Migraine and Headache

Far more than a bad headache: migraine's phases and aura, the trigeminal system and CGRP, the new generation of targeted treatments, other headache types, and the warning signs that need urgent care.

A brain disorder, not just a headache

Migraine is one of the most common neurological conditions, affecting an estimated one billion people worldwide, and is among the leading causes of disability, especially in people under 50. It is about two to three times more common in women after puberty, linked partly to hormonal changes.

The phases of an attack

An attack can unfold in phases. A prodrome hours to days before: yawning, food cravings, mood changes, neck stiffness. An aura in about a quarter to a third of people: usually visual — a shimmering zigzag line or blind spot spreading over 5–60 minutes — sometimes tingling or speech difficulty. The headache: often one-sided and throbbing, worse with movement, with nausea and sensitivity to light (photophobia) and sound. A postdrome: tiredness and fogginess afterwards.

What happens in the brain

The aura is thought to reflect cortical spreading depression: a slow wave of intense neural activity followed by suppression, creeping across the cortex at a few millimetres per minute — matching the slow spread of the visual disturbance. The pain involves activation of the trigeminal nerve and its connections with blood vessels in the meninges, releasing inflammatory neuropeptides, especially CGRP (calcitonin gene-related peptide). The old theory that migraine is simply a disorder of blood vessels has given way to a brain-centred view. Genes play a significant role.

Treatment

For attacks: simple painkillers and anti-inflammatories, anti-nausea drugs, and triptans (from the 1990s), which act on serotonin receptors. Since 2018, several anti-CGRP monoclonal antibodies (such as erenumab) for prevention and small-molecule gepants have been approved — the first drugs designed specifically for migraine. Botulinum toxin injections are approved for chronic migraine. Lifestyle factors — regular sleep and meals, managing stress, limiting overuse of painkillers (which can cause medication-overuse headache) — matter too.

Other headaches and red flags

Tension-type headache, a band-like pressure, is the most common headache. Cluster headache causes excruciating attacks around one eye, often at the same time each day. Seek urgent medical care for a sudden "thunderclap" headache (worst ever, peaking within a minute), headache with fever and stiff neck, new headache with weakness, confusion or vision loss, or a new headache after age 50 or after a head injury.