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CPD: Key questions on migraine

Learning Objectives

This module will update your knowledge on migraine, including:

  • Questions to ask to try to make the right diagnosis
  • Examinations to perform in a patient with suspected migraine 
  • How to approach prescribing analgesics without risking analgesia-induced headache through medication overuse
  • Triptan prescibing 
  • Prophylaxis medication and second- and third- line medications


Dr David Kernick is a headache GPSI in Exeter and the RCGP clinical champion for headache

I still find it difficult to decide whether a patient has a migraine or another type of headache, such as tension-pattern, particularly if the presentation is not of the ‘classic’ pattern with aura. What questions should I ask to try to make the right diagnosis?

‘Classic migraine’ is not recognised. Migraine is diagnosed either with or without aura – 30% of migraine is associated with aura. This is a transient focal sensory of motor neurological deficit that usually precedes headache and should not last for more than 60 minutes. The formal criterion for migraine is shown in the box below, but a positive answer to two out of the following three symptoms has a high sensitivity and specificity:

  • Recurrent headaches that interfere with function.
  • Nausea with headache.
  • Light bothers with headache more than when headache is absent.

I very rarely diagnose tension type headache. Usually there will be a family history or past history of migraine and I think a better perspective is to see it as part of the migraine spectrum.

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