 years is frequently bilateral and frontal (atypical for adult migraine), with shorter attack duration and more prominent abdominal symptoms — applying adult criteria may miss the diagnosis
Recurrent abdominal pain ("abdominal migraine") in children 5–12 years — episodic, midline, severe, with nausea and pallor — is a migraine variant; do not over-investigate gastrointestinal causes without considering this diagnosis

💊 Medication Safety & Reproductive Risk

Topiramate is a potent teratogen — patients of childbearing potential on topiramate must have effective contraception documented (Pregnancy Prevention Programme required by MHRA); must never be prescribed without contraception in place
Valproate (sodium valproate) used off-label for migraine prevention carries MHRA black-box teratogenicity warning — absolutely contraindicated in pregnancy; do not prescribe to women of childbearing potential unless Valproate Pregnancy Prevention Programme is in place
Combined OCP + migraine with aura = UKMEC 4 absolute contraindication — must be identified and resolved at every prescription review; failure to do so is a medico-legal risk
Codeine-containing medications and butalbital compounds: high potential for dependence; do not prescribe for acute migraine; identify and support patients already using these for MOH management

If a safeguarding concern is identified: For suspected DV-related headache: complete DASH screening tool in a private consultation; MASH referral if threshold met. For medication concerns: involve the pharmacy team and prescribing supervisor; do not abruptly stop opioids in dependent patients. Topiramate/valproate: every prescription requires contraception confirmation and documented counselling. Document all safeguarding discussions separately and contemporaneously.

1C — PMH · FH · Drug history · Social history: management impact

🧬 PMH / FH — changes management

Factor	Why it matters	Management impact
Cardiovascular disease / hypertension / smoking	Triptans cause mild coronary vasoconstriction — contraindicated in uncontrolled hypertension, ischaemic heart disease, previous MI/stroke, PVD, and Prinzmetal angina. Cardiovascular risk profiling is mandatory before prescribing triptans	Uncontrolled CVD or significant CV risk → avoid triptans; use NSAIDs + antiemetics. Ergotamines absolutely contraindicated in CVD. Consider simple analgesia + antiemetic combination instead.
Depression and anxiety	Major comorbidities of migraine — not incidental. Shared neurological pathways (serotonin, CGRP). Depression worsens migraine threshold. Tricyclic antidepressants (amitriptyline) treat both simultaneously	Amitriptyline 10–50mg ON preferred preventive if comorbid depression/anxiety/insomnia. Avoid propranolol if significant depression. SSRIs: some evidence for migraine prevention (less strong than tricyclics).
Epilepsy	Topiramate treats both epilepsy and migraine — may be particularly useful when both are present. Valproate also used for both (but teratogen) — extreme caution required in women of childbearing potential	Topiramate: NICE-approved for migraine prevention; also antiepileptic. Confirm contraception (Pregnancy Prevention Programme) before prescribing to women of reproductive age. Never use valproate in women unless Valproate PPP in place and contraception confirmed.
Hypertension	Beta-blockers (propranolol, metoprolol) treat both hypertension and migraine. Candesartan (ARB) is an NICE CG150-endorsed migraine preventive and also antihypertensive	Propranolol 40–120mg BD or candesartan 8–16mg OD provides dual clinical benefit. Review BP control as part of migraine management. Avoid propranolol in asthma, heart block, and significant cardiac disease.
Asthma / COPD	Beta-blockers (propranolol) contraindicated in asthma — standard first-line preventive cannot be used	Use amitriptyline or candesartan as first-line preventive instead. Topiramate if above not tolerated. Avoid all beta-blockers including atenolol.
Raynaud's disease	Propranolol (non-selective beta-blocker) can worsen Raynaud's phenomenon — peripheral vasoconstriction	Avoid propranolol if significant Raynaud's. Use amitriptyline or candesartan instead. Triptans generally safe in Raynaud's without CVD.
Renal / liver disease	Triptans (especially almotriptan) have hepatic metabolism; some NSAIDs require caution in renal impairment; topiramate requires dose adjustment in renal impairment	Check eGFR before regular NSAID use. Review topiramate dose in CKD. Avoid NSAIDs in advanced CKD. Sumatriptan: generally safe in mild-moderate renal or hepatic disease.
Previous thromboembolism / thrombophilia	Combined OCP + migraine with aura + thrombophilia represents multiplicatively increased stroke risk. All OCP-containing preparations are absolutely contraindicated in any of these alone; in combination the risk is substantial	Immediate review of contraception. All hormonal contraceptives containing oestrogen contraindicated. POP, implant, or IUD safe (UKMEC 1–2). Haematology involvement if thrombophilia. Aspirin not first-line for migraine prevention but may be relevant in thrombophilia context.

💊 Drug history · Social history — clinical impact

Factor	Why it matters	Management impact
Combined oral contraceptive (COC)	UKMEC 4 absolute contraindication with migraine with aura. No distinction between triphasic, monophasic, or low-dose formulations — all oestrogen-containing pills are equally contraindicated	Stop COC immediately. Offer alternative contraception today: POP (Cerazette/desogestrel), hormonal implant, IUS, copper IUD. Document decision and contraception offered. LARC (IUD/implant) has advantages of not relying on daily adherence.
Analgesic and triptan overuse (codeine, paracetamol, NSAIDs, sumatriptan)	MOH is the commonest cause of headache transformation — headaches become more frequent, less responsive to treatment, and often present on waking. The mechanism is central sensitisation driven by regular analgesic use lowering the headache threshold	Withdrawal of overused medication: abrupt or gradual depending on agent. For opioids/codeine: gradual taper over 4–12 weeks. For triptans/NSAIDs: can usually stop abruptly. Bridge therapy: naproxen 500mg BD for 3–4 weeks. Warn patient of 2–4-week worsening before improvement.
SSRIs and SNRIs	Serotonin syndrome risk when combined with high-dose triptans — theoretical but important. In practice, the risk with standard triptan doses is low but should be discussed. Some SSRIs (fluoxetine, paroxetine) inhibit CYP2D6 and raise sumatriptan levels	Low-dose triptan combinations with SSRIs are generally used in practice (caution, not absolute contraindication). Discuss serotonin syndrome symptoms. Avoid combining with MAOIs (sumatriptan contraindicated with MAOIs within 2 weeks).
MAOIs (phenelzine, tranylcypromine)	Absolute contraindication with all triptans — risk of hypertensive crisis and serotonin syndrome. MAOIs interact with multiple analgesics as well	Do NOT prescribe any triptan to a patient currently on an MAOI or within 2 weeks of stopping. Use simple analgesia and antiemetic combination for acute attacks while MAOI is being weaned.
Caffeine intake and withdrawal	"Weekend migraine" in high daily caffeine drinkers (≥3 cups coffee/day) is caffeine withdrawal. Caffeine withdrawal lowers pain threshold and is a potent migraine trigger in susceptible individuals	Stable, moderate caffeine intake (1–2 cups/day, same time each day) is preferable to elimination or excess. Gradual caffeine reduction if high intake. Caffeinated analgesics are used in some migraine preparations but can contribute to MOH.
Occupation — shift work, irregular schedule, high stress	Irregular sleep patterns from shift work, teaching (term-time stress / holiday let-down), and deadline-driven work are among the most potent migraine triggers. Teaching specifically: dehydration from inability to take regular water breaks, loud environments, fluorescent lights	Occupational health referral if significant disability. Disability record for sick days. Advise regular sleep schedule including weekends; hydration strategy at work. PHQ-9 for work-related stress. Fit note: "migraine — please consider reasonable adjustments including reduced noise, flexible break schedules."
Alcohol (type and pattern)	Alcohol triggers migraine in 30–35% of migraineurs — red wine (tyramine, histamine), beer (congeners), and binge drinking (dehydration). Daily moderate alcohol is a different risk from weekend binge drinking. Alcohol interacts with several migraine preventives (amitriptyline, topiramate)	Document alcohol units/week. Advise reduction or elimination if consistent trigger. Warning: amitriptyline + alcohol = increased sedation. Topiramate + alcohol = cognitive impairment amplified. AUDIT-C screen.
Sleep quality and quantity	Chronic sleep deprivation and oversleeping (weekend lie-in) are independent migraine triggers. Comorbid insomnia is common. Amitriptyline as migraine preventive improves sleep quality and reduces migraine frequency simultaneously	Sleep hygiene counselling at every review. Amitriptyline 10–25mg ON treats insomnia, migraine prevention, and anxiolytic effect simultaneously — particularly useful in the subset with sleep disruption + anxiety + migraine. Avoid zopiclone or z-drugs as these do not address the underlying sleep architecture disruption.

1D — ICE: Ideas · Concerns · Expectations — in every consultation, not just SCA

Migraine patients have almost universally experienced years of their condition being dismissed, undertreated, or misunderstood. Many have internalised the belief that migraine is "just a headache" — a sign of weakness or low pain threshold — rather than a neurological condition with a genetic basis, specific pathophysiology, and evidence-based treatments. ICE in migraine must uncover what the patient thinks is causing their headaches, what specifically they are frightened of (stroke? tumour? the medications?), and what outcome they are seeking today. For Aisha, the ICE elements are layered: she fears stroke because of her aunt's history and the pill; she fears "addiction" to her pain medications; and she expects help but may not be expecting the news that her contraceptive pill needs to stop immediately.

💭 Ideas

"What do you think is causing these headaches to be getting worse? Do you have any thoughts about whether the zigzag patterns before them are connected?"

Many migraine patients with new aura attribute it to stress, eye strain, or a brain tumour — not to a change in their migraine phenotype. Understanding their explanatory model allows you to connect the aura to the contraceptive discussion in a way that is comprehensible. A patient who thinks the auras are from a tumour needs a different conversation than one who suspects the pill is involved.

😟 Concerns

"What's worrying you most about what's happening? Is it the headaches themselves, the visual symptoms, or something else you've been thinking about?"

Stroke fear (family history of stroke at young age + awareness of "migraine-pill link") is the dominant hidden concern — and it must be identified before you break the news about the COC, or the patient will experience the UKMEC 4 discussion as confirmation of their worst fear. Naming the concern first — "I wonder if you're worried about stroke risk" — transforms the conversation from a clinical prescription to a shared response to a named fear.

🎯 Expectations

"What were you hoping we would do today — a referral, a scan, different tablets, or something else entirely?"

Many migraine patients have attended multiple GP appointments without their condition being adequately treated, and have very low expectations of the consultation. Others arrive expecting a brain scan. Knowing which expectation you are working with allows you to either validate it ("a scan makes sense given the new visual symptoms — let me explain why I'm recommending a different approach") or meet it ("I'd like to give you a proper treatment plan today, not just another prescription").

1E — Psychosocial context: the person behind the migraine

Migraine is the second leading cause of global disability years — yet it is among the most trivialised conditions in primary care. The patient with frequent migraine often lives with a secondary burden: years of not being believed, of being told to "just take a paracetamol," of relationships and careers shaped around anticipated pain. Aisha, at 32, is at the peak demographic for migraine. She has a demanding professional role, a contraceptive health crisis developing invisibly, a potential dependency on analgesics she may be using to hold her life together, and a family history that makes every new visual symptom an existential threat. None of this appears on the prescribing history. All of it determines whether she takes her medication and returns for follow-up.

💼 Work, School, and Professional Identity

Teaching during a migraine attack — fluorescent lights, noise, social performance demands, no ability to retreat to darkness — is one of the most provocative migraine environments possible. Teachers with migraine also have the "Monday morning migraine" pattern (weekend sleep-in + caffeine withdrawal) that creates a pattern of Monday sick days that appears unreliable to managers but is neurologically determined.

"Can I ask about work — how much are the headaches affecting your teaching, and what happens when you get one at school? Do you feel you have to push through, or can you get cover?"

Fit note if pattern of attacks disrupts teaching significantly. Reasonable adjustments: access to a dark quiet space during prodrome; flexible break schedule for hydration. MIDAS score documents impairment for occupational records.

🛡️ Contraception, Stroke Fear, and Reproductive Choices

The COC + aura combination is not just a clinical contraindication — it is a reproductive health crisis for a woman in her early 30s who may have started the pill for several reasons (acne, heavy periods, contraception). The discussion about stopping the COC must address: what alternative contraception is available now; what the stroke risk actually is in plain terms; and what happens to her migraine after stopping the pill. Starting the COC may itself have triggered the development of aura.

"I want to talk about your contraceptive pill — and I want to reassure you first that we have good alternatives that are safer for you. Can I explain what's happening and what I recommend?"

Alternative contraception offered today: POP, implant, IUS, copper IUD. LARC (long-acting reversible contraception) has advantages for a busy teacher. FSRH guidance on contraception in migraine with aura.

😰 Medication Overuse Anxiety ("Am I Addicted?")

The patient taking analgesics and triptans almost daily often carries shame and anxiety about her medication use. She may fear she is "addicted" to the painkillers, feel judged about the number of tablets she takes, and simultaneously feel she cannot function without them. This creates a barrier to discussing medication use honestly — and therefore to diagnosing and treating MOH. Non-judgmental, normalising language is essential.

"I want to ask about your tablets — not to judge how many you're taking, but because there's a pattern we sometimes see where the very medications that help short-term can change the brain chemistry in a way that makes headaches more frequent. I want to explore whether that might be happening."

The thermostat analogy (medications lower the pain threshold each time they are used, setting off the next headache sooner) is the most accessible explanation of MOH. Normalise the situation: "this happens to many people with migraine — it is not your fault."

😔 Depression, Anxiety, and Fatigue

Migraine and depression/anxiety are bidirectionally comorbid — each makes the other worse, through shared neurochemical pathways (serotonin, CGRP, HPA axis). Post-drome fatigue from frequent attacks significantly disrupts sleep architecture, creates anticipatory anxiety about the next attack, and progressively restricts the activities that previously gave life meaning. PHQ-9 and GAD-7 at diagnosis and every review are mandatory — not optional.

"How are you doing in yourself between the headaches — your mood, your energy, your enjoyment of things? Frequent migraines can really wear you down and affect how you feel about life more broadly."

Amitriptyline 10–50mg ON: simultaneously treats migraine prevention, depression, anxiety, and insomnia — one drug addressing four comorbidities. PHQ-9 at every review. NHS Talking Therapies for CBT. Cardiac rehabilitation analogue: headache management group programme if available locally.

🌙 Sleep, Circadian Rhythm, and Trigger Regularity

Migraine is a condition of threshold instability — the brain that generates migraines is exquisitely sensitive to perturbations in its biological environment. Irregular sleep is the single most potent and modifiable trigger. The paradox of the "weekend headache" — sleeping in to recover from the week — reliably triggers an attack. Understanding this mechanism helps the patient feel less victimised by their body and more in control of their triggers.

"Have you noticed that weekends or the start of holidays can be particularly bad for headaches? That's actually one of the most common patterns — and it's almost entirely about sleep regularity and caffeine timing, not stress. I can explain how to break that cycle."

Consistent sleep and wake times (including weekends) — the single most evidence-based lifestyle intervention for migraine prevention. Headache diary identifies the pattern. Light-blocking curtains, sleep hygiene programme. Amitriptyline simultaneously addresses sleep and prevention.

👨‍👩‍👧 Family, Relationships, and Invisible Illness

Partners, children, and employers who have not witnessed a migraine attack often fail to understand its severity — particularly because migraineurs appear entirely well between attacks. This creates relationship strain (missing family events, unreliability at work, intimacy affected by pain and fatigue), and an internalised sense of being a burden. For Aisha, concerns about her ability to manage teaching and personal responsibilities while managing migraine are likely significant.

"Has migraine affected your relationship with your family, or the things you do at home? And does your partner or school understand what you're going through?"

Patient information resources: The Migraine Trust (migrainetrust.org), NICE patient decision aids. Encourage partner to attend a review appointment if stigma or lack of understanding is a barrier. Social prescribing if social isolation is significant.

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"You mentioned new zigzag patterns — can you describe exactly what they look like, how long they last, and whether they always come before the headache?"

"I need to ask about your contraceptive pill — not to alarm you, but because there is a connection between migraine with aura and the combined pill that is really important for your safety."

"I'd like to count the number of days per month you're taking painkillers or sumatriptan — because there is a pattern we sometimes see where frequent use can actually make the headaches more frequent."

"Given what happened to your aunt, I can understand why the visual symptoms would be frightening. I want to address that directly."

Deductions (examiner flags)

Not asking about contraception in a woman of reproductive age with new migraine aura
Not quantifying analgesic and triptan use per month — misses the MOH diagnosis
Not screening for thunderclap headache or other red flag features before managing as migraine
Not asking about reproductive plans (pregnancy, breastfeeding) before recommending preventive therapy
Accepting the patient's attribution of symptoms to "stress" without exploring the medication pattern and contraceptive context
Not exploring the stroke fear and family history before delivering news about the COC

🔴 Red — failing

No contraception enquiry; no analgesic count; red flags not screened; aura not characterised; stroke fear not explored; UKMEC 4 not identified; MOH not diagnosed

🟠 Amber — borderline

Aura described but UKMEC 4 not connected; analgesic use asked but MOH threshold not applied; stroke fear acknowledged generically; COC identified but action not discussed; no MIDAS assessment; red flags partially screened

🟢 Green — passing

Open question; aura characterised (duration, type, reversibility); COC identified and UKMEC 4 articulated; analgesic/triptan count per month; MOH diagnosed; red flags screened; stroke fear named and addressed pre-emptively; ICE all three; MIDAS assessed; history complete by 7 min

Step 2

Triage Engine — Emergency · Urgent · Routine

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Migraine triage has one non-negotiable rule: always screen for red flags before managing a headache as migraine, regardless of how long the patient has had similar headaches. The most dangerous triage error is attributing a new severe headache in a known migraineur to "just another migraine" without asking whether this attack is different. SAH, cerebral venous thrombosis, and meningitis can all occur in patients with pre-existing migraine. Beyond the acute emergency screen, triage determines urgency of further assessment and whether same-day action is required (e.g. stopping the COC, addressing MOH).

🔴 Emergency

999 / A&E Now

Do not manage as migraine

Thunderclap headache — maximal intensity within 60 secondsSAH until proven otherwise; CT head within 6h (98% sensitivity); if CT negative → LP at 6–12h for xanthochromia; do not manage as migraine regardless of history
New neurological focal deficit persisting beyond 60 minutesFixed deficit = TIA/stroke; or cerebral venous thrombosis (CVT) especially with COC use and postpartum — urgent CT/MRI + CT venography; anticoagulation for CVT
Headache + fever + neck stiffness ± non-blanching rashBacterial meningitis / meningococcal disease; IV benzylpenicillin before transfer if meningococcal rash present; do not delay
Headache + haemodynamic instability or reduced consciousnessMass lesion, herniation, or intracranial haemorrhage; immediate CT head; neurosurgical emergency
New severe headache in pregnant woman ≥20 weeksEclampsia / HELLP syndrome — BP check immediately; platelets; LFTs; 999 if BP ≥160/110 with headache

🟠 Urgent

Same-Day / Same-Week Assessment

Days to 2 weeks

UKMEC 4 identified: COC + migraine with aura — same-day action requiredStop COC today; prescribe alternative contraception at same consultation; document; stroke risk does not require A&E but requires immediate contraceptive switch
New headache in patient aged ≥50, or new daily headache in any ageGCA (temporal arteritis) if ≥50 + scalp tenderness or jaw claudication: same-day ESR + CRP + prednisolone; MRI brain within 2 weeks for new daily persistent headache in any age
Hemiplegic migraine (motor weakness as aura component)Urgent neurology referral; MRI brain; triptans relatively contraindicated; specialist management required
Status migrainosus — attack lasting >72 hoursAdmission consideration or same-day urgent treatment: IV/IM antiemetic; IV/IM NSAID or corticosteroid (dexamethasone 8–24mg); sumatriptan if not used yet
Papilloedema detected on fundoscopyRaised ICP — urgent MRI brain within 24–48 hours; neurology referral; do not send home untreated

🟢 Routine

GP-Led Management

Weeks to months

Episodic migraine (with or without aura) — stable pattern, red flags excludedICHD-3 diagnosis confirmed; acute treatment optimised; prophylaxis threshold assessed; headache diary commenced
Medication overuse headache (MOH) — without urgent featuresMedication withdrawal plan; bridge therapy; preventive treatment; 4–8-week review to assess response
Migraine poorly controlled on current treatmentReview acute treatment choice (triptan + NSAID + antiemetic); initiate or review prophylaxis; headache diary review; MOH screen
Annual migraine review — stable, well-controlledContraception review (UKMEC 4 annual check); MOH screen; prophylaxis efficacy (≥50% reduction?); MIDAS score; PHQ-9; consider prophylaxis cessation trial after 6–12 months

🎓 SCA Checkpoint — Step 2TasksGlobal Skills

Triage reasoning shared with patient

"Before we talk about treatment, I always need to check for features that would mean we need to act more urgently than a standard migraine review. The visual symptoms you're describing — the zigzag patterns that come before the headache and resolve — are aura. That is important because it changes what contraception is safe for you."

"This isn't an emergency — but there is something I want to act on today, which is the connection between your combined pill and these visual symptoms. Can I explain that?"

Deductions

Not screening for red flags (thunderclap, fever/neck stiffness, fixed deficit) before classifying as routine migraine
Missing the UKMEC 4 issue and sending the patient home on a COC with migraine with aura
Over-triaging episodic migraine to A&E — wastes resources and unnecessarily alarms the patient
Not communicating the triage reasoning to the patient — failing Global Skills

🔴 Red

Red flags not screened; UKMEC 4 not identified; patient sent home on COC with aura; thunderclap not excluded; triage level not explained

🟠 Amber

Red flags asked but UKMEC 4 link not made; COC identified but action deferred; thunderclap excluded but meningism not screened; triage reasoning not shared with patient

🟢 Green

Red flags screened specifically; thunderclap, focal signs, and fever excluded; aura characterised; UKMEC 4 articulated; same-day contraceptive switch planned; triage reasoning explained to patient; MOH identified and addressed as urgent-routine

Step 3

Do I Need This Examination?

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Most migraine examinations are normal — but the examination is performed to exclude dangerous alternative diagnoses, not to confirm migraine. A normal neurological examination is the most important positive finding in a migraine consultation — it provides the clinical safety net that allows confident diagnosis and management without urgent imaging. The key examination findings that change management are: papilloedema (raised ICP), focal neurological signs (TIA/CVT/tumour), blood pressure (hypertensive headache or eclampsia risk), and temporal artery tenderness in older patients (GCA). Absent these, examination confirms the safety of a clinical migraine diagnosis.

Examination	Why it matters	What finding changes management	Changes management?
Neurological examination — cranial nerves, power, coordination, reflexes	The most important examination in headache assessment. A complete neurological examination provides the safety net for a clinical migraine diagnosis. Focal deficit (weakness, sensory loss, cranial nerve palsy, cerebellar signs) = urgent imaging required. Normal examination strongly supports migraine diagnosis and allows confident management without immediate MRI.Examining between attacks is the standard — a normal examination during an attack does not exclude serious pathology, and focal signs can be present during complex migraine aura. Any new focal sign warrants imaging.	Any focal deficit → urgent MRI brain; defer triptan prescribing. Normal → supports migraine diagnosis; imaging not urgently required. Cerebellar signs + aura → basilar-type migraine; specialist review.	YES — confirms safety of clinical diagnosis
Fundoscopy — optic disc assessment for papilloedema	Papilloedema (blurred disc margins, absent venous pulsations, disc haemorrhages) = raised intracranial pressure until proven otherwise. Can be the only sign of idiopathic intracranial hypertension (IIH), cerebral venous thrombosis, or space-occupying lesion. IIH is increasingly common in women of reproductive age with obesity — headache + visual obscurations + papilloedema is the classic triad.Idiopathic intracranial hypertension (IIH): most common in obese women of reproductive age; headache worse with Valsalva and position change, pulsatile tinnitus, visual obscurations. If papilloedema confirmed — urgent MRI brain + MR venography before LP.	Papilloedema → urgent MRI brain within 24–48h; neurology referral; do not prescribe triptans or NSAIDs until diagnosis clear. Normal disc margins → ICP likely normal; supports migraine diagnosis.	YES — papilloedema = urgent imaging
Blood pressure (bilateral)	Hypertensive headache (>180/120 mmHg) is a dangerous mimic of migraine. Severe hypertension is an independent cause of headache and a risk factor for hypertensive encephalopathy and intracerebral haemorrhage. In pregnancy, BP ≥140/90 with headache = eclampsia until proven otherwise. Blood pressure also determines triptan safety (contraindicated in uncontrolled hypertension).A patient with previously undetected severe hypertension presenting as "migraine" is a common primary care scenario. BP >180/120 with headache = hypertensive urgency — manage before prescribing migraine treatment.	BP >180/120 → hypertensive urgency; antihypertensive treatment; defer migraine-specific management. BP 140–180/90–120 → review antihypertensive control; note interaction with propranolol. Normal BP → triptan prescribing safe from BP perspective.	YES — determines triptan safety
Temporal artery examination (patients ≥50)	GCA presents with a new headache in patients ≥50, typically temporal, associated with scalp tenderness, jaw claudication, and systemic features (fatigue, weight loss, raised ESR/CRP). Visual loss from anterior ischaemic optic neuropathy occurs in 15–20% without treatment — and is irreversible within 24–72 hours of onset. Palpating for a thickened, tender, nodular temporal artery is the key examination.GCA cannot be excluded by examination alone — temporal artery biopsy is the gold standard. But the decision to start high-dose prednisolone must not wait for biopsy; start treatment when clinical suspicion is high and arrange biopsy within 48–72 hours of steroid initiation (sensitivity maintained for up to 2 weeks).	Tender/thickened temporal artery → same-day ESR + CRP; start prednisolone 40–60mg OD; urgent ophthalmology if visual symptoms; temporal artery biopsy arranged within 72h. Normal temporal artery exam → GCA less likely but not excluded.	YES — GCA requires same-day management
Neck examination — meningism, trigger points	Kernig's sign (pain/resistance to knee extension with hip flexed) and Brudzinski's sign (involuntary hip flexion on neck flexion) = meningeal irritation → meningitis or SAH. Cervical trigger points and suboccipital tenderness = cervicogenic headache component that may coexist with migraine. Neck stiffness in migraine prodrome does not involve meningeal signs and resolves spontaneously.The distinction between meningeal signs (Kernig's / Brudzinski's = involuntary, pain on passive movement) and musculoskeletal neck stiffness (voluntary guarding, reproducible on palpation) is critical and cannot be made without examination.	Meningeal signs present → 999; CT head; LP if CT negative. Cervical trigger points → physiotherapy referral for cervicogenic component; consider botulinum toxin if chronic cervicogenic + migraine. No meningism → meningitis less likely; proceed with migraine management.	YES — meningism = emergency
BMI and weight (relevant for preventive therapy choices)	Topiramate causes weight loss — beneficial in overweight patients, potentially harmful if underweight. Amitriptyline causes weight gain — consider in underweight patients, caution in obese. Idiopathic intracranial hypertension (IIH) is strongly associated with obesity in women of reproductive age — weight loss is the most effective treatment for IIH headache.For patients with IIH-pattern headache and high BMI: weight loss of even 5–10% dramatically reduces CSF pressure and may eliminate headaches without pharmacological intervention. Bariatric surgery has near-100% remission rate for IIH headache in eligible patients.	BMI >30 in woman with papilloedema → IIH workup; weight loss primary treatment; acetazolamide second-line. Obesity without papilloedema → prefer topiramate over amitriptyline for prevention (weight loss benefit). Underweight → prefer amitriptyline; avoid topiramate-related further weight loss.	Context — preventive drug choice
Skin examination — rash, herpes zoster	Herpes zoster (shingles) in the ophthalmic division (V1) of the trigeminal nerve presents with periorbital pain, headache, and vesicular rash — may precede the rash by 3–7 days ("zoster sine herpete"). Meningococcal rash: non-blanching petechiae in a patient with headache and fever = meningococcal disease. Neurofibromatosis type 2: skin lesions may indicate CNS tumour.	Unilateral periorbital/forehead rash → zoster ophthalmicus; urgent ophthalmology (corneal involvement); aciclovir 800mg 5× daily for 7 days. Non-blanching rash + fever + headache → 999 meningococcal protocol. Normal → proceed with migraine assessment.	Context — infectious/neurological diagnoses
Visual acuity and visual fields	Visual field defects from migraine aura are homonymous (same side both eyes), fully reversible, and have a characteristic march (spreading over minutes). Fixed visual field defect suggests posterior cortical lesion (stroke, tumour, AVM). Visual acuity reduced → optic neuritis (demyelination), acute angle-closure glaucoma, or IIH. Acute angle-closure glaucoma mimics migraine with eye pain, blurred vision, and nausea — important DDx.	Fixed visual field defect → urgent MRI; neurology. Reduced acuity + red eye + fixed pupil → acute angle-closure glaucoma; emergency ophthalmology. Visual obscurations + papilloedema → IIH; urgent neuro-ophthalmology. Visual field defect resolving in 60 min → migraine aura; manage accordingly.	YES — fixed vs reversible changes
Cognitive assessment (brief) — orientation, recent memory	Migraine with prolonged aura ("migraine confusional state" in adolescents) may include transient cognitive impairment. New cognitive impairment + headache in an older adult = subdural haematoma or tumour until proven otherwise. Transient global amnesia (TGA) has migraine association — sudden anterograde amnesia lasting hours; fully reversible; requires cardiac and MRI workup to exclude TIA.	New significant cognitive impairment + headache → urgent MRI brain; neurology. Normal cognition → supports migraine; no imaging urgently required on this basis alone. TGA episode + migraine → cardiac monitoring; MRI brain; aspirin/antiplatelet consideration.	Context — excludes serious pathology

🎓 SCA Checkpoint — Step 3TasksRelating to Others

Explaining examination rationale

"I'd like to examine you today — not because I think anything is seriously wrong, but because a normal neurological examination is an important part of being confident this is migraine and not something that needs immediate investigation."

"I'd like to look at the backs of your eyes with a light — this allows me to see whether there is any pressure on the optic nerve. This is a quick and painless test."

Deductions

Omitting neurological examination in a patient with headache + new visual symptoms
Not performing fundoscopy in a patient with visual symptoms and new headache pattern
Not checking blood pressure before prescribing triptans
Not examining for meningism (neck stiffness) in a patient with photophobia + headache

🔴 Red

No neurological examination; no fundoscopy; no BP check; no neck stiffness check; triptans prescribed without BP assessment

🟠 Amber

Neurological exam done but fundoscopy omitted; BP checked but not linked to triptan safety; neck examination performed but meningism not specifically assessed; findings not explained to patient

🟢 Green

Full neurological examination with findings shared; fundoscopy performed and explained; BP measured and linked to triptan prescribing; neck assessed for meningism; all normal findings communicated as reassurance; examination rationale explained before performing

Step 4

Do I Need This Investigation?

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Migraine is a clinical diagnosis — no investigation confirms it. NICE CG150 does not recommend routine brain imaging for patients with a typical history and normal neurological examination. The clinical role of investigations in migraine is to exclude dangerous alternative diagnoses (SAH, CVT, raised ICP, GCA), to screen for contraindications to treatment, and — where MOH or preventive therapy is being considered — to establish baseline bloods. Requesting an MRI without red flags increases patient anxiety, wastes NHS resources, and does not change management in typical migraine.

Investigation	Clinical question it answers	What result changes management?
MRI brain (with gadolinium if indicated)	NOT routine in typical migraine with normal examination. Indicated for: new atypical features or changed headache pattern, focal neurological signs, papilloedema, headache of abrupt onset, progressive worsening, first/worst headache of life, or clinical suspicion of space-occupying lesion / CVT. MRI superior to CT for posterior fossa, white matter lesions, and venous structures.	Space-occupying lesion → neurosurgery / oncology. White matter hyperintensities in young patient + migraine with aura → CADASIL screen; neurology. CVT → anticoagulation urgently. Normal MRI → reassurance; supports migraine diagnosis. Does NOT confirm migraine — migraine brain is structurally normal on standard MRI.
CT head (non-contrast)	First-line emergency investigation for thunderclap headache (sensitivity ~98% within 6 hours for SAH). Also appropriate for acute focal signs, acute onset with fever + suspicion of haemorrhage. NOT appropriate as screening for migraine diagnosis or for chronic headache evaluation — CT misses many significant posterior fossa pathologies. CT + LP (if CT negative) = gold standard for SAH.	Subarachnoid blood → neurosurgery emergency. Normal CT + thunderclap → LP at 6–12h for xanthochromia. Intracranial haemorrhage → neurosurgery. Normal CT in chronic headache with red flags → proceed to MRI brain. Normal CT alone does NOT exclude SAH — LP still mandatory after thunderclap onset.
ESR + CRP (urgent)	Giant cell arteritis (GCA) screening in patients ≥50 with new temporal headache, scalp tenderness, jaw claudication, or visual symptoms. ESR >50 mm/h + CRP elevated + clinical features = strong GCA suspicion; start prednisolone immediately. Normal ESR/CRP reduces (does not exclude) GCA probability.	ESR >50 + CRP elevated + clinical GCA features → start prednisolone 40–60mg OD same day; temporal artery biopsy within 72h; ophthalmology if visual symptoms. Normal inflammatory markers reduces GCA probability but does not exclude — if clinical suspicion very high, treat empirically while biopsy arranged.
FBC, U&E, LFTs, TFTs, glucose	Baseline bloods before starting preventive therapy — topiramate (check renal function: nephrolithiasis and dose adjustment), amitriptyline (ECG if cardiac risk or arrhythmia concern), propranolol (not a blood test but check HR before prescribing). Anaemia is a headache exacerbant. Hypothyroidism is an important reversible cause of headache and can worsen migraine frequency. Electrolyte disturbance (hyponatraemia) causes headache.	Anaemia → treat cause; re-evaluate headache. Hypothyroidism → levothyroxine; re-evaluate headache frequency. Renal impairment → adjust topiramate dose; avoid regular NSAIDs. Deranged LFTs → caution with hepatically metabolised drugs. Normal bloods → proceed with preventive therapy plan.
Pregnancy test (urine or serum β-hCG)	Migraine changes in pregnancy: improves in most women in the second and third trimester (oestrogen stabilisation); worsens in the first trimester. Triptans: sumatriptan has the largest safety data in pregnancy; generally not recommended in first trimester (limited evidence) but considered if benefit outweighs risk. Topiramate and valproate: absolutely contraindicated in pregnancy. Critical to establish pregnancy status before recommending preventive therapy.	Pregnancy confirmed → paracetamol first-line for acute attacks; sumatriptan with caution; propranolol safe for prevention; NO topiramate; NO valproate; NO ergotamines. Triptans in breastfeeding: sumatriptan considered compatible; express-and-discard for 24h after use as precaution if concerned. Normal → proceed with full management options.
ECG (before amitriptyline in patients with cardiac risk)	Amitriptyline causes QTc prolongation — particularly relevant at higher doses. ECG before starting amitriptyline is recommended in patients with cardiac disease, pre-existing arrhythmia, or concurrent QT-prolonging medications. In young healthy patients without risk factors, ECG is not routinely required before low-dose amitriptyline (10–25mg).	Prolonged QTc (>440ms men, >450ms women) → avoid amitriptyline; use propranolol or candesartan instead; cardiologist input if significantly prolonged. LBBB or AV block → cardiologist review before tricyclic. Normal ECG → amitriptyline safe to prescribe.
LP (lumbar puncture) — for xanthochromia after negative CT	Gold standard for excluding SAH in thunderclap headache after negative CT (done at 6–12 hours after headache onset). Xanthochromia (yellow discolouration of CSF from haemoglobin breakdown) is detectable from 2–4 hours after SAH onset and persists for up to 2 weeks. Opening pressure also elevated in IIH.	Xanthochromia positive → SAH confirmed; neurosurgery; nimodipine; CT angiography for aneurysm location. Elevated opening pressure + normal CSF → IIH; acetazolamide; weight loss; neuro-ophthalmology. Normal LP after thunderclap → SAH effectively excluded; proceed to further investigation for other causes (CVT, reversible cerebral vasconstriction syndrome).
Headache diary (paper or app) — 4–8 weeks	Not a laboratory test but the most diagnostically useful "investigation" in migraine management. Provides: objective attack frequency (establishes prophylaxis threshold); triggers identification (enables non-pharmacological prevention); medication use count (MOH diagnosis and monitoring); treatment response (enables dose adjustment and change); menstrual correlation (identifies perimenstrual migraine). Without a diary, clinical decisions are based on unreliable patient recall.	≥4 attacks/month documented → prophylaxis indicated. Analgesic/triptan use ≥10–15 days/month → MOH confirmed → withdrawal plan initiated. Perimenstrual pattern identified → perimenstrual prophylaxis (frovatriptan, naproxen). <4 attacks/month → acute-only management; diary continues as monitoring tool.

🎓 SCA Checkpoint — Step 4TasksRelating to Others

Explaining investigations in plain language

"I want to be upfront about the scan question. For a typical migraine history with a normal examination, a brain scan doesn't change the management and can sometimes create more anxiety than it resolves. The decision to scan depends on specific features — and right now, I don't see those features in your case. What I'd like to do instead is start the right treatment today."

"I'm going to ask you to keep a headache diary for the next 4–6 weeks. This is actually more useful than any blood test for understanding your migraine pattern — it tells us exactly how many attacks you're having, what triggers them, and how the medication is working."

Deductions

Requesting MRI brain for typical migraine with normal examination — not indicated per NICE CG150
Failing to request ESR + CRP in a patient ≥50 with new temporal headache
Not checking pregnancy status before recommending topiramate or other teratogenic preventives
Not recommending a headache diary — the most diagnostically useful "investigation"

🔴 Red

MRI requested for typical migraine without red flags; pregnancy test not done before topiramate; ESR/CRP not done in ≥50 with new headache; no headache diary recommended; thunderclap not investigated with CT+LP

🟠 Amber

MRI "just to reassure" without red flags; pregnancy test not done; bloods requested but rationale not explained; headache diary mentioned but not specifically recommended with instructions; LP not mentioned for thunderclap DDx

🟢 Green

MRI not requested (no red flags); rationale explained ("normal exam means no urgent imaging needed"); pregnancy test before preventive therapy; bloods explained individually; headache diary specifically recommended with instructions; CT+LP pathway explained for thunderclap emergency; patient satisfied with investigation plan

Step 5

Reaching a Diagnosis & DDx — Explained in Plain Language

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Migraine is a diagnosis of pattern and criteria, not of exclusion. The ICHD-3 criteria provide an objective framework, but the diagnostic conversation with the patient is the clinical skill. A patient who receives a diagnosis of "migraine" and nothing else has been told a word — not given an understanding. The lay explanation must convey: why the brain generates this pattern of symptoms; why aura is a separate phenomenon from the headache; and why medication overuse is itself a diagnosis, not a moral failing. The therapeutic alliance required for preventive therapy success depends on this understanding.

🗣️ Explaining Migraine in Plain Language — say something like this

"Migraine is a neurological condition — it's not just a bad headache, it's a specific pattern of brain activity. Think of your brain as having a dimmer switch rather than an on-off switch. In migraine, that dimmer switch is set too sensitively — it responds to triggers like lack of sleep, hormone changes, or bright lights by generating a wave of electrical and chemical activity that spreads across the brain. That wave is what causes the zigzag visual patterns you see first — the brain's visual processing area is being activated. Then, as the wave spreads, it triggers the release of inflammatory chemicals around the pain-sensing nerves of the head — that's the throbbing headache, the nausea, the sensitivity to light and sound. The headache diary helps us identify what's lowering your dimmer switch — and the treatments we have raise it back up."

💬 Addressing the patient's own explanation

"I think it's just stress — everything is so busy right now."
"Stress is definitely one of the things that can lower your migraine threshold — it's a real trigger, not imaginary. But stress alone doesn't explain the specific pattern of visual zigzag symptoms, the one-sided throbbing, the nausea, and the relief with rest that you're describing. Those features are very specifically migraine. The good news is that treating the migraine directly — not just the stress — will also help you cope better with stress, because you won't be fighting through headaches at the same time."

"Am I addicted to the painkillers? I feel terrible saying how many I'm taking."
"I want to address that directly — what's happening isn't an addiction in the way people usually mean it. It's a recognised medical phenomenon called medication overuse headache. When you take pain relief — even standard ibuprofen — very frequently, the brain's pain-regulation system starts to interpret the absence of medication as pain. It literally creates the next headache. It's the medication making you need more medication. This is not your fault — it's a known complication of treating migraine without a proper prevention plan, and it's treatable."

A — GP Diagnosis with ICHD-3 Criteria

Clinical diagnosis — no imaging required

Migraine Without Aura (ICHD-3 1.1)

≥5 attacks; 4–72h; 2+ of: unilateral, pulsating, moderate/severe, worsens with activity; 1+ of: nausea/vomiting, photophobia+phonophobia; not better explained by another diagnosis.

Migraine With Aura (ICHD-3 1.2)

≥2 attacks with ≥1 fully reversible aura symptom (visual, sensory, speech/language); duration 5–60 min; aura followed within 60 min by headache. Visual aura most common — scintillating scotoma, fortification spectra, photopsia.

Medication Overuse Headache (ICHD-3 8.2)

≥15 headache days/month; regular overuse of ≥1 acute/symptomatic headache drug for >3 months (simple analgesics ≥15 days/month; triptans/opioids/ergotamines ≥10 days/month); headache developing or markedly worsening during medication overuse.

B — Suspected — Refer or Specialist Management

Neurology / headache clinic

Hemiplegic Migraine

Motor weakness (unilateral) as part of aura — can last up to 24 hours. Triptans and ergotamines avoided (theoretical risk). Familial form: genetic diagnosis (CACNA1A, ATP1A2, SCN1A). Specialist management.

Idiopathic Intracranial Hypertension (IIH)

Daily headache + papilloedema + visual obscurations in obese woman of reproductive age. Normal MRI; elevated CSF opening pressure (>25 cmH₂O) on LP. Acetazolamide; weight loss; neuro-ophthalmology.

New Daily Persistent Headache (NDPH)

Daily headache from day one with no prior headache history — remembered onset. Requires MRI + neurological assessment to exclude sinister cause. Specialist treatment.

C — Emergency — Act Now

999 immediately

Subarachnoid Haemorrhage

Thunderclap onset, maximal in seconds — "worst headache of my life." May have neck stiffness, photophobia, ± loss of consciousness. 10–15% mortality before hospital. CT head + LP (xanthochromia at 6–12h). 999.

Cerebral Venous Thrombosis (CVT)

Progressive headache + focal signs in women on COC, postpartum, or with thrombophilia. CT venography / MR venography diagnostic. Anticoagulation urgently. 999. This is the most important specific DDx in Aisha's case.

📊 ICHD-3 Migraine Classification & POUND Diagnostic Guide

POUND feature	Clinical description	Specificity	Score	Management implication
P — Pulsating quality	Throbbing or pounding character; may vary from attack to attack; present in attack but not necessarily between	Moderate (~80%)	1 point	Confirms ischaemic/inflammatory mechanism; responds to triptans
O — One-day duration (4–72h)	4–72 hours untreated or inadequately treated; attacks <4h = consider short-duration migraine variant or trigeminal autonomic cephalalgia	High	1 point	Duration >72h = status migrainosus; IV treatment consideration
U — Unilateral	Typically unilateral at onset; may become bilateral. Always bilateral = less typical; consider tension-type, secondary headache	Moderate (~70%)	1 point	Always bilateral + other features → consider secondary cause; MRI
N — Nausea and/or vomiting	Present in 87% of migraine attacks. Also photophobia + phonophobia (not captured in POUND but highly specific: present in >90% of attacks)	High (87%)	1 point	Nausea/vomiting → add antiemetic; consider nasal/parenteral triptan route if vomiting prevents oral medication
D — Disabling	Moderate-to-severe pain preventing normal activities; or pain worsened by physical activity (bending, stairs); requires rest in a dark room	Very high	1 point	MIDAS score quantifies disability; documents preventive therapy indication
POUND interpretation	Score interpretation for migraine without aura diagnosis	4–5 points = 93% PPV · 3 points = 64% PPV · <3 points = reconsider diagnosis; consider secondary headache causes; neurological review

🎓 SCA Checkpoint — Step 5TasksRelating to OthersGlobal Skills

Diagnosis in plain language

"What you have is migraine with aura — the zigzag visual patterns are the aura, which is a wave of activity spreading across the visual processing part of the brain before the headache starts. Migraine is a neurological condition, not just a severe headache."

"You also have something called medication overuse headache. The frequent use of ibuprofen and sumatriptan has — through no fault of yours — reset your brain's pain threshold so that it creates a headache to demand the next dose of medication. The treatment for this is to withdraw those medications, which I know sounds counterintuitive."

"The zigzag patterns have a specific significance for the contraceptive pill you're taking. I need to explain this carefully because it requires action today."

Deductions

Using "migraine" without explaining the neurological mechanism or the aura-specific implications
Not explaining MOH as a diagnosis — leaving the patient feeling blamed for their medication use
Not distinguishing migraine with aura from migraine without aura — the distinction is clinically critical for contraception
Not connecting the aura diagnosis to the COC safety issue at this point in the consultation

🔴 Red

Diagnosis not shared; MOH not named; aura significance not explained; COC connection not made; ICHD-3 criteria not applied; "migraine" said without explanation

🟠 Amber

Migraine named but no plain language explanation; MOH explained but patient felt blamed; aura identified but UKMEC 4 connection deferred; dimmer switch analogy absent; MOH mechanism not explained

🟢 Green

Migraine + neurological explanation + dimmer switch analogy; aura distinguished from headache phase; MOH explained as physiological mechanism (not moral failure); ICHD-3 criteria applied; COC-aura link signposted; patient understood diagnosis before management plan

Step 6

If Referral Is Needed — What the GP Does Before & During

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Most migraine is managed entirely in primary care. Neurology referral is indicated for: atypical features not meeting ICHD-3 criteria; failure of two or more preventive therapies; hemiplegic migraine; basilar-type migraine; suspected secondary headache requiring specialist investigation; and chronic migraine with MOH that has not responded to withdrawal. The GP must initiate acute and preventive treatment before referral — waiting for a neurology appointment (often 3–12 months) without any treatment in place is not acceptable. The referral letter must document: ICHD-3 criteria met, medications tried and failed, MOH status, contraception reviewed, and red flags excluded.

Condition	Urgency	What GP does before referral	What GP must NOT do
Thunderclap headache / suspected SAH	999 now	Call 999. Do not give analgesics (may mask symptoms). Document time of onset and exact description of onset. Do not send to GP walk-in or minor injuries — direct to A&E neurosurgery pathway.	Do NOT manage as migraine. Do NOT prescribe triptans. Do NOT delay for LP in primary care. Do NOT send home with analgesia.
Suspected GCA (≥50, temporal headache, systemic features)	Same day	ESR + CRP urgently. Start prednisolone 40–60mg OD immediately if clinical suspicion high — do not wait for biopsy. If visual symptoms: ophthalmology same-day. Arrange temporal artery biopsy within 72h of steroid initiation.	Do NOT delay prednisolone waiting for biopsy results. Do NOT dismiss GCA in a patient ≥50 with new headache and raised inflammatory markers.
Migraine failing ≥2 preventives in primary care	Routine neurology	Document preventives tried, doses, duration, and reason for failure. Optimise acute treatment. Consider topiramate or amitriptyline if not tried. CGRP antagonist/antibody (gepants, monoclonal antibodies) available via specialist pathway. Refer with MIDAS score and headache diary.	Do NOT refer without trying adequate doses for ≥3 months of each preventive. Do NOT stop preventives before referral is actioned.
Hemiplegic migraine (motor aura)	Urgent neurology	MRI brain urgently (exclude structural cause for focal weakness). Do not prescribe triptans or ergotamines (relatively contraindicated — no RCT evidence but theoretical cardiovascular risk). Use NSAIDs + antiemetics for acute attacks. Genetic testing referral may be indicated.	Do NOT prescribe triptans or ergotamines without specialist review. Do NOT attribute motor weakness to migraine aura without imaging exclusion of structural cause.
Suspected idiopathic intracranial hypertension (IIH)	Urgent neuro-ophthalmology	Arrange urgent MRI brain + MR venography (exclude CVT, mass). Advise weight loss. Do not start acetazolamide without specialist confirmation of LP opening pressure. Arrange formal visual field testing.	Do NOT perform LP in primary care if IIH suspected. Do NOT start acetazolamide without diagnostic confirmation. Do NOT miss progressive visual field loss.
Botulinum toxin (Botox) for chronic migraine (≥15 headache days/month)	Specialist pathway	NICE TA260: botulinum toxin type A (Botox) is recommended for adults with chronic migraine who have tried ≥3 preventive treatments. Refer to headache clinic or neurology with documentation of failed preventives.	Do NOT refer without documented failure of ≥3 oral preventive agents. Do NOT prescribe Botox in primary care.
CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab)	Specialist / headache clinic	NICE TA682, TA696, TA837: CGRP antibodies available for episodic and chronic migraine failing ≥3 preventives. GP initiates referral; headache clinic prescribes. Monthly subcutaneous injection or 3-monthly. Highly effective (50%+ response in ~50% of patients).	Do NOT prescribe CGRP antibodies in primary care without specialist initiation. Document all failed preventives carefully — this is the evidence required for NICE funding approval.

🎓 SCA Checkpoint — Step 6TasksGlobal Skills

Explaining the management pathway

"Most migraine is managed very well in primary care, and I'd like to start a proper treatment plan today. We don't need a specialist for what you're describing right now. But if your headaches don't improve significantly with the treatments I'm going to prescribe — or if anything changes — we can escalate to a neurologist who specialises in headaches."

"There is a new generation of very effective migraine injections — given monthly or every three months — which are available through a specialist pathway for people whose migraines don't respond to the usual treatments. If we get to that point, I'll refer you."

Deductions

Referring immediately to neurology for typical migraine without trying primary care treatment first
Not treating before the neurology referral — sending the patient away with no treatment while they wait months
Referring for botulinum toxin without documenting three failed preventive agents
Not explaining what the patient can expect from the referral process

🔴 Red

Immediate neurology referral for typical migraine; no treatment started before referral; GCA not started on prednisolone same-day; CGRP antibodies prescribed in primary care

🟠 Amber

Neurology referral discussed but acute treatment not started; CGRP pathway mentioned without explaining failed-preventive documentation requirement; GCA treatment deferred pending biopsy

🟢 Green

Primary care management initiated today; neurology referral criteria explained clearly; GCA same-day prednisolone if indicated; CGRP specialist pathway explained; patient understands when and why escalation would occur; referral letter would document treatments tried and red flags excluded

Step 7

Management — Expectation · Goals · Lifestyle · Drug Selector · Drug Cards · Psychosocial · Follow-Up · Safety-Netting

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7A — Address the patient's expectation first: validate → explain → negotiate

🤝

Never dismiss the expectation — acknowledge it, share your reasoning, then agree a shared plan

Validate — name their expectation

Aisha likely expects better treatment for her headaches — she is not expecting to be told that her contraceptive pill needs to stop today. That news must be delivered after the concerns about stroke risk have been named and addressed, not before. Validate her fear before delivering the clinical information.

"I think you already suspect that the visual symptoms and the pill might be connected — your family history has probably made you wonder about that. I want to address that directly, and I want to reassure you that what we're going to do today will reduce your risk, not increase it."

Explain — share your clinical reasoning

The combined pill + migraine with aura increases stroke risk — not enormously in absolute terms, but enough that it is an absolute contraindication (UKMEC 4). The good news is: stopping the pill removes this added risk immediately. There are excellent alternatives. And treating the migraine properly — including preventing MOH — is likely to make her feel substantially better.

"The combined pill contains oestrogen, which in women who have migraine with visual aura increases the risk of a certain type of stroke — enough that the medical guidance is an absolute contraindication. I need to stop it today and give you an alternative. The alternatives are equally effective for contraception and completely safe with migraine."

Negotiate — offer something today

Concrete actions today: stop COC + start POP/issue LARC referral; initiate acute treatment (triptan + NSAID) + MOH withdrawal plan; headache diary; follow-up appointment in 4–6 weeks. The patient should leave with a clear, actionable plan — not just news about what must stop.

"Today I'm going to give you a new contraceptive prescription — a progesterone-only pill — that is completely safe with your migraines. I'm also going to give you the right medication for the headaches themselves, and we're going to make a plan together for gradually reducing the daily painkillers that are making your headaches more frequent. You'll come back in 6 weeks and we'll review how it's all going."

Key principle: The UKMEC 4 conversation must be led by the patient's safety narrative, not the prescribing regulations. "I am stopping your pill because the regulations say I must" is a very different conversation from "I am stopping your pill because your safety matters to me, and because this significantly reduces your stroke risk." The second conversation creates a therapeutic alliance; the first creates fear and resentment.

7B — Why treatment matters: goals tailored to this patient

Treatment goals

Eliminate UKMEC 4 risk — stop COC today; offer safe alternative contraceptionDiagnose and treat medication overuse headache (MOH) Effective acute attack treatment: headache-free at 2 hours in ≥50% of attacksReduce attack frequency by ≥50% with preventive therapy Reduce headache days to <4 per month from current near-daily patternRestore ability to work and function without planning around attacks Headache diary completed and MOH resolved within 2–3 monthsPreventive therapy trial of ≥3 months before assessing efficacy

Motivational language — tailored to this patient

"Most people with migraines at your stage have never been given a proper plan — they've just been given more painkillers. What we're doing today is fundamentally different. We're treating the cause, not just the symptom. Many people go from near-daily headaches to one or two a month with the right approach."

"I know teaching with a migraine is incredibly difficult — the lights, the noise, the need to be present. Getting these headaches under control isn't just about your health, it's about being able to do your job properly and enjoy your life again."

7C — Non-medication management: mechanism + evidence + tailored advice

Lifestyle modification in migraine targets the brain's sensitivity threshold — raising it through biological regularity and lowering the triggers that tip it over. Each recommendation must be framed with a mechanism, not delivered as generic advice. The headache diary is the cornerstone tool that makes lifestyle interventions evidence-based for the individual patient.

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Sleep Regularity

Target: same wake time 7 days/week (±30 min)

Mechanism

Irregular sleep is the single most potent migraine trigger — both sleep deprivation and oversleeping lower the excitability threshold of the migrainogenic brain. The circadian variation in cortical excitability is disrupted, triggering the neurological cascade. "Weekend headache" from Saturday lie-ins is almost always sleep-schedule disruption.

Practical

Same wake time every day including weekends and holidays — this is non-negotiable for migraine control. Set a single alarm 7 days per week. Sleep duration can vary, but wake time must not. Light therapy in winter to anchor circadian rhythm. Temperature-cool bedroom (18°C). Amitriptyline (if prescribed) also directly improves sleep architecture.

Most evidence-based single lifestyle intervention — prevents attacks at source

💧

Hydration

Target: 1.5–2 litres water/day; consistent throughout day

Mechanism

Dehydration causes cerebral vasoconstriction and electrolyte shifts that lower the migraine threshold. Even mild dehydration (1–2% body weight) significantly increases headache probability in migraine-prone individuals. Teaching environments — without regular access to water — are particularly high-risk for dehydration-triggered attacks.

Practical

Keep a water bottle visible at the desk throughout the school day. Morning hydration before caffeine. Urine colour target: pale yellow. Electrolyte balance (sodium, magnesium) important — consider magnesium glycinate 400mg OD as evidence-based supplement. Avoid using caffeinated drinks as the primary fluid source.

RCT evidence: increased hydration reduces migraine frequency and severity

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Caffeine Management

Target: stable 1–2 cups/day at consistent times

Mechanism

Regular caffeine intake causes adenosine receptor upregulation. When caffeine is absent (weekend mornings, caffeine-free days), adenosine floods these receptors causing cerebral vasodilation — the mechanism of caffeine-withdrawal headache. Cutting down is worse than maintaining a low-level stable habit. Elimination is an option but requires a gradual taper over 3–4 weeks.

Practical

If currently consuming 3–5 cups/day: reduce by half a cup per week; avoid abrupt cessation. Aim for 1–2 cups at the same time each day. No caffeine after 2pm (sleep disruption risk). Caffeinated analgesics (Anadin Extra, some compound preparations) contribute to MOH — identify and phase out.

Caffeine withdrawal attacks often eliminated entirely by stable low intake

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Meal Regularity

Target: 3 meals daily at consistent times; no skipping breakfast

Mechanism

Hypoglycaemia from missed meals triggers cortical spreading depression through low glucose availability for the highly metabolically active migrainogenic brain. The typical pattern: skipped breakfast + morning coffee + busy school morning = headache by 10am. Consistent blood glucose is as important as any preventive drug for many patients.

Practical

Breakfast within 1 hour of waking regardless of appetite. Protein + slow-release carbohydrate (porridge, eggs, nuts) rather than sugar-spike breakfasts. Snack mid-morning and mid-afternoon to prevent glucose dips. Meal prep for school days when time is limited. Low GI diet overall: Mediterranean diet associated with reduced migraine frequency.

Eliminating glucose dips prevents 15–25% of attacks in susceptible patients

📓

Headache Diary

Target: complete daily for 4–8 weeks minimum

Mechanism

A systematic diary converts subjective recall into objective data. It reveals: (a) true attack frequency (patients typically underestimate by 30–40%); (b) trigger patterns; (c) medication use count (MOH diagnosis); (d) menstrual correlation; (e) response to treatment changes. It is the only tool that can demonstrate whether prophylaxis is achieving the ≥50% reduction target.

Practical

Paper diary or app: Migraine Buddy (most comprehensive), N1-Headache, NHS-endorsed apps. Record: date, time, severity (1–10), location, duration, medication used, probable trigger, menstrual cycle day, sleep hours. Bring diary to every review appointment. The diary itself often motivates lifestyle change as patterns become visible.

Enables evidence-based individual treatment optimisation — more powerful than any single drug

🧘

Stress Management & Exercise

Target: 150 min moderate aerobic exercise/week; stress reduction programme

Mechanism

Regular aerobic exercise raises the migraine threshold via beta-endorphin release, HPA axis regulation, and improved sleep quality. However, very vigorous exercise can trigger acute attacks — the exertional headache pattern. Stress is a powerful precipitant; the "stress let-down" migraine (post-exam, first day of holiday) is particularly common. CBT and biofeedback have RCT evidence for migraine prevention.

Practical

Regular moderate aerobic exercise (brisk walking, swimming, cycling) at consistent times reduces attack frequency. Avoid sudden intense exertion without warm-up. Stress management: CBT for migraine (NHS Talking Therapies referral with migraine-specific focus), mindfulness (Headspace/Calm apps). Biofeedback: formal biofeedback therapy reduces frequency comparably to propranolol in RCTs.

RCT: regular aerobic exercise reduces migraine days by ~25% (comparable to propranolol)

7D — Prescribing guide: acute treatment, MOH withdrawal, and preventive therapy

Migraine prescribing has three parallel tracks: (1) acute attack treatment — optimised with triptan + NSAID + antiemetic combination, taken early; (2) MOH withdrawal — stopping the overused agent with bridge therapy; (3) preventive therapy — started once MOH is resolving. All three tracks should be initiated simultaneously, though the patient needs careful education about the temporary worsening expected during MOH withdrawal.

Acute Attack Treatment — Optimise First

Sumatriptan 50–100mg + Ibuprofen 400mg or Naproxen 500mg (taken together)

Take at the first sign of headache (not at aura — too early; not when severe — too late for triptan to work optimally)
Add metoclopramide 10mg or prochlorperazine 3mg buccal at the same time (improves gastric emptying and drug absorption during migraine; reduces nausea)
Triptan non-response to one formulation: try different triptan (rizatriptan, zolmitriptan) or different route (nasal spray, wafer)
Limit to ≤10 treatment days/month to prevent MOH; do not restart regular ibuprofen

Combination therapy (triptan + NSAID simultaneously) is significantly more effective than either drug alone — this is the standard of care, not an escalation option.

MOH Withdrawal — Concurrent with Preventive Start

Stop overused analgesics; bridge with naproxen 500mg BD for 3–4 weeks

For ibuprofen/paracetamol/triptan overuse: abrupt cessation is preferred (fewer complications than gradual withdrawal)
For opioid/codeine overuse: gradual taper over 4–12 weeks to prevent withdrawal syndrome
Bridge therapy: naproxen 500mg BD or prednisolone 60mg 5-day course to manage the withdrawal headache worsening (days 1–14 typically worse before improving)
Warn explicitly: "your headaches will get worse for 2–4 weeks before they get better — this is expected and is part of treatment, not treatment failure"

MOH resolves in 60–70% of patients after withdrawal alone, without additional preventive therapy. If it resolves: reassess whether preventive is still needed.

Preventive Therapy — NICE CG150 First-Line Options

Consider when ≥4 attacks/month, attacks significantly disabling, or patient preference

Propranolol 40–80mg BD (first-line; avoid in asthma, Raynaud's, significant depression)
Amitriptyline 10–50mg ON (first-line if comorbid insomnia, anxiety, or depression; titrate slowly)
Topiramate 25–100mg OD (first-line; requires Pregnancy Prevention Programme in women of reproductive age — teratogenic)
Candesartan 8–16mg OD (NICE CG150-endorsed; fewer side effects; option if above not tolerated)
Trial each for ≥3 months at maximum tolerated dose before declaring failure

Start preventive therapy simultaneously with MOH withdrawal. Do not delay prophylaxis until MOH is fully resolved — they work together.

Specialist / Second-Line Options

CGRP monoclonal antibodies (erenumab/fremanezumab/galcanezumab): NICE-approved via specialist; failure of ≥3 preventives required; monthly or 3-monthly SC injection; 50%+ response rate
Botulinum toxin type A (Botox): NICE TA260 for chronic migraine (≥15 days/month) failing ≥3 preventives; headache clinic
Gepants (ubrogepant, rimegepant): oral CGRP receptor antagonists for acute treatment and prevention; available for patients with contraindications to triptans
Perimenstrual migraine: frovatriptan 2.5mg BD for 6 days perimenstrually (days -2 to +3) or naproxen 500mg BD for 5 days; oestrogen patch supplement (if menstrual migraine from oestrogen withdrawal)

Contraception — UKMEC 4 Action Today

Stop combined OCP (Rigevidon/Microgynon) immediately — all combined hormonal contraceptives are UKMEC 4 with migraine with aura
Start desogestrel POP (Cerazette 75 micrograms OD) same day — UKMEC 2 (advantages generally outweigh risks) with migraine with aura
Alternative LARCs: hormonal implant (Nexplanon) UKMEC 1; IUS (Mirena) UKMEC 1; copper IUD UKMEC 1 — all safe
Combined patch and combined vaginal ring: UKMEC 4 — same as combined pill; not safe
Combined contraceptive injection (DMPA/Depo-Provera): UKMEC 2 — progesterone only; safe
Document every contraceptive discussion in notes — medicolegally essential

⚙ Interactive Medication Chooser — tick the patient profile, options re-tier live against NICE / BNF

A live, topic-scoped version of the standalone Medication Chooser. The static selector and reference cards below are unchanged.

7E — Medication selection tool — choose patient characteristics for tailored drug recommendations

Select patient characteristics — see drug cards and guidance below

Migraine with aura Medication overuse headache (MOH) Asthma / COPD (beta-blocker contraindicated) Comorbid depression or insomnia Pregnant or planning pregnancy Currently on combined OCP

Migraine drug selection guide

Migraine with aura + COC: Stop COC immediately — UKMEC 4. Start POP (desogestrel 75mcg OD). MOH: withdraw overused agent; bridge naproxen 500mg BD; start preventive simultaneously. Asthma: avoid propranolol — use amitriptyline 10–50mg ON or candesartan 8–16mg OD. Depression + insomnia: amitriptyline 10–50mg ON (triple benefit). Pregnancy: paracetamol first-line; propranolol safe preventive; NO topiramate, NO valproate, NO ergotamines. Acute treatment: sumatriptan 50–100mg + naproxen 500mg + metoclopramide 10mg simultaneously at headache onset. See drug cards below.

7F — Drug reference cards: triptan · NSAID + antiemetic · preventive agents

Sumatriptan (Triptan — Acute Attack)

Sumatriptan 50mg / 100mg tablets · 10mg nasal spray · 6mg SC injection

✓ Recommended

First-line acute migraine50–100mg oral at headache onset

✓ Prefer when

Moderate-to-severe migraine attack — first-line specific acute treatment; take at headache onset (not at aura — too early; not when severe — central sensitisation reduces efficacy)

Nausea/vomiting prevent oral medication → nasal spray 10–20mg or SC injection 6mg (fastest onset; most reliable)

Migraine with aura: triptans ARE safe in typical visual aura (common misconception they are not); contraindicated only in hemiplegic migraine and basilar-type migraine

Combination with NSAID (naproxen/ibuprofen) taken simultaneously improves pain-free rate from ~30% to ~55%

✗ Avoid if

Ischaemic heart disease, uncontrolled hypertension, prior stroke or TIA, PVD, Prinzmetal's angina — triptan-induced coronary vasoconstriction is dangerous in these conditions

Hemiplegic migraine and basilar-type migraine — triptans not recommended; specialist guidance required

MAOIs (within 2 weeks) — risk of hypertensive crisis

Pregnancy (first trimester) — limited data; use if benefit outweighs risk; sumatriptan has most safety data

⚠ Side effects

Triptan sensations: chest tightness, throat tightness, heaviness in limbs — typically benign (not cardiac); related to peripheral 5-HT1B receptor effects; warn patient pre-emptively

Drowsiness, dizziness, flushing, tingling — common; usually mild

Medication overuse headache if used ≥10 days/month for 3+ months

🔬 Monitor

Count of use days per month — if ≥10 days/month → MOH risk; review preventive therapy need

BP check before prescribing (hypertension contraindication). If current triptan not working → try different triptan (rizatriptan 10mg, zolmitriptan 2.5mg) before concluding all triptans fail

💬 Counselling

"Take this tablet at the first sign of the headache — not during the aura, not when the headache is already severe. Take it with one of your naproxen tablets at the same time. If you feel a strange tightness in your chest after taking it, this is a known side effect of the medication — it is not a heart problem — but please contact us if it is severe. Use it no more than twice in 24 hours, and no more than 10 days per month."

Critical SCA pearl: triptans ARE safe in migraine with typical visual aura (they are NOT contraindicated as commonly believed). They ARE contraindicated in hemiplegic migraine and basilar-type migraine. The combination of sumatriptan + NSAID simultaneously — not sequentially — is the evidence-based standard. Take at headache onset, not at aura or when severe.

NSAIDs — Ibuprofen / Naproxen (Acute Attack)

Ibuprofen 400mg tablets · Naproxen 500mg tablets · Aspirin 900mg dispersible

✓ Recommended

Acute migraine — with triptanNaproxen 500–1000mg with sumatriptan

✓ Prefer when

Taken simultaneously with sumatriptan at headache onset — significantly improves 2-hour pain-free rate compared to triptan alone

Naproxen 500mg preferred over ibuprofen 400mg — longer half-life means sustained effect throughout the attack; less frequent re-dosing

Aspirin 900mg dispersible (Migraleve) — fast absorption; effective in mild-moderate attacks and as MOH bridge; listed in NICE CG150

Sole acute treatment in patients with triptan contraindications or preference

✗ Avoid if

Peptic ulcer disease, GI bleeding, severe renal failure, aspirin-sensitive asthma

Regular use ≥15 days/month → MOH risk; worse than triptans for MOH threshold. Add PPI (lansoprazole 15–30mg) if regular NSAID use or GI risk factors

Third trimester of pregnancy — avoid NSAIDs; use paracetamol

⚠ Side effects

GI upset, nausea (take with food; add PPI if regular use)

Renal impairment with long-term regular use — not relevant at therapeutic acute dosing if normal renal function

🔬 Monitor

Days of NSAID use per month — critical for MOH monitoring. ≥15 days/month for 3+ months = MOH from simple analgesics. Document in notes at every review

💬 Counselling

"Take this at the same time as your sumatriptan — not after it has failed, but together at the start of the headache. This combination is significantly more effective than either tablet alone. Take it with food or milk. If you find you are using it very often — more than 10–12 days a month — please let us know, because that level of use can itself make headaches more frequent."

NICE CG150 evidence: triptan + NSAID combination taken simultaneously is the most effective acute treatment for migraine. Naproxen 500mg is preferred over ibuprofen 400mg for sustained coverage during the attack. Aspirin 900mg dispersible is an NICE-endorsed alternative. The key teaching point: simultaneous, not sequential.

Antiemetics — Metoclopramide / Prochlorperazine

Metoclopramide 10mg tablets · Prochlorperazine 3mg buccal tabs (Buccastem)

✓ Recommended

Acute migraine — with triptan + NSAIDMetoclopramide 10mg or Prochlorperazine 3mg buccal

✓ Prefer when

Taken alongside triptan + NSAID — metoclopramide improves gastric emptying (reversed by migraine), accelerating absorption of concurrent oral medications

Nausea or vomiting during attack — prochlorperazine 3mg buccal tablet dissolves under the lip; absorbed without swallowing; ideal when vomiting prevents oral route

Standalone acute treatment if triptans contraindicated — domperidone 10mg + aspirin 900mg + codeine-free analgesia

✗ Avoid if

Metoclopramide: Parkinson's disease, dystonia history, young women under 20 years (dystonic reaction risk higher)

Prochlorperazine: Parkinson's, prolonged QT, epilepsy

Extrapyramidal side effects (dystonic reactions) — more common in young women; warn before prescribing; procyclidine antidote if reaction occurs

⚠ Side effects

Metoclopramide: drowsiness; dystonic reaction (acute muscle spasm, oculogyric crisis in young patients) — warn specifically; antidote procyclidine 5mg IM/IV

Prochlorperazine: sedation; prolonged use → tardive dyskinesia; avoid >1 week continuous use

🔬 Monitor

Acute dystonic reaction: if patient reports muscle spasm, jaw locking, or eye rolling after metoclopramide → stop immediately; procyclidine 5–10mg if severe. No routine blood monitoring needed for acute use.

💬 Counselling

"This tablet for nausea has an additional benefit during migraine — it helps your stomach start working again, which means the sumatriptan and naproxen are absorbed much faster and work better. Take all three tablets together at the start of the headache. For the buccal form: place it between the cheek and gum, don't swallow it — it absorbs directly through the cheek lining, which is ideal if you feel like vomiting."

Metoclopramide's mechanism in migraine goes beyond antiemesis — it reverses the gastric stasis that migraine causes, improving absorption of other acute treatments taken simultaneously. Dystonic reaction in young women: warn specifically before prescribing. Procyclidine antidote. Prochlorperazine buccal: key advantage when oral route is compromised by vomiting.

Propranolol (Beta-Blocker — Prevention)

Propranolol modified release 80mg capsules · Propranolol 10–40mg tablets BD

✓ Recommended

First-line preventivePropranolol MR 80mg OD (or 40mg BD) → up to 160mg daily

✓ Prefer when

First-line NICE CG150 preventive for migraine with or without aura — reduces attack frequency by 40–50% in responders

Coexistent hypertension — dual anti-migraine + antihypertensive benefit

Coexistent anxiety — beta-blocker also reduces somatic anxiety symptoms (tachycardia, palpitations)

Safe in pregnancy — used for migraine prevention in pregnant patients when benefit outweighs risk

✗ Avoid if

Asthma / significant COPD — non-selective beta-blocker; bronchospasm risk

Significant depression — propranolol worsens depression; use amitriptyline instead

Heart block (2nd/3rd degree), significant bradycardia, decompensated heart failure

Raynaud's phenomenon — non-selective beta-blocker worsens peripheral vasoconstriction; use candesartan instead

Diabetes on insulin — may mask hypoglycaemia warning signs; use with caution

⚠ Side effects

Fatigue, cold extremities — common initially; usually improves. Start low (40mg BD or 80mg MR OD) and titrate

Sleep disturbance, vivid dreams — take in the morning to minimise. Consider modified release formulation

Depression worsening — monitor PHQ-9; switch to amitriptyline if mood affected

🔬 Monitor

HR at every appointment — avoid bradycardia (<50 bpm). Headache diary review at 3 months: has frequency reduced by ≥50%? If not → increase dose or switch preventive. Trial minimum 3 months at adequate dose before declaring failure

PHQ-9 at start and 6 weeks — depression risk. NEVER stop abruptly — taper over 1–2 weeks (rebound tachycardia, migraine exacerbation)

💬 Counselling

"This tablet won't stop a headache once it has started — it is taken every day to reduce the number of headaches you get. It works by reducing the sensitivity of your nervous system to migraine triggers. It takes 6–8 weeks to build up full effect. Please don't stop it suddenly — let me know first and we'll reduce it gradually. Give it at least 3 months before deciding whether it's working."

Never stop propranolol abruptly (rebound tachycardia + migraine exacerbation). Trial period: minimum 3 months at adequate dose before switching. Do not use in asthma (use amitriptyline or candesartan instead). Do not use if significant depression (use amitriptyline — dual benefit). Propranolol is safe in pregnancy for migraine prevention.

Topiramate (Anticonvulsant — Prevention)

Topiramate 25mg / 50mg / 100mg tablets

✓ Recommended

First-line preventive25mg ON → titrate to 50–100mg OD over 8 weeks

✓ Prefer when

Overweight patients — topiramate causes weight loss (average 3–5kg); beneficial in patients where obesity contributes to migraine or IIH

Comorbid epilepsy — dual indication; reduces both seizure and migraine frequency

Propranolol and amitriptyline not tolerated or contraindicated

Effective: reduces migraine frequency by 40–50% in responders; comparable to propranolol

✗ Avoid if

Pregnancy — TERATOGEN: neural tube defects, oral clefts, low birth weight, cognitive development impairment in exposed offspring

Planning pregnancy — must stop topiramate ≥3 months before conception. Pregnancy Prevention Programme (PPP) MHRA-mandated: effective contraception required throughout; annual pregnancy test; patient acknowledgement card; documented counselling at EVERY prescription

Kidney stones (nephrolithiasis) — topiramate causes renal tubular acidosis and reduced urinary citrate; adequate hydration essential; stop if renal calculi develop

⚠ Side effects

Cognitive effects: "dopamax" — word-finding difficulties, slow thinking, memory impairment; dose-related; slow titration (25mg every 2 weeks) minimises; warn patient pre-prescription

Paraesthesia (tingling in hands and feet) — common; usually transient; related to carbonic anhydrase inhibition

Weight loss — benefit or problem depending on patient; monitor closely if already underweight

🔬 Monitor

Pregnancy Prevention Programme: effective contraception confirmed at every prescription. Annual pregnancy test. Patient holds yellow PPP card. Document contraception and counselling in notes at every visit

Renal function at baseline (nephrolithiasis risk). Cognitive side effects screen at 6 weeks. Headache diary: ≥50% frequency reduction at 3 months = responder

💬 Counselling

"This tablet is effective for migraine prevention but has two important things to know. First: it can affect your thinking and memory, particularly at the start — some people call it 'dopamax.' I'll start you at a very low dose and increase slowly to reduce this. Second, and most importantly: this medication can seriously harm an unborn baby. It is absolutely essential that you do not become pregnant while taking it. I need to confirm today what contraception you are using, and we'll need to check this at every repeat prescription."

MHRA Pregnancy Prevention Programme (PPP) for topiramate is a mandatory regulatory requirement — not optional. Must be documented at every prescription. Cognitive effects ("dopamax") are dose-dependent and manageable with slow titration. Nephrolithiasis risk: adequate hydration, avoid dehydration. Teratogenicity is the dominant safety concern — more serious than valproate in terms of regulatory requirement.

Amitriptyline (Tricyclic — Prevention)

Amitriptyline 10mg / 25mg / 50mg tablets

✓ Recommended

First-line preventive10mg ON → titrate to 25–50mg ON over 4–6 weeks

✓ Prefer when

Comorbid insomnia — amitriptyline taken at night directly improves sleep architecture (reduces sleep latency and increases deep sleep) while simultaneously preventing migraines

Comorbid depression or anxiety — simultaneous antidepressant + antimigraine benefit at a single low dose

Asthma (propranolol contraindicated) — amitriptyline is an excellent first-line alternative

Comorbid tension-type headache or chronic daily headache — tricyclics are first-line for tension-type headache prevention

✗ Avoid if

Cardiac arrhythmia, recent MI, long QT syndrome — tricyclics prolong QTc

Glaucoma (narrow-angle) — anticholinergic effects increase intraocular pressure

Epilepsy — lowers seizure threshold; use with caution; consider topiramate instead (antiepileptic + antimigraine)

Urinary retention, significant prostatic hypertrophy — anticholinergic effects

⚠ Side effects

Drowsiness — take at bedtime; therapeutic at migraine doses (10–50mg); start at 10mg and titrate

Weight gain — common; relevant in overweight patients; consider topiramate instead

Dry mouth, constipation, blurred vision — anticholinergic effects; usually mild at migraine prevention doses

Cardiac arrhythmia risk at higher doses — ECG recommended in patients >40 or with cardiac risk factors

🔬 Monitor

ECG at baseline if cardiac risk or age >40. PHQ-9 at start and 6 weeks (monitoring antidepressant effect). Headache diary: ≥50% frequency reduction at 3 months = responder. NEVER stop abruptly — taper over 2–4 weeks

💬 Counselling

"Take this tablet at night — it has a mild sedative effect which is actually useful because it helps with sleep. I'm starting you on a very low dose (10mg — which is much lower than the antidepressant dose), and we'll increase slowly. The most common side effects are dry mouth and slight grogginess in the morning — these usually settle within 2 weeks. Like the propranolol, don't stop it suddenly. It takes 6–8 weeks to see the full effect on headache frequency."

Amitriptyline 10–50mg is used for migraine prevention at doses significantly lower than antidepressant doses (150–200mg). Clarify this to patients who are concerned about taking an "antidepressant." The triple benefit — migraine prevention + sleep improvement + anxiolytic — makes it particularly useful in patients with insomnia, anxiety, and frequent migraine. NEVER stop abruptly.

7G — Psychosocial impact of the diagnosis: work, relationships, reproductive health & daily life

🫂

Living with migraine — invisible disability, reproductive consequences, and the cost of being believed

Migraine causes more disability years globally than any other neurological condition except stroke. Yet it is routinely undertreated, dismissed, or attributed to stress and weakness. The patient who presents to a GP with frequent migraine has usually already endured years of inadequate treatment, unhelpful advice, and the social cost of an invisible illness. The psychosocial consequences of migraine are inseparable from the clinical management — and often determine whether the patient takes the medication, returns for follow-up, or spirals further into MOH.

💼

Occupation — Teaching in a Migraine World

Teaching combines multiple migraine triggers simultaneously: fluorescent lighting, noise, performance demands, inability to take breaks, dehydration, and high psychological stress. A migraine attack during a teaching day is not manageable — the patient cannot retreat to a dark room while 30 students wait. This creates the cycle of pushing through attacks, taking more medication, and worsening MOH.

Monday-morning migraine is particularly common in teachers: weekday stress + weekend sleep-in + caffeine timing change = reliable weekly attack. Documenting this pattern (via diary) and addressing sleep regularity is more valuable than any medication change for this subgroup.

MIDAS score documents occupational impairment for fit note purposes. "Migraine — unable to perform professional duties without reasonable adjustments" is a valid fit note descriptor that enables HR to provide appropriate support without requiring full sick leave.

"I want to help you with your teaching specifically — can we look at your headache diary together and identify what's happening in your working week that's triggering or worsening the headaches?"

🛡️

Contraception — Reproductive Choices after UKMEC 4

Being told your contraceptive pill must stop immediately is a significant life event — not just a prescribing note. Aisha may have started the pill for reasons beyond contraception (period pain, acne, endometriosis). The UKMEC 4 conversation must address what the pill was doing for her (contraception, period regulation), and ensure the alternative addresses those needs.

The POP (desogestrel) is equally effective for contraception but does not regulate periods in the same way as the combined pill — it may cause irregular or absent bleeding. IUS (Mirena/Kyleena) offers both contraception and period lightening/absence, which may address the period-related concerns that originally prompted the combined pill.

Migraine often improves significantly after stopping the combined OCP — oestrogen fluctuations are a potent migraine trigger. This should be communicated as good news: "stopping the pill may itself improve your migraines."

"I know the pill was working well for you in other ways. Let me make sure what we switch to addresses all of those needs — not just the contraception."

🤰

Pregnancy, Breastfeeding & Migraine

Migraine typically improves significantly in the second and third trimester of pregnancy (rising oestrogen levels stabilise the migraine threshold). However, the first trimester and postpartum period can be worse. For women considering pregnancy, the medication review is critical: topiramate and valproate are absolutely contraindicated and must be stopped months before conception; propranolol is safe; sumatriptan has the most data in pregnancy and is generally considered acceptable.

Breastfeeding: sumatriptan is generally considered compatible with breastfeeding; express-and-discard for 24 hours is a precaution sometimes recommended. NSAIDs (ibuprofen, naproxen): short-term use generally acceptable in breastfeeding. Topiramate transfers into breast milk — avoid. Amitriptyline: some transfer; generally considered acceptable at low doses.

"If you are planning a pregnancy in the next year or two, there are things we need to change about your medication plan now. The preventive tablet I'm considering has a specific warning about pregnancy — so let's build that into our planning."

😰

Medication Overuse Shame and Addiction Anxiety

The MOH patient often experiences significant shame and guilt about their medication use — they feel they have "caused" their own problem, that they are "addicted," or that the GP will judge them for taking so many tablets. This shame is a barrier to honest disclosure and to engaging with the withdrawal plan.

The thermostat analogy: "the medication is lowering the threshold at which your brain triggers the next headache — it's not willpower, it's neuroscience." De-medicalising the shame while medicalising the mechanism allows the patient to engage with withdrawal as a treatment, not a punishment.

Codeine-containing compounds carry the highest MOH risk and the most potential for dependency beyond MOH. Identifying codeine use specifically and managing the withdrawal with appropriate support (including brief addiction medicine input if needed) is important. Document clearly that this is MOH, not opioid addiction in the colloquial sense.

"I want to be very clear about this: what's happened is not your fault. This is a recognised medical pattern called medication overuse headache — and the reason nobody told you earlier is that it's often not explained to migraine patients. It's completely reversible once we make a plan."

😔

Depression, Anxiety, and Health Surveillance

Migraine and major depressive disorder share significant genetic and neurobiological overlap — comorbidity rates are 2–4× higher than the general population. The causal relationship is bidirectional: depression lowers the migraine threshold, and frequent disabling migraine attacks cause depression. Anticipatory anxiety about the next attack — planning every day around the possibility of a headache — is one of the most disabling aspects of frequent migraine.

Health surveillance anxiety (googling symptoms between attacks, catastrophising about aura) is common and self-reinforcing. Providing a clear diagnosis with a specific mechanism removes the ambiguity that drives this surveillance. PHQ-9 and GAD-7 at every review. CBT for migraine-specific health anxiety is available through NHS Talking Therapies and specialist headache psychology services.

"Between the headaches — how are you doing in yourself? Migraine can really affect mood and anxiety, particularly when it's been as frequent and disruptive as yours has been. I want to make sure we address that as part of your overall plan."

👨‍👩‍👧

Family and Social Life — Invisible Illness

Migraine attacks are completely invisible to others between episodes — the patient looks well, functions, and participates. When an attack strikes, the sudden withdrawal from family activities, cancelled plans, and inability to parent can strain relationships and create guilt and resentment on both sides. Partners who have not experienced migraine often struggle to understand why this cannot be "pushed through."

The genetic component of migraine means children of migraineurs have a significantly higher risk of migraine themselves — early recognition and appropriate management in children avoids the years of diagnostic delay that many adult patients experienced.

Patient information: The Migraine Trust (migrainetrust.org) — excellent evidence-based resources for patients and family members. Migraine Buddy app for diary and community support. BASH (British Association for the Study of Headache) patient information leaflets — GP-endorsed.

"Is there someone in your life who would benefit from understanding what migraine actually is? Sometimes bringing a partner or family member to a review appointment can make a real difference to how well the people around you are able to support you."

7H — Follow-up schedule

4–6 Weeks — MOH Withdrawal Review

Has the patient been able to stop the overused analgesics? Expected worsening for first 2 weeks — reassure this is normal. How is the naproxen bridge working? Is the POP being tolerated and taken correctly? Any contraception concerns? Triptan + NSAID combination — is it being taken at the right time (headache onset)? Headache diary review — getting reliable data? PHQ-9 first screen post-change. Any aura features continuing? If worse after 4 weeks: review plan; consider prednisolone bridge.

MOH withdrawal progressPOP tolerance checkHeadache diary check

3 Months — Preventive Therapy Response

Headache diary review: has frequency reduced by ≥50% from baseline? MIDAS score — disability improved? Preventive medication: tolerance (fatigue on propranolol, cognitive effects of topiramate, drowsiness on amitriptyline). Dose titration if response partial and side effects tolerable. MOH: fully resolved or still present? Contraception review: UKMEC 4 confirmed; alternative contraception working. PHQ-9 review. Bloods if due (TFTs check at baseline if not done; renal function for topiramate). Trigger identification from diary.

≥50% reduction achieved?Preventive dose reviewPHQ-9 + contraception

6 Months — Consolidation and Escalation Decision

If ≥50% reduction achieved → continue current preventive; plan 6–12-month cessation trial. If <50% reduction → switch preventive agent or increase dose; ensure MOH has been addressed. If two preventives have failed → consider topiramate (if not tried) or referral to neurology/headache clinic. Menstrual migraine assessment: perimenstrual pattern identified? Frovatriptan or naproxen perimenstrual? Annual UKMEC 4 contraception check.

Switch preventive if no responseNeurology referral if two failures

12 Months — Well-Controlled Migraine Review

Preventive cessation trial after 6–12 months of ≥50% reduction and no significant disability. Reduce prophylaxis gradually over 4–8 weeks; continue headache diary; reinstate if headaches return at problematic frequency. Annual contraception and UKMEC 4 review. PHQ-9. Trigger awareness — any new triggers? Topiramate PPP check if continuing. MIDAS score comparison with baseline. Discuss smoking cessation if relevant (additional cardiovascular risk in migraine with aura).

Cessation trial if stableAnnual UKMEC 4 check

Ongoing — At Any Review Interval

Screen for: new change in headache pattern (red flag); MOH recurrence (analgesic/triptan use count); new pregnancy or breastfeeding status (medication review); new cardiovascular risk factors affecting triptan safety; contraception change (recheck UKMEC 4 if hormonal contraception restarted); depression screen (PHQ-9); emerging menopause (migraine patterns change; HRT guidance for women with aura: oestrogen patches preferable to oral HRT; avoid tibolone if possible).

Always recheck MOHAlways recheck UKMEC 4 if OCP restarted

7I — Monitoring: headache diary targets + drug surveillance

Memory rule — the migraine monitoring framework

At every migraine review: headache diary (attack frequency, severity, medication use count); MIDAS score (disability — has it improved?); MOH screen (analgesic/triptan use ≥10–15 days/month for 3+ months = MOH); UKMEC 4 contraception check (COC + aura = absolute CI — check at every appointment); topiramate PPP (contraception confirmed at every prescription); PHQ-9 at every review. Target: ≥50% reduction in attack frequency from baseline at 3 months on preventive therapy.

Drug / Target	Monitoring test	Timing	Action threshold
Propranolol (preventive)	HR + BP; PHQ-9; headache diary	4 weeks post-start; 3 months; annually	HR <50 → hold/reduce. PHQ-9 worsening → switch to amitriptyline. <50% frequency reduction at 3 months → increase dose or switch.
Amitriptyline (preventive)	PHQ-9; ECG (if cardiac risk); weight; headache diary	4–6 weeks; 3 months; annually	QTc prolongation → switch drug. Significant weight gain → consider topiramate. <50% reduction → increase dose (max 75mg) or switch.
Topiramate (preventive)	Pregnancy test + contraception confirmation (PPP); eGFR; cognitive symptoms; headache diary	Every prescription; 3 months; annually	Pregnancy risk identified → stop immediately; teratology counselling. eGFR decline → reduce dose. Intolerable cognitive effects → switch drug.
MOH surveillance (all patients)	Headache diary medication use count	Every appointment	Analgesic use ≥15 days/month → MOH alert. Triptan use ≥10 days/month → MOH alert. Re-initiate withdrawal plan.
UKMEC 4 contraception	Contraception check — is COC still being used?	Every appointment where migraine with aura is documented	COC identified → stop immediately; prescribe POP/LARC; document. Any combined hormonal contraception = UKMEC 4 with aura.

Target / Clinical group	Acute treatment	Prevention target
Episodic migraine (4–14 days/month)	Sumatriptan 50–100mg + naproxen 500mg + metoclopramide 10mg	≥50% reduction in attack frequency at 3 months
Chronic migraine (≥15 days/month)	As above; add nasal spray or SC triptan if vomiting prevents oral	Neurology referral; Botox (TA260) if 3 preventives failed
Migraine in pregnancy (any trimester)	Paracetamol 1g first-line; sumatriptan if benefit outweighs risk (most data in 2nd/3rd trimester)	Propranolol safe; NO topiramate; NO valproate; avoid ergotamines
Migraine + asthma / COPD	Sumatriptan + naproxen (with PPI); avoid aspirin if aspirin-sensitive asthma	Amitriptyline or candesartan first-line (not propranolol)
Perimenstrual migraine	Frovatriptan 2.5mg BD days -2 to +3; or naproxen 500mg BD perimenstrually	Oestrogen supplement patch perimenstrually (if oestrogen withdrawal pattern)
MOH + migraine	Stop overused drug; naproxen 500mg BD bridge × 4 weeks; prednisolone 60mg × 5 days if severe withdrawal	Start preventive simultaneously with withdrawal — do not delay prophylaxis

7J — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

Thunderclap headache safety-net must be documented at every migraine consultation — "patient advised to call 999 for sudden-onset severe headache different from usual migraine" in notes

UKMEC 4 documentation: "patient informed that combined OCP is absolutely contraindicated with migraine with aura; Rigevidon stopped today; desogestrel 75mcg started" — must be in every consultation note where this change is made

Topiramate PPP: "contraception confirmed (specify method); patient counselled about teratogenicity; yellow PPP card issued; annual pregnancy test arranged" — required at every prescription

MOH withdrawal warning documented: "patient warned that headaches will worsen for 2–4 weeks during withdrawal; naproxen bridge prescribed; patient agrees to continue plan"

Fixed neurological deficit safety-net: "patient advised to call 999 if aura lasts >1 hour or causes fixed deficit not resolving within 60 minutes"

Valproate / topiramate reproductive counselling: if either drug is prescribed to a woman of reproductive age, PPP documentation is mandatory and its absence is a regulatory breach

4–6 WeeksMOH withdrawal progress; POP tolerance; headache diary check; PHQ-9; triptan + NSAID timing confirmed

3 Months≥50% frequency reduction on preventive? Dose titration; MIDAS score; contraception review; topiramate PPP if applicable

AnnualUKMEC 4 contraception check; MOH re-screen; PHQ-9; preventive cessation trial if well-controlled; MIDAS comparison; new red flag screen

🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing the consultation

"I'm stopping the Rigevidon today — and I'm giving you a prescription for a different contraceptive pill called desogestrel. This is a progesterone-only pill that is completely safe with your migraines and equally effective. The Rigevidon was increasing your stroke risk — stopping it reduces it."

"I'm giving you sumatriptan + naproxen to take together at the start of each headache — not during the aura, not when it's severe. I'm also giving you a tablet for the nausea that helps the other tablets work faster."

"We're going to gradually reduce the daily ibuprofen and codeine. Your headaches will be worse for about 2 weeks — I know that sounds frightening, but this is the only way to break the cycle. I'll give you naproxen as a bridge."

"I'm starting propranolol to prevent the headaches from happening so often. It takes 6–8 weeks to work, so we'll review in 6 weeks to see how the withdrawal is going and at 3 months to check the full response."

"If you ever get a headache that comes on suddenly and feels completely different from your usual ones — call 999, not us. Is there anything else you want to ask before we finish?"

Deductions — closing

Sending patient home on COC with diagnosed migraine with aura — the most serious error in this consultation
Not explaining MOH withdrawal worsening — patient will abandon the plan when headaches worsen as expected
Not prescribing triptan + NSAID combination (prescribing one without the other)
Not giving thunderclap headache safety-net
Starting topiramate without confirming contraception and documenting PPP
Not naming the paternal stroke fear directly before delivering the COC news

Tasks domain — full criteria

UKMEC 4 identified → COC stopped → POP or LARC offered today
MOH diagnosed and withdrawal plan explained with expected worsening warning
Acute treatment: triptan + NSAID + antiemetic simultaneously at headache onset
Preventive therapy started with correct drug choice and timeline
Thunderclap headache safety-net given verbally and in writing

Relating to Others — full criteria

Stroke fear addressed directly before delivering COC news
MOH framed as physiological mechanism, not moral failure
Dimmer switch / thermostat analogy used for migraine / MOH respectively
ICE all three explored and explicitly referenced in the plan
Reproductive health discussed with respect and offer of choice
Closing question asked genuinely; patient agreement sought

🔴 Red — failing

COC not stopped; MOH not diagnosed; withdrawal worsening not warned; thunderclap safety-net absent; topiramate started without PPP; triptan prescribed without NSAID combination; stroke fear unaddressed

🟠 Amber — borderline

COC stopped but no alternative offered; MOH identified but withdrawal plan vague; triptan given without NSAID; withdrawal worsening not mentioned; thunderclap safety-net given but generic; stroke fear mentioned but not addressed before COC news

🟢 Green — strong pass

UKMEC 4 identified; COC stopped; POP offered today; MOH explained with thermostat analogy (not moral failure); withdrawal worsening warned specifically; triptan + NSAID + antiemetic together at headache onset; propranolol started; thunderclap safety-net verbal + written; stroke fear addressed before COC discussion; ICE all three; headache diary recommended; closing question

"I've had these headaches for years — they've always been there — but recently they're getting worse. I'm getting them more often, the tablets aren't working as well, and I've been getting these strange zigzag patterns in my vision before some of them. I'm probably just run-down — it's been a really stressful term at school."

Who you are

Aisha Rahman, 32-year-old secondary school teacher. Eight-year history of migraine (diagnosed at 24, confirmed by previous GP). Attacks typically 2–3 per month, unilateral, throbbing, with nausea and light sensitivity, lasting 12–18 hours. Married. No children currently; not actively trying to conceive but hasn't ruled it out. Started Rigevidon (combined oral contraceptive, 30 micrograms ethinylestradiol + 150 micrograms levonorgestrel) 4 months ago — prescribed by a nurse practitioner for period regulation and contraception at a different surgery. Aunt had a stroke aged 42 and was left with permanent weakness. She has heard there is "some connection" between migraines and the pill but does not know the specifics.

What has changed

Over the past 4 months (coinciding with starting Rigevidon), Aisha has noticed: (1) new visual zigzag patterns lasting 20–30 minutes before some headaches — she finds these frightening; (2) attack frequency increasing to 4–5 per month; (3) headache present on most days (often milder, sometimes severe); (4) sumatriptan barely working any more. She is now taking ibuprofen 400mg or co-codamol 30/500mg on approximately 18 days per month, and using sumatriptan on approximately 12 days per month. She carries co-codamol everywhere and takes it pre-emptively when she feels the first hint of a headache coming on at school.

Hidden agenda (two layers)

Layer 1 — Stroke fear: Aisha is frightened that the visual zigzag patterns are a warning sign of a stroke — her aunt's stroke at 42 is very present in her mind. She is aware there is "some link" between migraine, the pill, and stroke risk but does not know the details. She will not volunteer this fear unless specifically invited — but if the doctor asks something like "is there something specific about the visual symptoms that's worrying you, beyond the headache?", she will admit it. If the doctor delivers the UKMEC 4 news (pill must stop) without first exploring this fear, she will experience it as confirmation of her worst fear and become very anxious. If the doctor names the fear first and frames the pill-stopping as risk-reduction, she will receive the news with relief rather than terror.

Layer 2 — Medication shame ("am I addicted?"): Aisha is taking co-codamol on 18 days per month and sumatriptan on 12 days. She feels guilty and embarrassed about this. She fears she is "addicted to painkillers" and will be judged. She will not volunteer the exact number of days of use unless asked specifically — she will say "when I need to" or "a few times a week" if not pressed. If asked directly and non-judgementally ("I need to ask exactly how many days in the last month you've used each tablet"), she will give the true numbers. If the doctor responds to these numbers with judgment or alarm, she will shut down. If the doctor explains MOH as a physiological mechanism (not an addiction or moral failure), she will engage fully with the withdrawal plan.

Symptoms if asked directly

Headaches: unilateral (right or left, varies), throbbing, 7–9/10 severity, made worse by movement and light, associated with nausea (vomits occasionally)
Visual aura: zigzag arc of lights or herringbone pattern starting centrally, expanding to periphery over 15–20 minutes, then disappears; followed by headache within 30–60 minutes; always fully resolves (no permanent vision change)
Frequency: 4–5 migraine attacks per month + daily mild-moderate headaches (these are MOH)
Trigger questions: worse at the start of school terms, better on long holidays; bad on Mondays (caffeine withdrawal + sleep change); fluorescent lights at school worsen them; skipping lunch worsens them
No fever, neck stiffness, weakness, speech problems, loss of consciousness
No photophobia between attacks (only during attacks)
Headache is NOT maximal at onset (not thunderclap) — builds over 30–60 minutes
Periods: regular on Rigevidon; previously had moderate dysmenorrhoea and heavy periods (one of the reasons she started the pill)

Reactions to key moments

When asked about stroke fear (pre-emptively): Relieved — "yes, actually, that's been at the back of my mind since I started getting the visual things. My aunt... it just keeps coming up." Engages fully with the explanation.
When told the pill must stop (without fear being addressed first): Visibly anxious — "wait, is it really that dangerous? Have I been putting myself at risk for months?" Difficult to re-engage with management plan until fears addressed.
When COC news framed as risk-reduction: "Oh — so stopping it actually makes me safer? That's... actually a relief." Engages with alternative contraception discussion.
When told she has "medication overuse headache" without explanation: Shuts down — "so it's my fault the headaches are worse?" Needs thermostat analogy and explicit de-shaming before engaging.
When withdrawal worsening is not mentioned: If headaches worsen at week 2 post-withdrawal, she will call the surgery and likely restart co-codamol. The 2–4-week warning is essential for adherence.
When asked about triptans in aura: "I thought you weren't supposed to take sumatriptan if you have aura?" — allow her to voice this misconception; correct it directly: triptans are safe in typical visual aura.
When asked about reproductive plans: "We're not trying yet but... maybe in the next year or two." This is the trigger to check preventive therapy teratogenicity (topiramate). If propranolol chosen as first-line, less teratogen concern.
Scan expectation: If the candidate does not mention imaging, Aisha may ask: "Should I have a brain scan — to rule out a tumour or something?" Candidate should acknowledge the question, explain the role of examination in excluding serious causes, and explain that routine imaging is not indicated when the examination is normal and the pattern is typical migraine.

"I've been reading online and it says some people with migraine shouldn't take triptans if they have the visual symptoms. And — I know this sounds silly — but with my aunt, I've been wondering if these zigzag things could mean something more serious. My previous GP just kept giving me more ibuprofen and I always felt a bit like I was being fobbed off."

Resolution: Aisha will fully engage with the management plan if the candidate: (1) asks about stroke fear directly before delivering the COC news; (2) frames the COC stopping as protective, not alarming; (3) explains MOH as a physiological mechanism without judgment; (4) warns about the withdrawal worsening period explicitly; (5) prescribes the triptan + NSAID + antiemetic combination with clear timing instructions; (6) corrects the triptan-in-aura misconception; (7) gives the thunderclap safety-net clearly; (8) involves her in contraception choice. She will disengage or feel dismissed if: the pill-stopping news is delivered as clinical news without emotional framing; the medication use is met with alarm or judgment; she is not warned about withdrawal worsening; or the consultation is closed without checking whether she has questions.

🏥

Clinic Quick Reference

Migraine — Clinical Decision Framework

NICE CG150 (2021) · ICHD-3 Criteria · UKMEC 2025 · CKS Migraine (2023) · MHRA topiramate PPP

▼expand

🚦 1 — Triage Algorithm

Patient with headache (new or worsening)

↓

🔴 Emergency — 999

Thunderclap onset (maximal in 60 seconds): SAH — CT head + LP; do NOT manage as migraine
Fixed neurological deficit >60 min: TIA/stroke or CVT — 999; stroke protocol
Fever + neck stiffness ± non-blanching rash: meningitis — 999; IV benzylpenicillin if meningococcal
Headache + haemodynamic instability or reduced consciousness: intracranial haemorrhage
Severe headache in pregnancy ≥20 weeks: eclampsia — BP check + 999 if ≥160/110

Never assume thunderclap = migraine · LP mandatory after negative CT

🟠 Urgent — same-day to 2 weeks

UKMEC 4 identified (COC + aura): stop COC today; POP/LARC same consultation
GCA suspected (≥50 + temporal headache): ESR + CRP + prednisolone same day; biopsy within 72h
Hemiplegic migraine: MRI brain urgently; avoid triptans; neurology
Status migrainosus (>72h): IV/IM treatment; admission consideration
Papilloedema on fundoscopy: urgent MRI brain + neuro-ophthalmology

Start acute treatment before referral; do not send patient away unmedicated

🟢 Routine — GP-led

Episodic migraine, red flags excluded: optimise acute and preventive treatment
MOH (≥10–15 analgesic days/month for ≥3 months): withdrawal + bridge + preventive
Annual review: UKMEC 4 check; MOH screen; PHQ-9; diary review; PPP if topiramate

Diary + three-track plan: acute / MOH withdrawal / preventive — all simultaneously

🔬 2 — Diagnostic Framework

POUND Mnemonic — Clinical Migraine Diagnosis

P — Pulsating / throbbing quality

O — One-day duration (4–72 hours untreated)

U — Unilateral

N — Nausea or vomiting

D — Disabling (prevents normal activity)

4/5 = 93% PPV for migraine 3/5 = 64% PPV

MOH Diagnostic Thresholds (ICHD-3)

≥15 days/monthSimple analgesics (aspirin, paracetamol, NSAIDs, combinations)

≥10 days/monthTriptans, opioids, ergotamines

≥3 monthsDuration of regular overuse required for diagnosis

Ask for exact days per month — patients typically underestimate by 30–40%

📊 3 — Key Numbers

≥5 attacks

ICHD-3 minimum for migraine without aura diagnosis

UKMEC 4

Combined OCP + migraine with aura — absolute contraindication; stop COC today

≥10 / ≥15

MOH days/month threshold (triptans / analgesics)

4/5 POUND

93% positive predictive value for migraine

4–72 hours

Typical untreated attack duration

≥50%

Frequency reduction = prophylaxis success at 3 months

3 months

Minimum preventive therapy trial before switching agent

≥4/month

Threshold for considering preventive therapy (NICE CG150)

2–4 weeks

Expected MOH withdrawal worsening period — warn explicitly

PPP

Topiramate Pregnancy Prevention Programme — mandatory at every prescription

60 seconds

Thunderclap headache: maximal intensity within 60s = SAH until proven otherwise

5–60 min

Typical aura duration; >60 min = prolonged aura; motor weakness = hemiplegic

💊 4 — Prescribing Framework

Three-Track Management — All Simultaneously

Acute: Sumatriptan 50–100mg + Naproxen 500mg + Metoclopramide 10mg simultaneously at headache onset (not aura; not severe)

MOH withdrawal: Stop overused drugs; naproxen 500mg BD bridge ×4 weeks; warn 2–4 week worsening; prednisolone 60mg ×5 days for severe withdrawal

Preventive: Propranolol 40–80mg BD or Amitriptyline 10mg ON (if insomnia/depression) or Topiramate 25–100mg (PPP mandatory) or Candesartan 8–16mg

⛔ COC + aura = UKMEC 4 — stop same day · Topiramate = teratogen PPP mandatory · Triptans safe in typical aura (NOT hemiplegic) · Avoid triptans in CVD, uncontrolled HTN, prior stroke

Drug Choice by Scenario

Asthma (propranolol CI)

Amitriptyline 10mg ON

Insomnia + anxiety + migraine

Amitriptyline (triple benefit)

Overweight (BMI >30)

Topiramate (weight loss benefit)

Pregnancy

Propranolol · NO topiramate

Raynaud's / depression

Candesartan or amitriptyline

Perimenstrual migraine

Frovatriptan BD days -2 to +3

Triptans CI or refractory

Gepants (rimegepant) — specialist

⚠ 5 — Safety-Netting & Monitoring

Follow-up timeline

4–6 weeks: MOH withdrawal progress; POP tolerance; diary check; PHQ-9; triptan timing confirmed

3 months: ≥50% frequency reduction? Dose titration; MIDAS; UKMEC 4 check; topiramate PPP

6 months: Switch preventive if no response; neurology referral if two agents failed

Annual: MOH re-screen; UKMEC 4 check; PHQ-9; cessation trial if stable ≥6 months

📌 At every appointment: ask medication days per month (MOH screen) + check contraception if migraine with aura (UKMEC 4)

🔬 6 — Monitoring Targets & Red Flags

Parameter	Test	Timing	Action threshold
Attack frequency (diary)	Headache diary review	Every appointment	Not ≥50% reduced at 3 months → increase dose or switch preventive. Frequency ≥15 days/month → chronic migraine; neurology referral.
Medication use count (MOH)	Patient self-report; diary	Every appointment	Analgesic ≥15 days or triptan ≥10 days/month → MOH diagnosed; withdrawal plan. Re-initiate if recurrence detected.
Topiramate PPP	Contraception confirmation + pregnancy test	Every prescription	Contraception not confirmed → do not prescribe. Pregnancy test positive → stop immediately; teratology counselling urgently.
UKMEC 4 check	Contraception review	Every appointment (migraine with aura)	COC identified → stop immediately; POP/LARC offered same day; document in notes.
Propranolol (HR)	HR at every appointment	Every review	HR <50 → reduce dose. Worsening depression → switch to amitriptyline. NEVER stop abruptly.

🚨 Emergency flags: Thunderclap headache (SAH until proven — CT + LP); fixed neurological deficit >60 min (TIA/CVT — 999); fever + neck stiffness ± rash (meningitis — 999 + IV benzylpenicillin); papilloedema on fundoscopy (raised ICP — urgent MRI); eclampsia in pregnancy (BP ≥160/110 + headache — 999); first or worst headache of life regardless of migraine history

🛡️ Safeguarding: UKMEC 4 — failure to stop COC with migraine with aura is a medico-legal risk; topiramate PPP omission is a regulatory breach; codeine dependence in MOH — brief addiction medicine input if needed; post-traumatic headache from DV — ask in private; headache in child with psychosocial stress — somatic presentation of abuse; valproate in women without PPP — absolute prohibition

🎓

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

▼expand

🕐 12-Minute Consultation Flow — with Domain Scoring

0–1 min

Warm Opening + Open Question

"I can see you've been dealing with worsening headaches. Before I ask anything specific — can you just tell me in your own words what's been happening?"

Open narrative yields POUND features, aura description, medication pattern, and emotional context simultaneously. Do not start with "is it one-sided?" — that leads the witness and loses diagnostic value.

Global SkillsTasksRelating to Others

✗ Starting with closed SOCRATES questions · ✗ Interrupting the narrative to ask about aura too early

1–5 min

Red Flags + POUND + Medication Count + Aura + Contraception

"Has this headache ever come on suddenly — maximal in seconds? Any fever or neck stiffness?"

"On how many days in the last month did you take ibuprofen? Co-codamol? Sumatriptan? I need exact numbers — not to judge, but because there's a pattern I want to explain."

"I need to ask about the zigzag patterns specifically — how long do they last, do they fully go away, do they spread gradually across your vision? And are you on any hormonal contraception?"

Four parallel screens happening simultaneously: red flags excluded; MOH quantified; aura characterised (duration, reversibility, type); COC identified. All four must be completed before moving to management.

TasksGlobal Skills

✗ Not quantifying medication days per month · ✗ Not asking about contraception · ✗ Not characterising aura duration and reversibility

5–6 min

ICE — Stroke Fear Before COC Discussion

"Before I explain what I think is happening, I want to ask — is there something specific about the visual symptoms that's been worrying you? Given your family history, I wonder if stroke has been at the back of your mind?"

"What were you hoping we'd do today — different tablets, a scan, something else?"

Name the stroke fear BEFORE delivering UKMEC 4 news. If fear is named first, the COC news lands as risk-reduction. If COC news comes first, it lands as risk-confirmation. This sequencing is the most important communication act in this consultation.

Relating to OthersGlobal Skills

✗ Delivering "your pill must stop" before addressing stroke fear · ✗ Not exploring ICE before management

6–7 min

Examination + Diagnosis in Plain Language

"I'd like to do a quick neurological examination — check your reflexes, coordination, and look at the backs of your eyes. A normal examination is actually an important reassurance that this is migraine and not something that needs urgent imaging."

"Migraine is a neurological condition — think of your brain as having a dimmer switch for pain and sensory sensitivity that's set too low. The zigzag patterns are your brain's visual area being activated by a wave of electrical activity — the aura. The medication overuse is a separate issue I'll explain with a different analogy."

Normal neurological examination communicated as reassurance, not just ticked off. Dimmer switch analogy for migraine. Then: MOH with thermostat analogy before withdrawal plan.

TasksGlobal Skills

✗ Skipping examination · ✗ Not explaining what normal examination means for the patient · ✗ No plain-language diagnosis

7–12 min

Three-Track Plan + COC + Safety-Nets + Closing

"I'm stopping the Rigevidon today and giving you a progesterone-only pill instead — this is equally effective and completely safe with your migraines. Stopping the combined pill actually reduces your stroke risk."

"For the headaches: sumatriptan + naproxen + the anti-nausea tablet, all three together at the very first sign of the headache — not during the aura, not when it's severe. At headache onset."

"I need to tell you that when you stop the daily painkillers, your headaches will be worse for 2–4 weeks. This is not failure — it is the brain recalibrating. I'm giving you naproxen to help bridge that period."

"I'm starting propranolol to reduce how often the headaches happen. It takes 6–8 weeks. Please don't stop it suddenly. We'll review in 6 weeks."

"One emergency rule: a headache that comes on in seconds — call 999, not us. Is there anything else before we finish?"

TasksRelating to OthersGlobal Skills

✗ COC not stopped · ✗ No alternative contraception · ✗ No MOH withdrawal worsening warning · ✗ Triptan without NSAID · ✗ No thunderclap safety-net · ✗ No closing question

🔴🟠🟢 RAG Scoring — All 3 Domains

Tasks Domain

🟢

UKMEC 4 identified; COC stopped; POP offered today; POUND applied; aura characterised; MOH diagnosed with days count; thermostat analogy; withdrawal worsening warned; triptan + NSAID + antiemetic simultaneously; propranolol started; thunderclap 999 safety-net verbal + written; topiramate PPP if applicable; diary recommended; 6-week follow-up booked

🟠

COC stopped but no alternative offered; MOH identified but days not counted; withdrawal worsening not warned; triptan without NSAID; thunderclap safety-net generic not specific; aura identified but duration not characterised; preventive started but no timeline given; diary not mentioned

🔴

COC not stopped; MOH not identified; red flags not screened; thunderclap safety-net absent; triptan prescribed without NSAID; topiramate without PPP; stroke fear not addressed; withdrawal worsening not mentioned; no acute combination treatment

Relating to Others

🟢

Stroke fear named before COC news; medication shame de-pathologised with thermostat analogy; dimmer switch used for migraine; ICE all three explored and referenced in plan; reproductive health discussed with genuine choice; patient agreement sought; chunk-and-check through three-track plan; closing question

🟠

Stroke fear acknowledged generically not specifically; MOH framed as "your fault" or "common" without mechanism; ICE only one or two; COC news before fear addressed; reproductive health discussed but choice not offered; no chunk-and-check

🔴

Stroke fear ignored; medication shame reinforced; no ICE; COC news delivered without framing; patient overwhelmed by three-track plan without checking understanding; no closing question

Global Skills

🟢

Open question; stroke fear before COC news; dimmer switch + thermostat analogies; plain language throughout; history + examination + diagnosis + plan all within 12 minutes; signposting at each transition; responds to emotional cues immediately

🟠

Closed questions early; plain language inconsistent; analogies absent; COC news before fear; signposting missing at key transitions; time management poor (history still ongoing at 9 minutes)

🔴

Immediate closed SOCRATES; medical jargon; no analogies; emotional cues missed; three-track plan delivered as a monologue; no understanding checked; consultation ran beyond 12 minutes

💬 Key Phrases — ICE, Analogies & Plan

💭 Ideas — stress attribution

"Stress is definitely a real migraine trigger — it lowers your sensitivity threshold. But stress alone doesn't account for the specific visual zigzag pattern or the way your medication use has changed. I want to explain what I think is actually driving the worsening."

😟 Concerns — stroke fear first

"Before I explain what needs to change, I want to check — is there something specific that's been frightening you about the visual symptoms? With your aunt's history, I wonder if stroke has been at the back of your mind. Am I right?"

🎯 Expectations — scan question

"Were you expecting a brain scan today? I want to explain why — with a normal neurological examination — routine imaging is not what I'm recommending, and why that's not a gap in your care."

🌡️ Thermostat analogy — MOH

"Think of your brain's pain threshold like a thermostat. Every time you take a painkiller, it resets the thermostat a little lower — making the next headache happen sooner. The medication is creating the demand for more medication. That's not addiction — it's brain chemistry, and it's reversible."

🔆 Dimmer switch analogy — migraine

"Your brain has a sensitivity dial — in migraine, it's set too low, so it responds to triggers like irregular sleep or the hormonal pill with an electrical wave that spreads across the brain. The zigzag you see is that wave hitting your visual cortex. The headache is the inflammatory aftermath."

🛡️ COC framing — risk reduction

"Stopping the pill reduces your stroke risk — it doesn't mean you've been in danger for months. The risk from the combination is real, which is why we're acting today, and why the alternative I'm giving you is completely safe."

🚫 9 Danger Zones — Instant Deductions

✗

COC not stopped in migraine with aura→ UKMEC 4 is an absolute contraindication — no distinction between pill brands or dose. Stop COC today; prescribe POP or LARC at same consultation. Document. This is a medico-legal obligation.

✗

MOH not diagnosed because medication count not done→ Ask exact days per month for every analgesic and triptan. Patients underestimate by 30–40%. Without a number, MOH cannot be diagnosed. Ask: "How many days in the last month did you take ibuprofen?"

✗

Thunderclap headache safety-net not given→ Every migraine consultation must include: "sudden-onset maximal-intensity headache = call 999, not the GP." Document it. Failure to provide this is documented medico-legal risk in headache management.

✗

Triptan prescribed without NSAID (or vice versa)→ NICE CG150 evidence: triptan + NSAID simultaneously is significantly more effective than either alone. Sumatriptan + naproxen together at headache onset is the standard. Not sequential — simultaneous.

✗

MOH withdrawal worsening not warned→ Without this warning, patients will interpret the expected 2–4 week worsening as treatment failure and restart their overused medications. The warning is the intervention. Document it explicitly: "patient warned headaches will worsen for 2–4 weeks."

✗

Topiramate started without PPP documentation→ MHRA Pregnancy Prevention Programme is a mandatory regulatory requirement for topiramate in women of reproductive potential. Contraception confirmed, yellow card issued, annual pregnancy test, documented at every prescription. Not optional.

✗

Triptans said to be contraindicated in migraine with aura (incorrect)→ Triptans are SAFE in typical visual aura (scintillating scotoma, fortification spectra). They are contraindicated only in hemiplegic migraine and basilar-type migraine. This is one of the most common migraine misconceptions — stating the truth explicitly scores in Tasks.

✗

Propranolol started without abrupt discontinuation warning→ Never stop propranolol suddenly — rebound tachycardia and migraine exacerbation. Taper over 1–2 weeks. Document this at every prescription. Same principle as beta-blockers in angina.

✗

Stroke fear not addressed before delivering COC news→ Sequencing matters. Naming the fear first ("I think stroke has been in the back of your mind") before saying "the pill must stop" frames the COC news as protective action. Reversing this order creates terror, not reassurance. This is Relating to Others domain failure.

💊 Drug Quick-Pick

Acute attack — first-line triptan

→

Sumatriptan 50–100mg

At headache onset

Acute — add simultaneously

→

Naproxen 500mg

Not sequential

Acute — antiemetic

→

Metoclopramide 10mg

Aids absorption

MOH bridge

→

Naproxen 500mg BD × 4wks

Warn worsening

Prevention first-line

→

Propranolol 40mg BD

Not in asthma

Prevention + insomnia/anxiety

→

Amitriptyline 10mg ON

Triple benefit

Prevention + overweight

→

Topiramate 25mg → 100mg

PPP mandatory

⛔ COC + aura = UKMEC 4 — stop same day · Triptans safe in typical aura (NOT hemiplegic) · Topiramate = teratogen PPP mandatory · Triptan + NSAID simultaneously not sequentially · Warn MOH withdrawal worsening · Thunderclap = 999 not GP · Propranolol never stop abruptly

Migraine · GP Clinical Reasoning Framework v2 · NICE CG150 — Headaches in over 12s (2021) · ICHD-3 Diagnostic Criteria · UKMEC 2025 (COC + aura = Category 4) · CKS Migraine (2023) · MHRA Topiramate Pregnancy Prevention Programme · BNF Chapter 4.7

v2: Three-track management (acute / MOH withdrawal / preventive) · UKMEC 4 absolute contraindication (COC + migraine with aura) · MOH diagnostic thresholds (≥10 triptan / ≥15 analgesic days/month) · Topiramate PPP mandatory documentation · Dimmer switch analogy (migraine) + thermostat analogy (MOH) · POUND mnemonic (4/5 = 93% PPV) · Drug cards: sumatriptan / NSAID / metoclopramide / propranolol / topiramate (PPP) / amitriptyline · Triptans safe in typical aura (contraindicated only in hemiplegic / basilar-type) · Perimenstrual migraine: frovatriptan BD days -2 to +3 · CGRP antibodies via specialist pathway

Teaching clinicians why each step matters — not just what to do · Always consult current BNF/SPC and local formulary · Clinical judgement takes precedence over any framework · Address stroke fear before delivering COC news · Warn MOH withdrawal worsening explicitly · Thunderclap headache safety-net at every consultation

Migraine

Red Flags — act before continuing history

Safeguarding Considerations — Consider in Every Consultation

🏠 Domestic Abuse & Trauma-Related Headache

👴 Older Adults — New Headache Flags

🧒 Children and Young People

💊 Medication Safety & Reproductive Risk

💼 Work, School, and Professional Identity

🛡️ Contraception, Stroke Fear, and Reproductive Choices

😰 Medication Overuse Anxiety ("Am I Addicted?")

😔 Depression, Anxiety, and Fatigue

🌙 Sleep, Circadian Rhythm, and Trigger Regularity

👨‍👩‍👧 Family, Relationships, and Invisible Illness

999 / A&E Now

Same-Day / Same-Week Assessment

GP-Led Management

Hemiplegic Migraine

Idiopathic Intracranial Hypertension (IIH)

New Daily Persistent Headache (NDPH)

Subarachnoid Haemorrhage

Cerebral Venous Thrombosis (CVT)

Validate — name their expectation

Explain — share your clinical reasoning

Negotiate — offer something today

Select patient characteristics — see drug cards and guidance below

Occupation — Teaching in a Migraine World

Contraception — Reproductive Choices after UKMEC 4

Pregnancy, Breastfeeding & Migraine

Medication Overuse Shame and Addiction Anxiety

Depression, Anxiety, and Health Surveillance

Family and Social Life — Invisible Illness

4–6 Weeks — MOH Withdrawal Review

3 Months — Preventive Therapy Response

6 Months — Consolidation and Escalation Decision

12 Months — Well-Controlled Migraine Review

Ongoing — At Any Review Interval

Memory rule — the migraine monitoring framework

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

🎭 Patient actor brief — click to practise

Who you are

What has changed

Hidden agenda (two layers)

Symptoms if asked directly

Reactions to key moments