Migraine: From First Symptoms to Specialist Care (UK Guide)

If you’ve ever wondered “Do I have migraine or just a bad headache?”, you’re not alone. Migraine is often misunderstood, underdiagnosed, and undertreated.

This guide walks you through:

• When to see your GP
• What happens at your appointment
• First-line treatments (including triptans)
• Preventative medications
• When you’re referred to a neurologist
• Advanced treatments & alternatives

What Does a Migraine Feel Like?

Migraine is more than just a headache.

Common symptoms include:

• Throbbing or one-sided head pain
• Sensitivity to light (photophobia)
• Nausea or vomiting
• Visual disturbances (aura)
• Fatigue, brain fog, dizziness

If your headaches are recurrent and disabling, it’s time to speak to your GP.

When Should You Go to the GP?

You should see your GP if:

• You’re getting frequent headaches
• Pain is affecting your daily life
• Over-the-counter medication isn’t working
• You have neurological symptoms (e.g. aura, vision changes)
• GPs diagnose migraine clinically (based on symptoms), not usually with scans.

 First-Line Treatment: Acute Migraine Relief

Step 1: Basic Treatment

Your GP will usually start with:

• Paracetamol
• Ibuprofen or NSAIDs
• Anti-sickness medication

If this doesn’t work…

Triptans: what they are and the forms available in the UK

Triptans are migraine-specific medicines used to treat an attack once it has started. They work best when taken early in the headache phase, rather than during the aura. If one triptan does not help, your GP may advise trying a different triptan on a future attack, because people often respond differently to different triptans. If a triptan helps but the migraine comes back later, a repeat dose of the same triptan may sometimes be taken after the interval stated for that medicine. 

All 7 triptans are available as tablets. In addition, some UK options come in non-tablet forms, which can be helpful if nausea or vomiting makes swallowing difficult. Sumatriptan is available as tablets, nasal spray, and subcutaneous injection. Zolmitriptan is available as tablets, orodispersible/melt-on-the-tongue tablets, and nasal spray. Rizatriptan is available as tablets and orodispersible/wafer-style tablets. Orodispersible forms can be more convenient when you feel sick or do not have water, but they are not absorbed faster in the mouth than standard tablets. 

Pros of triptans

• They are migraine-specific, rather than just general painkillers.
• They can be very effective when taken early in the attack.
• There are several options, so if one is ineffective or poorly tolerated, another may suit you better.
• Non-oral forms such as nasal sprays and sumatriptan injection can be useful when vomiting is a major problem. 

Cons of triptans

• They do not work for everyone, and some people need to try more than one.
• They can cause side effects such as chest or jaw tightness/pressure, flushing, nausea, dizziness or tiredness. Nasal sprays can cause a strange taste or nasal irritation, and injections can cause local bruising or swelling.
• They are not suitable for some people, particularly those with certain heart or blood vessel conditions or uncontrolled high blood pressure.
• Using them too often can contribute to medication overuse headache. 

The 7 triptans in the UK: pros and cons

Sumatriptan

Forms: tablet, nasal spray, injection.

Pros: often the first one prescribed; multiple formats; the injection is the fastest-acting option and nasal spray can help if vomiting is an issue. Injection is usually prescribed after other triptans and options have failed.

Cons: more likely than some longer-acting triptans to wear off and the headache can return; nasal spray can cause a bad taste; injection can sting or bruise. 

Rizatriptan

Forms: tablet, orodispersible/wafer.

Pros: convenient melt-on-the-tongue option if swallowing is difficult.

Cons: the melt form is mainly for convenience rather than faster absorption; still not ideal if severe vomiting means you cannot keep medication down. 

Zolmitriptan

Forms: tablet, orodispersible tablet, nasal spray.

Pros: useful range of formats; nasal spray is helpful when nausea or vomiting is prominent.

Cons: nasal spray may cause an unpleasant taste or nasal/throat irritation.

Naratriptan

Forms: tablet.

Pros: one of the longer-acting triptans, which can suit some people whose migraine tends to recur.

Cons: tablet only, so less helpful if vomiting is a major issue. 

Almotriptan

Forms: tablet.

Pros: another option if first-line triptans are ineffective or not well tolerated.

Cons: tablet only, and may be less commonly used depending on local NHS formulary choices. 

Eletriptan

Forms: tablet.

Pros: can work well for some people who do not respond to earlier triptan options.

Cons: tablet only; like the others, it may still need trial and error to see whether it suits you.

Frovatriptan

Forms: tablet.

Pros: longer-acting and sometimes considered in menstrual migraine settings.

Cons: tablet only, and because it is longer-acting it may not feel like the quickest option for rapid relief. 

NICE guidelines for migraine medication

NICE says that for acute migraine, adults should usually be offered a triptan together with either an NSAID or paracetamol. If someone prefers to take just one medicine, options can include a triptan, an NSAID, high-dose aspirin, or paracetamol. An anti-emetic may also be offered. If oral medicines do not work well, or cannot be taken, NICE says non-oral options such as metoclopramide or prochlorperazine, and a non-oral NSAID or triptan, may be offered. NICE also says ergots and opioids should not be used for migraine treatment.

For migraine prevention, NICE recommends offering topiramate or propranolol, and says amitriptyline may be offered depending on preference, co-existing conditions and side effects. NICE advises not offering gabapentin for migraine prevention because evidence shows it is not effective. If topiramate and propranolol are unsuitable or ineffective, NICE says a course of up to 10 sessions of acupuncture may be considered. NICE also advises reviewing preventive treatment after 6 months, and notes that riboflavin may help some people. 

NICE recommends a triptan plus either an NSAID or paracetamol as first-line acute treatment for many adults with migraine. If one medicine is preferred, options include a triptan, NSAID, high-dose aspirin or paracetamol, with anti-sickness treatment added when needed.

Preventative Treatment for Migraine (UK)

Preventative (or “prophylactic”) treatment is recommended if your migraines are frequent, severe, or significantly affecting your quality of life.

 Episodic vs Chronic Migraine

Understanding this helps guide treatment:

Episodic migraine:

• Fewer than 15 headache days per month

Chronic migraine:

• 15 or more headache days per month, with at least 8 having migraine features
• Chronic migraine is more complex and often requires specialist input.

When Are Preventatives Started?

Your GP may suggest preventative treatment if:

You have 4 or more migraine days per month

Attacks are severe or long-lasting

Acute treatments (like triptans) aren’t enough

Preventatives are taken daily, not just during an attack.

 GP-Prescribed Preventative Medications

Propranolol (Beta-blocker)

What it is: A medication commonly used for high blood pressure and anxiety.

How it works: Calms the nervous system and reduces overactivity in the brain that can trigger migraine.

Pros:

• Often first-line
• Can also help with anxiety symptoms

Cons:

• Not suitable for asthma
• Can cause fatigue or low blood pressure

Topiramate (Anti-epileptic)

What it is: A medication originally used for epilepsy.

How it works: Stabilises brain activity and reduces abnormal nerve signalling involved in migraine.

Pros:

• Effective for many people
• Can reduce frequency significantly

Cons:

• Side effects may include:
• Brain fog
• Tingling sensations
• Weight loss
• Not suitable during pregnancy

Amitriptyline (Tricyclic antidepressant)

What it is: An antidepressant used at low doses for pain conditions.

How it works: Affects serotonin and pain pathways in the brain, helping reduce migraine sensitivity.

Pros:

• Helps with sleep
• Useful if migraine is linked to stress or poor sleep

Cons:

• Can cause drowsiness
• Dry mouth
• Weight gain in some people

How Long Do Preventatives Take to Work?

Each medication is usually trialled for: 8–12 weeks

• This allows time to:
• Adjust the dose

See if it reduces migraine frequency

 Important NICE Guidance

According to NICE:

• First-line preventatives include:  Propranolol or Topiramate
• Amitriptyline may also be offered

 Medication Overuse Headache (MOH)

NICE also advises: Avoid using acute treatments (e.g. triptans, painkillers) on more than: 10 days per month

Why?

 Overuse can actually:

• Make headaches more frequent
• Reduce effectiveness of treatment

 Key Takeaway

• Preventative treatment is about:  Reducing how often migraine attacks occur
• Making them less severe
• Improving quality of life

It may take:

• Time
• Trial and error
• But finding the right preventative can be life-changing.

When Are You Referred to a Neurologist

Migraine treatment usually begins with your GP, where you will trial preventative medications to help reduce the frequency and severity of your attacks. If these treatments are not effective or not well tolerated, you can ask your GP for a referral to a neurologist for further assessment and specialist care.

In practice, most NHS pathways expect patients to have tried at least two to three preventative medications before being referred. Access to certain specialist treatments, such as Botox or newer migraine-specific therapies, often requires that three preventative options have been tried without success.

Advanced Treatments: CGRP Medications

If your migraine does not improve with standard preventative treatments, a neurologist may prescribe CGRP-targeting medications.

These are newer, migraine-specific treatments designed to block the calcitonin gene-related peptide (CGRP) pathway, which plays a key role in triggering migraine attacks.

CGRP Injection Treatments

These are usually given as monthly injections:

• Aimovig (erenumab) -Targets the CGRP receptor
• Ajovy (fremanezumab) -Targets the CGRP ligand
• Emgality (galcanezumab) -Targets the CGRP ligand

It is important to know that if one CGRP injection does not work, you may still respond to another. This is because some medications target the CGRP receptor, while others target the CGRP molecule itself, meaning they act on different parts of the migraine pathway.

Oral CGRP Treatments

Atogepant

A daily tablet used for preventing migraine. It works by blocking the CGRP pathway and is a good option for people who prefer tablets rather than injections.

Rimegepant

A tablet that can be used both as an acute treatment during a migraine attack and, in some cases, as a preventative treatment when taken regularly.

Dual use makes it a flexible option for people who need both immediate relief and ongoing prevention.

CGRP Infusion – Vyepti (eptinezumab)

This treatment is given as an intravenous infusion, usually every 12 weeks, in a hospital or specialist clinic.

It may be offered to people with frequent migraine attacks or those who have not responded well to other treatments.

Access in the UK

CGRP medications are usually prescribed by a neurologist and are typically offered after several preventative treatments have been tried first.

Pros and Cons of CGRP Treatments

Pros

• Specifically designed for migraine
• Can significantly reduce frequency and severity
• Often well tolerated
• Fewer systemic side effects than older medications

Cons

• Not first-line and require specialist referral
• Access may be limited depending on NHS criteria
• Injections or infusions may not suit everyone
• Can be expensive without NHS approval

Key Takeaway

CGRP medications have transformed migraine treatment. However, as with all migraine therapies, what works for one person may not work for another. Finding the right treatment often takes time and specialist support.

Advanced Treatments: Botox and Nerve Block Injections

If migraine becomes frequent or chronic and do not respond to standard preventative treatments, a neurologist may recommend procedures such as Botox or nerve block injections.

These treatments are typically used in more complex cases and are carried out in specialist clinics.

Botox for Chronic Migraine

Botox (botulinum toxin type A) is an approved treatment for chronic migraine, which is defined as having 15 or more headache days per month, with at least 8 being migraine.

How it works: Botox is injected into specific areas around the head and neck. It works by blocking pain signals and reducing the release of chemicals involved in migraine pathways.

How it is given

• Multiple small injections across the forehead, temples, back of the head, and neck
• Usually given every 12 weeks
• Performed by a trained specialist

Who it is for

• People with chronic migraine
• Those who have not responded to several preventative medications

Pros and Cons of Botox

Pros

• Can significantly reduce migraine frequency
• Helps reduce severity and duration of attacks
• Well established and widely used in the NHS
• Treatment is repeated only every 3 months

Cons

• Requires multiple injections per session
• Takes time to see full benefit (often after 2 treatment cycles
• Not suitable for episodic migraine
• Must be administered by a specialist

Nerve Block Injections

Nerve blocks are another specialist treatment option, often used for people with persistent or severe migraine.

How they work: A local anaesthetic  combined with a steroid is injected around specific nerves, most commonly the greater occipital nerve at the back of the head.

This helps to:

• Interrupt pain signals
• Reduce inflammation
• Provide short-term relief

When Are Nerve Blocks Used?

They may be offered:

• During a severe or prolonged migraine
• As a “bridge” while waiting for other treatments to work
• For people with chronic migraine or frequent attacks

Pros and Cons of Nerve Blocks

Pros

• Can provide rapid relief
• Useful for severe or ongoing migraine attacks
• Minimally invasive
• Can be repeated if needed

Cons

• Effects are usually temporary (weeks to months)
• Not a long-term standalone solution
• Requires specialist administration

Key Takeaway

Botox and nerve block injections are important options for people with more severe or chronic migraine.

They are not first-line treatments, but for the right person, they can significantly improve quality of life and reduce the impact of migraine.

Migraine is a complex neurological condition, and for many people, the journey to finding the right treatment can take time, patience, and support. From initial GP visits and trying different medications, through to specialist treatments such as CGRP therapies, Botox, or nerve blocks, each step is about building a personalised approach that works for you. Alongside medical treatment, understanding your triggers and making small adjustments to your daily environment can make a meaningful difference. With the right combination of care, support, and tools, it is possible to reduce the impact of migraine and regain a greater sense of control over your day-to-day life.