A neurological condition, not a bad headache — and there are far more treatment options than most people are offered.
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Migraine is a neurological condition, not a severe headache. It involves changes in brain activity and the trigeminal nerve system, and the headache is only one part of it — which is why treating it as pain alone works so poorly.
It affects around one in seven people, women roughly three times as often as men, and it is one of the leading causes of years lived with disability worldwide. Despite that, migraine is substantially under-diagnosed and under-treated in the UK. A great many people manage for years on paracetamol, having never been offered a triptan or a preventive, and having never been told that painkillers taken too often are making things worse.
Two things on this page are more important than the rest.
Timing of acute treatment. Migraine slows stomach emptying early in an attack, so a tablet taken an hour in may not absorb. Taking treatment at the very first sign, in soluble form, changes outcomes dramatically.
Migraine with aura and the combined pill. If you get visual aura before your headaches, you should not take the combined oral contraceptive pill — the combination raises stroke risk. This is a firm contraindication and it is missed more often than it should be.
Migraine runs strongly in families and involves inherited differences in how the brain regulates sensory input. The current understanding centres on a wave of altered activity across the cortex — which produces aura — and activation of the trigeminal system releasing CGRP, a molecule that newer preventive drugs specifically target.
The useful concept is a threshold rather than a single cause. Most attacks follow a combination of factors on the same day, which is why a trigger seems to cause an attack sometimes and not others.
Chocolate and cheese are widely blamed and the evidence is weak — chocolate craving is frequently part of the prodrome, so it is a symptom mistaken for a cause.
Migraine is a clinical diagnosis, made on the pattern of attacks. There is no test for it, and scans are normal — which is worth knowing, because people often assume a normal scan means their headaches are not real or not migraine. It means neither.
Recurrent attacks lasting four to 72 hours, with at least two of: one-sided, throbbing, moderate or severe, worse on movement — plus either nausea or light and sound sensitivity.
A headache diary is the most valuable diagnostic tool available, and costs nothing. Record dates, duration, severity, what you took and when, and where you were in your cycle. Over two to three months it reveals patterns nobody remembers accurately, identifies medication overuse, and shows whether a preventive is working.
Imaging is not indicated for typical migraine with a normal neurological examination. It is warranted where there are red flags: a change in the established pattern, onset over 50, headache worse lying down or on coughing, neurological signs that persist, or a thunderclap onset.
Migraine assesses well remotely. The diagnosis comes from the history, and much of what improves it — correct acute treatment, stopping overuse, starting a preventive — is a conversation and a prescription.
Worth considering with four or more attacks a month, or attacks that are disabling despite good acute treatment. Options include propranolol, amitriptyline, topiramate and candesartan. Each needs six to eight weeks at an adequate dose before judging.
Topiramate carries a specific warning: it causes serious birth defects and developmental problems, and it must not be used in pregnancy or in anyone who could become pregnant without highly effective contraception and a formal discussion.
For chronic migraine not responding to standard preventives, CGRP monoclonal antibodies have transformed outcomes. They are specialist-initiated and we refer.
Where attacks cluster around your period, a short course of an NSAID or a triptan taken around that window, or continuous rather than cyclical hormonal treatment, can prevent them. This is straightforward and rarely offered unprompted.
Migraine with aura is a firm contraindication to combined hormonal contraception — the pill, patch or ring — because the combination increases ischaemic stroke risk. Progestogen-only methods, the coil and the implant are all fine. If you have aura and are on the combined pill, please raise it.
Call 999 for:
Seek same-day assessment for:
Book a routine consultation if: attacks occur four or more times a month; over-the-counter treatment is not working; you take painkillers on more than 10 days a month; your usual pattern has changed; or migraine is affecting work, study or family life. All of those are treatable situations.
The migraine brain dislikes change. Keeping things steady lowers the frequency of attacks more reliably than avoiding any particular food.
Two to three months of dates, severity, medication taken and cycle position. It identifies your pattern, proves or disproves suspected triggers, catches medication overuse, and is the only reliable way to tell whether a preventive is working.
Do not take acute painkillers on more than two days a week. Regular use — particularly of anything containing codeine — converts episodic migraine into daily headache, and it is one of the commonest reasons migraine becomes chronic. Codeine-containing painkillers are best avoided entirely in migraine.
Riboflavin (vitamin B2) at 400mg daily and magnesium have modest evidence for reducing frequency. They are inexpensive and low-risk, and reasonable to try alongside — not instead of — proper treatment.
Your NHS GP treats migraine free, and every effective treatment is NHS-funded — including the newer CGRP monoclonal antibodies, which are available through NHS neurology for people meeting NICE criteria.
Triptans are cheap generics, and sumatriptan is available over the counter from pharmacies for people with an established migraine diagnosis.
Two things are worth more than any prescription and both are free. First, a headache diary — which identifies patterns, triggers and, critically, how many days a month you are taking painkillers. Second, recognising medication overuse headache, where treating attacks on 10 or more days a month turns episodic migraine into chronic daily headache. That is extremely common, and the treatment is withdrawal rather than more medication.
The other under-used option is preventive treatment. Anyone having migraines on four or more days a month should be offered a preventer — propranolol, amitriptyline, candesartan or topiramate — and a great many people have never been offered one, cycling through acute treatment instead.
Where a private consultation earns its fee is exactly that review: are you overusing acute medication, and should you be on a preventer? That takes longer than ten minutes.
What needs urgent assessment: a sudden severe headache peaking within minutes, migraine with new neurological symptoms, or a marked change in your usual pattern.
NICE CG150, Headaches in over 12s, is the governing guideline. It recommends combination therapy with a triptan and an NSAID or paracetamol for acute migraine, and an antiemetic even without nausea.
CG150 recommends prophylaxis — propranolol or topiramate first-line, with amitriptyline as an option — for people with frequent or disabling attacks, and notes topiramate is teratogenic and interacts with hormonal contraception.
CG150 defines medication overuse headache and recommends abrupt withdrawal, warning that symptoms initially worsen.
NICE technology appraisals TA631, TA659, TA764 and others cover erenumab, fremanezumab, galcanezumab and rimegepant for migraine prevention, available through specialist NHS services.
FSRH and NICE guidance state that migraine with aura is a contraindication to combined hormonal contraception because of stroke risk — a point regularly missed.
Most likely medication overuse headache. Taking any acute painkiller on more than 10 days a month — or a triptan or codeine-containing drug on more than 10 — causes the brain to produce more headaches, not fewer. The way out is to stop the overused drug, which involves a difficult two to four weeks and then a marked improvement. It is worth doing with support rather than alone.
Usually not. Typical migraine with a normal examination does not require imaging, and a scan cannot diagnose migraine — it is normal in migraine. Scanning is indicated where there are specific warning features: a changed pattern, onset over 50, headache worse lying down or on coughing, or persisting neurological signs.
Aura itself is not, and it fully resolves. It matters for two reasons: it must be distinguished from a stroke — aura builds over minutes and goes away, a stroke starts suddenly and persists — and aura means you should not use combined hormonal contraception, because of the stroke risk when the two combine.
For many women, substantially. The oestrogen drop just before a period is one of the strongest triggers known, and menstrual attacks tend to be longer and more severe. Migraine often improves in pregnancy and worsens through perimenopause before settling afterwards. Targeted treatment around the period works well.
Probably not in the way people think. Craving chocolate is frequently part of the prodrome — so the attack was already beginning and the chocolate got the blame. The evidence for dietary triggers generally is much weaker than for irregular sleep, missed meals and dehydration.
Try taking it earlier — timing is the commonest problem. Then try a different triptan, since response varies considerably and there are several. Then add an anti-sickness tablet, which improves absorption. Most people who conclude triptans do not work for them have tried exactly one, once, taken too late.
Not cured, but very often well controlled — and current preventive treatment, including the newer CGRP drugs, is considerably better than what was available a decade ago. Many people find attacks become less frequent with age, and migraine commonly improves after the menopause.
No. Migraine is not something to be endured with willpower, and continuing to function through an attack tends to prolong it. Treat early, stop, rest — and if attacks are frequent enough that you are regularly having to push through, you need a preventive rather than more determination.
August 23, 2026
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It means the diagnosis can usually be made from your history and photographs, and that treatment can be arranged safely without examining you. Where a condition is not marked treatable online, it is because examination is the diagnosis — listening to a chest, feeling an abdomen, examining an ear or a joint — or because a procedure or device is needed.
Yes, where there is a genuine bacterial infection — cellulitis, impetigo, bacterial urine infections, confirmed strep throat. We will also frequently tell you that you do not need one. Most sore throats, coughs, colds and earaches are viral, and an antibiotic gives you the side effects with none of the benefit.
If your problem turns out to be genuinely outside what we can do remotely, the doctor will tell you straight away, point you to the right service, and refund your fee in full. We would rather do that than fill twenty minutes to justify the charge.
Call 999 or go to A&E — do not book an online appointment and do not wait for a reply to an email. For urgent problems that are not emergencies, NHS 111 is available 24 hours a day, online or by phone, and can direct you to the right service.
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