Migraine and headache: causes, treatments and when to seek emergency care

01Understanding the difference between migraine and tension-type headache#

Headaches are among the most frequent complaints in medical consultations, and they actually cover several distinct clinical entities that it is essential to differentiate because their management is not the same. Migraine and tension-type headache are the two main forms of primary headache (i.e. not linked to another pathology), with different pathophysiological mechanisms, symptoms and treatments.

The World Health Organization ranks migraine among the 20 most disabling pathologies in the world, which can be surprising given how this disease is often trivialised by those around the patient and even by some professionals. It represents a major cause of professional and school absenteeism, and its impact on quality of life can be considerable. According to WHO, about 15% of adults suffer from migraine worldwide, with a very marked female predominance: three women for one man, due to the role of hormonal fluctuations. In Morocco, the Moroccan Society of Neurology estimates that nearly 4 million people suffer from migraine, i.e. about 12% of the adult population. The pathology generally begins between 10 and 40 years, with a peak intensity between 25 and 50 years, then a progressive attenuation after menopause in women.

The main clinical distinctions between the two entities are summarised in the following table.

This distinction is not just academic: tension-type headache responds well to simple analgesics and relaxation measures, while migraine requires specific treatments (triptans during attacks, prophylactic treatments for frequent forms) that are useless or even counterproductive in tension-type headache.

02Typical symptoms of migraine#

The diagnosis of migraine is based on precise clinical criteria established by the International Headache Society (IHS) in the International Classification of Headache Disorders (ICHD-3, current version). These criteria, used in Morocco as in the rest of the world, allow reliable diagnosis without resorting to additional examinations in the vast majority of cases.

To establish the diagnosis of migraine without aura (the most common form), at least 5 attacks meeting the following criteria are required: duration of 4 to 72 hours without treatment (or with ineffective treatment); at least two of the four following pain characteristics — unilateral location, pulsating character, moderate to severe intensity, aggravation by usual physical activity (walking, climbing stairs); at least one of the two associated symptoms — nausea and/or vomiting, photophobia associated with phonophobia. These rigorous criteria distinguish true migraine from other headaches that may share certain characteristics without having the entire picture.

The typical migraine attack unfolds in several phases whose knowledge helps to better recognise and manage it. The prodromal phase (hours to 1-2 days before the attack, present in 60% of patients) manifests with subtle changes: mood changes, irritability, unusual fatigue, food cravings (often for sweets), repeated yawning, neck stiffness, sometimes polyuria. Recognising these prodromes sometimes allows anticipating the attack and initiating early treatment.

Migraine aura, present in 20 to 30% of cases, immediately precedes the headache and typically lasts 5 to 60 minutes. It most often takes the form of visual disturbances: scintillating scotoma (a bright spot that gradually enlarges), zigzag lights at the edge of the visual field (fortification spectra), black dots, blurred vision. More rarely, it manifests as paraesthesia (tingling progressively rising from the hand to the arm, face, sometimes the tongue), transient language disturbances (word-finding difficulty, articulation difficulty), or motor disturbances in the rare forms of hemiplegic migraine. The aura completely regresses before or during the painful phase.

The painful phase itself lasts from 4 to 72 hours without treatment. The pain, classically unilateral and pulsating, can be bilateral in 30 to 40% of cases. It is often accompanied by great sensitivity to the environment, the patient seeking darkness, silence and rest. Nausea and vomiting can be intense to the point of preventing oral medication intake. The attack generally resolves with sleep, after which the patient may experience a postdromal phase of exhaustion, cognitive difficulties ("brain fog"), sometimes paradoxical depressive or euphoric mood, which can last 24 hours.

03Migraine with aura: a more complex picture#

Migraine aura deserves particular attention because it can be confused with other serious neurological pathologies, especially stroke (CVA) or transient ischaemic attack (TIA). Differentiation is crucial and sometimes requires emergency examinations.

The typical characteristics of migraine aura are as follows: gradual installation over 5 to 30 minutes (and not abrupt as in CVA), duration of 5 to 60 minutes (not prolonged for several hours), complete recovery without sequelae, typically followed by a characteristic headache, personal or family migraine history. Migraine visual disturbances typically affect both eyes simultaneously (bilateral scotoma), even if the patient often perceives them as unilateral.

Conversely, several warning signals must raise suspicion of CVA or another serious neurological cause and justify an emergency cerebral MRI: aura lasting more than 60 minutes, motor deficit (persistent weakness of a limb), monocular aura (involvement of one eye suggesting amaurosis fugax or retinal artery occlusion), aura accompanied by disturbances of consciousness, first aura after age 50, aura without typical headache in a patient who has never had migraine. These situations, particularly in subjects with vascular risk (smoking, hypertension, diabetes, cardiovascular history), may reflect cerebral infarction rather than migraine and require immediate specialist management.

Patients with migraine with aura also have a slightly increased vascular risk: risk of ischaemic stroke approximately doubled, particularly in young women smokers on combined oral contraception. This association justifies vigilance regarding cardiovascular risk factors and the avoidance of combined oral contraception in these patients in favour of oestrogen-free alternatives.

04Identifying triggering factors#

Migraine attacks do not occur randomly: in most cases they are triggered by identifiable precipitating factors, knowledge of which allows often effective non-medicinal prevention. Not all patients have the same triggers, and keeping a headache diary for 2 to 3 months is the best method to identify one's own factors.

Dietary factors classically incriminated include chocolate (rich in tyramine), red wine (alcohol and tyramine), fermented and aged cheeses (parmesan, roquefort, ripe camembert), monosodium glutamate found in some Asian cuisines and ready meals, excess citrus fruits, nitrites found in industrial cured meats, aspartame in some. Note however that these dietary triggers are sometimes overestimated and that systematic avoidance without individual testing can lead to unnecessary dietary restrictions.

Hormonal fluctuations are a major trigger in women: menstrual migraine, occurring within the 2 days before or the first 3 days of menstruation, affects about 60% of female migraine sufferers. Combined oral contraception can worsen migraines (and is even contraindicated in women with migraine with aura). Pregnancy hormonal variations generally improve migraines (especially in the 2nd and 3rd trimester) but can trigger them in early pregnancy. Menopause is often a period of transient worsening before lasting improvement.

Sleep is paradoxically a trigger in two opposite directions: sleep deprivation but also excessive sleep (weekend lie-ins, prolonged naps) can provoke attacks. Regularity of sleep schedules is therefore essential. Stress is a recognised trigger, but often in an unexpected form: it is rather the post-stress release ("weekend migraine" or "holiday migraine") that triggers attacks, rather than the stress peak itself.

Several environmental factors are also implicated: sudden weather changes (drop in atmospheric pressure before a storm), strong heat, intense lighting (sun, screens, fluorescent lamps), strong odours (perfumes, tobacco, chemical products), continuous noise, jet lag. Dietary factors such as fasting or skipping a meal are very strong triggers, particularly relevant in Morocco during Ramadan when migraines can worsen significantly in predisposed patients. Dehydration, sometimes associated with fasting or simply with insufficient water intake, is another frequent and easily correctable trigger.

05Warning signs: when to consult urgently#

The vast majority of headaches are benign, but certain pictures must raise suspicion of a serious cause and justify an emergency consultation or call to 141. Knowing these warning signs is essential not to miss a neurological emergency.

Thunderclap headache is probably the most important signal. It is characterised by a sudden onset, reaching maximum intensity in less than a minute, sometimes described as "the worst headache of my life". This presentation may reflect a subarachnoid haemorrhage through cerebral aneurysm rupture, an absolute neurosurgical emergency. Brain imaging (preferably non-contrast CT scan, followed by lumbar puncture if negative) must be performed urgently.

A headache associated with high fever and neck stiffness (impossibility to flex the neck forward) suggests infectious meningitis (bacterial, viral, or sometimes tuberculous). The picture may be completed by disturbances of consciousness, intense photophobia, nausea, and in infants by bulging fontanelle, moaning, hypotonia. Bacterial meningitis is a vital emergency requiring intravenous antibiotics within the hour.

The appearance of a focal neurological deficit (paralysis of a limb or half of the body, loss of speech with inability to produce or understand words, major visual disturbances) at the time of or following a headache must raise suspicion of an ischaemic or haemorrhagic stroke. The therapeutic window for thrombolysis being a maximum of 4 hours 30, every minute counts — call 141 without delay.

A headache after head trauma, particularly if it appears in the hours following the impact and worsens, may reflect a subdural or extradural haematoma, sometimes several days after the initial trauma in elderly subjects or those on anticoagulants. A first significant headache after age 50, without personal migraine history, must always prompt the search for an organic cause: brain tumour, subdural haematoma, temporal arteritis (Horton's disease), vascular disorders.

An unusual worsening of a known migraine (headache more intense than usual, no longer responding to usual treatments, associated with new symptoms) also justifies medical reassessment, ideally neurological. Finally, a chronic progressive headache worsening over several weeks, especially in the morning, sometimes associated with morning nausea and visual disturbances, must raise suspicion of intracranial hypertension and require a brain MRI.

06Diagnosis and workup#

The diagnosis of migraine is above all clinical, based on rigorous interview about headache characteristics, evolution, family history, triggering factors, efficacy of previous treatments. A complete neurological examination must be normal between attacks to confirm the diagnosis. The IHS ICHD-3 criteria guide positive and differential diagnosis.

Brain imaging (CT scan or MRI) is not indicated in typical uncomplicated migraine, where it is unnecessarily costly and anxiety-provoking. It becomes necessary in several particular situations: presence of a warning sign among those mentioned above, abnormal neurological examination between attacks, recent change in headache character, late first attack (after age 50), atypical or prolonged aura, chronic daily headache, suspicion of intracranial hypertension. Brain MRI is preferable to CT scan for the workup of a chronic headache as it is more efficient at visualising non-haemorrhagic abnormalities (tumours, vascular malformations, multiple sclerosis).

The electroencephalogram (EEG) has no indication in the workup of simple migraine. It is reserved for cases where associated epilepsy or complex basilar migraine is suspected.

In Morocco, several reference neurological centres manage complex migraines: the CHU Ibn Rochd in Casablanca, Ibn Sina in Rabat, Hassan II in Fes, Mohammed VI in Marrakech, as well as numerous neurologists practising in private practice in major cities. A neurology consultation costs 400 to 700 MAD in the private sector, partially reimbursed. Brain MRI, when necessary, costs 1,800 to 3,000 MAD depending on the facilities, reimbursed at 70-80% by AMO on justified prescription.

07Acute and prophylactic treatments#

The therapeutic management of migraine is structured in two complementary parts: the acute treatment to relieve the acute episode, and the prophylactic treatment for frequent or disabling forms.

Acute treatment

The objective is to stop the attack quickly (ideally in less than 2 hours) with return to normal functioning and without relapse within 24 hours. The treatment must be taken at the onset of the attack, the earlier the more effective. Simple analgesics are sufficient in mild to moderate forms: paracetamol 1 gram (up to 3 grams per 24 hours), or non-steroidal anti-inflammatory drugs such as ibuprofen (400 to 600 mg), ketoprofen (50 to 100 mg) or diclofenac (50 to 100 mg). The combination paracetamol + NSAID is often more effective than each molecule alone.

For moderate to severe attacks or those not responding to simple analgesics, triptans are the migraine-specific molecules. They act by blocking 5-HT1B/1D serotonergic receptors at the level of cerebral vessels and trigeminal terminations. Several molecules are available in Morocco on prescription: sumatriptan (50 or 100 mg, tablets or injectable), rizatriptan (10 mg, orodispersible tablet), almotriptan, zolmitriptan. The choice depends on the desired speed of action, duration of action, tolerated side effects. The cost of a box of 2 tablets is between 80 and 150 MAD depending on the molecules, with reimbursement at 50% by CNSS and 80% by CNOPS. Triptans are contraindicated in case of vascular history (myocardial infarction, stroke, peripheral artery disease), uncontrolled hypertension, hemiplegic or basilar migraine.

Antiemetics (metoclopramide/Primpéran, domperidone) can be associated in case of significant nausea — they have the additional advantage of improving gastric absorption of other analgesics. Referral to emergency care is necessary in case of resistant attack, vomiting preventing oral intake, or atypical presentation.

A capital point: medication overuse (taking analgesics more than 10-15 days per month for several consecutive months) is one of the main causes of transformation of episodic migraine into chronic migraine with daily headaches. This medication overuse headache is often underdiagnosed and requires structured medication withdrawal to recover.

Prophylactic treatment

Indicated from 4 attacks per month or more, or in case of less frequent but severe and disabling attacks, or in case of medication overuse. The objective is to reduce the frequency and intensity of attacks by at least 50%. Several therapeutic classes are validated.

Beta-blockers (propranolol, metoprolol) are the first-line prophylactic treatment, with efficacy demonstrated by numerous studies. The dose is progressively increased over a few weeks to test tolerance. Possible side effects: fatigue, hypotension, cardiac slowing, sometimes nightmares. Contraindications: asthma, severe heart failure, rhythm disturbances, severe depression.

Topiramate, an antiepileptic also effective in migraine, is an alternative or second choice. It is administered progressively from 25 to 100 mg per day. Side effects: paraesthesias of the extremities, cognitive disturbances, weight loss (sometimes beneficial in overweight patients), risk of urinary stones. Contraindications: history of kidney stones, glaucoma, pregnancy (potentially teratogenic).

Amitriptyline at low dose (10 to 50 mg in the evening), a tricyclic antidepressant, is useful particularly when sleep disturbances or anxiety are associated. Side effects: drowsiness, dry mouth, constipation, weight gain.

Anti-CGRP monoclonal antibodies (erenumab/Aimovig, fremanezumab/Ajovy, galcanezumab/Emgality) represent the recent therapeutic revolution of migraine, with major efficacy (50-75% reduction in migraine days in good responders) and excellent tolerance. They are administered by monthly injection (subcutaneous). Their high cost (8,000 to 12,000 MAD per month) still limits their access, and they are not reimbursed in Morocco in the majority of cases, restricting their use to patients able to bear the cost or benefiting from a complementary mutuelle with agreement. They are indicated in migraines refractory to other prophylactic treatments.

Botulinum toxin (Botox) in pericranial injections (PREEMPT protocol) is effective in chronic migraines (15 days of headaches per month or more). Cost of about 4,000 to 6,000 MAD per session, to be repeated every 3 months.

08Daily preventive measures#

Drug treatment is only one aspect of management. Non-medicinal measures are essential and must be systematically addressed.

Keeping a headache diary for 2 to 3 months is probably the most useful measure, as it allows identifying personal triggers (often surprising), assessing the real efficacy of treatments, and objectifying evolution. Several dedicated mobile applications (Migraine Buddy, for example) facilitate this approach.

Regularity of life rhythm is essential: stable sleep schedules (even on weekends, avoiding prolonged lie-ins), meals at regular times (without skipping a meal), sufficient hydration (1.5 to 2 litres of water per day). During Ramadan, these rules are particularly important for migraine sufferers: avoid fasting if migraine is severe and frequent, or organise a copious and hydrated suhour, and an adapted f'tour to limit metabolic triggers.

Regular aerobic physical activity (at least 30 minutes 3 times a week of brisk walking, cycling, swimming) has a demonstrated preventive effect on the frequency of migraines and additionally improves sleep quality and stress management. Stress management techniques such as mindfulness meditation, cardiac coherence, sophrology, gentle yoga, also have validated efficacy. Cervical physiotherapy can be useful in case of associated cervical pain that can trigger or maintain headaches.

On the dietary front, identifying and avoiding one's own specific triggers is more useful than systematic restriction of all classically incriminated foods. In some patients, moderate and regular caffeine (2 to 3 coffees per day at fixed times) can be preventive — but sudden cessation after chronic consumption often causes withdrawal headaches. Finally, for women with frequent menstrual migraines, several hormonal strategies can be discussed with the gynaecologist (continuous pill, magnesium supplementation in the perimenstrual period, prophylactic NSAID during at-risk days).