Migraine headache: symptoms, red flags and when to seek help

Many people picture migraine as only the headache, but the NHS describes a set of symptoms that make up an attack. The main ones are a throbbing headache that can be severe, often on one side of the head and worse when you move around, feeling or being sick, and being very sensitive to light and sounds.

Before the pain begins some people notice early signs, which the NHS lists as feeling very tired and yawning a lot, craving certain foods or feeling thirsty, mood changes, a stiff neck and peeing more. These can start hours, or up to two days, before the head pain and finish after it stops.

A subset of people also have aura. The NHS describes this as warning signs such as zigzag lines or flashing lights, numbness or pins-and-needles, dizziness and difficulty speaking, which should not last for longer than an hour.

The NHS says most headaches go away on their own and are not a sign of something more serious, and that severe headaches can sometimes be caused by a migraine or cluster headache. Tension-type headache is usually a dull band-like pressure on both sides without nausea. Cluster headache is brief, excruciating pain around one eye with a watering eye or blocked nostril, occurring in bouts. A migraine sits between them, with nausea and sensory sensitivity as its signature.

The NHS lists skipping meals, stress, alcohol, dehydration, too many painkillers and hormonal changes among common headache causes, and suggests keeping a headache diary to work out triggers. It says migraine attacks that happen just before or during your period are called menstrual migraines and are often longer and more severe than at other times, and that most people find attacks slowly improve with age, in women often after the menopause and sometimes in pregnancy.

Common personal triggers include irregular sleep, long gaps between meals, bright or flickering light, strong smells, caffeine changes and weather shifts. Triggers are often a combination rather than a single culprit, so a diary over two or three months is more informative than a single suspicious food.

The NHS says to call 999 if you or your child have a headache that came on suddenly and is extremely painful, problems speaking or remembering things, loss of vision or blurred or double vision, drowsiness or confusion, a seizure or fit, a very high temperature with symptoms of meningitis, weakness in the arms or legs on one side of the body or one side of the face, or a recent head injury.

The headaches page adds numbness or weakness in the body or face, difficulty balancing or walking, a rash that does not fade when a glass is rolled over it, and a stiff neck or bright lights bothering you. It advises urgent advice for headache with vision or eye problems, headache triggered or made worse by coughing, sneezing, bending down or exercising, headache with vomiting, jaw pain when eating or a sore or tender scalp, and, for a child, a headache that is getting worse or wakes them at night.

The NHS migraine page also says to seek urgent advice if you are pregnant or have just had a baby and have a migraine attack. A first-ever migraine-type headache after 50 or a clear change in your usual pattern should be assessed rather than assumed to be migraine.

Diagnosis rests on the history. Expect questions about the pain location, quality and timing, associated nausea or light sensitivity, aura, how long attacks last and how many days a month you are affected, what you do to cope and which medicines you use and how often. The clinician will want to know about family history, hormonal contraception, pregnancy, and sleep and mood.

Examination covers blood pressure, eyes, neck, and a brief neurological check of strength, sensation, balance and speech. Most people with a typical history and a normal examination need no scan. Imaging is reserved for headaches with features suggesting another cause.

The NHS says migraine cannot be cured but treatment can help manage the symptoms of an attack and prevent attacks. For symptoms it lists painkillers such as ibuprofen and paracetamol, medicines called triptans and gepants, and anti-sickness medicines, and advises taking painkillers as soon as the headache starts.

For prevention it lists medicines such as beta blockers, antidepressants and epilepsy medicines, acupuncture, relaxation techniques and cognitive behavioural therapy, and vitamin B2, with lifestyle changes such as eating at regular times and drinking less caffeine. You may have to try a combination before finding what works, and if nothing helps you may be referred to a specialist.

The NHS says to see a GP if attacks are severe, getting worse or lasting longer than usual, if you have attacks more than once a week, if migraine is hard to control, or if you regularly get migraine before or during your period.

Regular meals, steady fluids, consistent sleep and wake times, regular exercise and sensible caffeine intake form the base of self-management. Resting in a dark, quiet room during an attack helps many people. Keep to the painkiller limit the NHS describes, because frequent use of painkillers can itself produce a pattern of near-daily headache.