Migraine
Repeated attacks of throbbing headache, often with nausea and a strong dislike of light and sound. Some people get an aura first. Very treatable: treat attacks early, and prevent them smartly.
The migraine ladder
Treat attacks early. If they hit 4 or more days a month, add prevention. Give each preventive 2 to 3 months before judging it.
- Step 1 · Self-careRoutine and a headache diaryRegular sleep, meals and water, steady caffeine, and a diary to spot triggers and count headache days.
- Works
- Few good trials; low risk, and helps some people have fewer attacks
- Cost
- Free
- How long
- Keep the diary for 2–3 months
- Watch for
- Chasing every possible food trigger. Most people don’t need a restrictive diet.
Migraine brains like boring. Same bedtime, same breakfast, same coffee count.
- Step 2 · PharmacyEarly pain relief plus an anti-nausea medicineAspirin, ibuprofen or paracetamol at the first sign of headache. Anti-nausea medicine eases sickness and helps the pain relief absorb.
- Works
- About half get good relief within 2 hours, vs about 1 in 3 on a dummy treatment
- Cost
- About $5–15 a pack
- How long
- Take at the first sign, not once it’s a 9 out of 10
- Watch for
- Stomach upset with aspirin or ibuprofen. Pain relief on 15 or more days a month causes rebound headaches.
“Wait and see if it gets bad” is a strategy. Just not a good one.
- Step 3 · PharmacyMagnesium or riboflavin (vitamin B2)Supplements that may reduce how often attacks happen.
- Works
- Small trials; may cut attacks a little; evidence is weak to moderate
- Cost
- About $15–30 a month
- How long
- 3 months to judge
- Watch for
- Magnesium: loose bowels. Riboflavin: bright yellow wee (harmless).
Yes, the neon wee is normal. No, it’s not a superpower.
- Step 4 · PrescriptionTriptans (such as sumatriptan or rizatriptan)Migraine-specific tablets, wafers or sprays for attacks that simple pain relief doesn’t fix.
- Works
- About 6 in 10 get relief and 3 in 10 are pain-free at 2 hours (vs 3 in 10 and 1 in 10 on a dummy treatment)
- Cost
- Under the $25 PBS co-payment, about $20–25 for 4 tablets
- How long
- Take early in the headache. Can repeat once after 2 hours if it comes back
- Watch for
- Chest or throat tightness, tingling, drowsiness. Not with heart disease or past stroke. Keep to under 10 days a month.
If one triptan flops, try another. They don’t all have the same personality.
- Step 5 · PrescriptionPreventive tabletsDaily tablets such as propranolol, amitriptyline, candesartan or topiramate, if attacks hit 4 or more days a month or are disabling.
- Works
- About 4 to 5 in 10 have migraine days halved, vs 2 to 3 in 10 on a dummy treatment
- Cost
- Usually under the $25 PBS co-payment, about $10–25 a month
- How long
- 2–3 months to judge; often 6–12 months, then review
- Watch for
- Propranolol: tiredness, cold hands, not with asthma. Amitriptyline: drowsiness, dry mouth. Topiramate: tingling, not in pregnancy.
Start low, go slow, and don’t judge it in week two.
- Step 6 · Allied healthPsychology: CBT, relaxation and biofeedbackSkills that calm the nervous system and lower attack frequency.
- Works
- Small to moderate benefit in trials; helps reduce how often attacks happen
- Cost
- About $150–250 a session; Medicare rebates may apply with a GP plan
- How long
- Usually 6–10 sessions
- Watch for
- Needs practice between sessions. It doesn’t mean the pain is “in your head”.
A real treatment, not a consolation prize.
- Step 7 · SpecialistCGRP antibody injections or botulinum toxinFor frequent migraine when several preventives haven’t worked, through a neurologist.
- Works
- About half get migraine days at least halved, vs about 1 in 4 on a dummy treatment
- Cost
- $25 per script on the PBS ($7.70 concession) for chronic migraine after 3 preventives; otherwise several hundred dollars a month
- How long
- Monthly injections (CGRP) or every 12 weeks (botulinum toxin); reviewed after a few months
- Watch for
- Injection-site reactions and constipation with some CGRP medicines. Botulinum toxin: neck pain, droopy eyelid.
The newer options are genuinely good. The paperwork is genuinely long.
Save your money
Popular, heavily marketed or often asked about, but the evidence is weak or says no.
- Codeine and other opioidsNo better than anti-inflammatories for migraine, and a fast track to rebound headaches and dependence.
- Brain scans for typical migraineWith a normal examination, a scan doesn’t change treatment and often finds harmless things that cause worry.
- ButterburSome older trials looked positive, but products have caused serious liver damage. Not worth the risk.
- FeverfewMixed results from small trials. May help a little, may do nothing.
- Heart “hole” (PFO) closureTrials haven’t shown a clear benefit for migraine, so it isn’t done for migraine alone.
- IgG food intolerance testsNot reliable. They measure normal exposure to foods, then sell you a list of things to stop eating.
What you can do
- Treat early: pain relief at the first twinge, not the tenth.
- Regular sleep, meals and water. Keep caffeine to 1 to 2 cups a day.
- Keep a headache diary. It spots triggers and counts headache days, which decide your treatment.
- Reaching for pain relief more than 2 to 3 days a week? That’s a prevention problem, not a tablet shortage.
See your GP if
- Attacks are frequent or getting worse
- You use pain relief more than 2 to 3 days a week
- Headaches have changed pattern, or first started after age 50
Call 000 or go to the emergency department for a sudden severe “worst ever” headache, fever with a stiff neck, new weakness, confusion or trouble speaking.
Some migraine medicines, including topiramate, valproate and candesartan, aren’t safe in pregnancy, and the combined pill isn’t recommended with migraine with aura. Tell your doctor if you’re pregnant or planning to be.
Common questions
What is the best thing to take for a migraine?
Aspirin, ibuprofen or paracetamol taken at the first sign of headache, ideally with an anti-nausea medicine. If that isn’t enough, triptans are migraine-specific tablets, wafers or sprays on prescription.
When should I take a preventive medicine for migraine?
If attacks happen on 4 or more days a month or are disabling. Options include propranolol, amitriptyline, candesartan and topiramate. Give each one 2 to 3 months before judging it.
Can painkillers make headaches worse?
Yes. Simple pain relief on 15 or more days a month, or triptans on 10 or more, can cause rebound (medication-overuse) headaches.
When is a headache an emergency?
Call 000 or go to the emergency department for a sudden severe “worst ever” headache, fever with a stiff neck, new weakness, confusion or trouble speaking.
What triggers migraines?
Common triggers are stress (or the let-down after it), poor or changed sleep, skipped meals, dehydration, periods, alcohol and bright or flickering light. Cravings for chocolate can be an early migraine symptom rather than the cause. A headache diary helps spot your own pattern.
How long does a migraine last?
Usually 4 hours to 3 days without treatment. Many people feel drained or foggy for a day afterwards (the “migraine hangover”). A migraine lasting more than 3 days needs medical review.
What is a migraine with aura?
About 1 in 4 people with migraine get an aura: zigzag lines, flashing lights, blind spots or pins and needles that spread over 5 to 60 minutes, usually before the headache. Weakness, slurred speech or a first-ever aura needs urgent assessment. The combined pill is usually avoided with aura.
Are migraines genetic?
Yes, migraine often runs in families. Having a parent with migraine makes it more likely, and it’s about three times more common in women, partly because of hormone changes.
Helpful resources
- The Migraine Trust: Headache diaryA simple monthly diary (Word or PDF) to count headache days and spot triggers. Free, UK.
- Migraine & Headache AustraliaPatient charity with a helpline (1300 886 660), fact sheets and a directory of headache doctors and clinics. Australia.
- Migraine support groupsA private online support group plus local groups. Free online group, Australia.
Evidence and more information
- Healthdirect: Migraine
- Headache Australia
- NICE: Headaches in over 12s
- Cochrane: Aspirin with or without an antiemetic for migraine (2013)
- Cochrane: Oral sumatriptan for migraine (2012)
- Cochrane: Topiramate for preventing migraine (2013)
- NEJM: Erenumab (CGRP antibody) for episodic migraine, STRIVE trial (2017)
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