Diagnosis and management of migraine in ten steps

Overview

Migraine is one of the most common and disabling neurological disorders, yet it is often underdiagnosed and undertreated. This expert consensus paper sets out a structured ten-step approach to diagnosing and managing migraine in everyday practice. It is written mainly for general practitioners and non-specialist clinicians, and it aims to make evidence-based care accessible outside headache centres.

Diagnosis

The first steps focus on a correct diagnosis. This rests on a careful headache history and the internationally accepted diagnostic criteria for migraine with and without aura. Clinicians are guided to recognise warning features that suggest a secondary headache and call for further investigation. Medication-overuse headache should be identified and addressed, because it can perpetuate frequent headaches and undermine treatment. A headache diary is encouraged to document attack frequency, triggers and response to treatment.

Treatment

Acute treatment should be effective, taken early in the attack, and escalated in a stepwise way when simpler options fail, with attention to associated symptoms such as nausea. Preventive treatment is recommended when attacks are frequent, disabling or poorly controlled by acute therapy. The choice of preventive treatment is guided by comorbidities, contraindications and patient preference. Non-pharmacological measures are also part of care: regular sleep and meals, physical activity, stress management and identifying personal triggers.

Follow-up and referral

The final steps cover how to evaluate treatment response over time, when to adjust or stop preventive therapy, and when to refer to a headache specialist, for example when the diagnosis is uncertain or standard treatments fail. The approach supports consistent, patient-centred migraine care in primary care.