Migraine Headaches: Diagnostic and Treatment Tips
Kenny Lin, MD, MPH
Posted on April 21, 2025
A patient with a history of headaches is brought by ambulance to the emergency department for the abrupt onset of weakness and decreased sensation in their left arm and leg. A code stroke is called. Are these symptoms of an acute stroke or a stroke mimic, such as a hemiplegic migraine?
A retrospective analysis of characteristics of 15 consecutive years of code stroke cases at a hospital in Barcelona, Spain, found that patients who were ultimately diagnosed with migraine headache with aura (1.1%) were more likely to be younger, female, and have fewer vascular risk factors than patients with ischemic strokes. In addition, an initial NIH Stroke Scale of greater than 6 (odds ratio = 3.74) and a fibrinogen level of greater than 400 mg/dL (odds ratio = 2.98) distinguished strokes from migraine headaches.
An article on acute migraine headaches in the April 2025 issue of American Family Physician reviews current treatment strategies for acute migraine headaches, which “account for … 3.6 million primary care visits annually and are the fifth most common reason for emergency department visits” in the United States. The POUND mnemonic (ie, pulsatile quality, one-day duration, unilateral headache, nausea or vomiting, disabling intensity) can help clinicians make the diagnosis of migraine in primary care, and the Migraine Disability Assessment (MIDAS) quantifies headache severity. Scores that indicate MIDAS grades III and IV should prompt clinicians to consider targeted migraine medications rather than simple analgesics.
Although several drug classes are effective for acute migraine, a 2024 systematic review and network meta-analysis of 137 randomized controlled trials (summarized in a POEM in the April 2025 issue of American Family Physician) found that triptans produced greater pain relief at 2 hours and less use of rescue drugs in the first 2 to 24 hours than the newer and more expensive medications ubrogepant, rimegepant, and lasmiditan.
Clinical practice guidelines on the management of episodic migraine headache, including the 2023 US Veterans Affairs/Department of Defense guideline, preferentially recommend triptans for most patients. Last month, the American College of Physicians released a pharmacologic treatment guideline that recommends adding a triptan in nonpregnant adults with moderate to severe migraines who have not responded to a nonsteroidal anti-inflammatory drug or acetaminophen. Triptans can cause vasospasm, so they are contraindicated in patients with coronary artery disease, cardiovascular disease, and peripheral artery disease and should not be used in combination with ergot alkaloids.