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CPD module: Migraine – Recognition and common misdiagnosis

CPD module: Migraine – Recognition and common misdiagnosis

Dr Nazeli Manukyan guides you through the recognition of migraines and the potential for misdiagnosis in this CPD module

Headache accounts for one in 10 general practitioner consultations and is the most common cause of neurological referrals in the UK. One in seven people in the UK (10 million) are affected by migraine which is often underdiagnosed in primary care.

This module will enable you to review the main primary headache disorders and where migraine fits in, understand the main characteristics and features of migraine, and understand how to avoid misdiagnosis.

Migraine is a spectrum condition, presenting with a constellation of painful and painless symptoms creating diagnostic confusion and delays in diagnosis. It is much more common in women, affecting  one in five women compared with one in 15 men.

There is a complex sequence of symptoms occurring in the hours and days before and after the attack.

Symptoms occurring prior to the onset of the migraine are known as premonitory, while those occurring after the headache resolution are termed postdromal. Headache may not always be the dominant symptom.

Migraine is characterised by episodic attacks of head pains with accompanying disabling neurological (cognitive slowing, vertigo, motion intolerance, sensory sensitivity) and gastrointestinal (nausea, vomiting, abdominal pain, diarrhoea) symptoms. 

Untreated attacks should last more than four hours, frequently up to three days in adults. The location of the head pain is not the diagnosing feature, as it can vary. It can be unilateral or bilateral, and can change throughout the attack, involving face, eyes, forehead, temples, occipitus and neck. 

The characteristic feature is the gradual escalation of symptoms, the sequential progression from the premonitory phase to the headache phase and then slow resolution, with postdrome of fatigue and hangover feeling.

Key points

  • Ask about the duration of the pain phase and other symptoms during the attack
  • Ask about the features of previous headaches before they became troublesome with frequent, prolonged and nearly daily symptoms as it will help to recognise the phenotype of migraine 
  • Migraine with visual aura in late middle age is associated with increased risk of cardioembolic stroke so any doubtful presentation needs further assessment in the Emergency Department or TIA clinic
  • Suspect migraine in a patient with a long-standing stable pattern of episodic headaches and offer migraine specific treatments such as triptans for the attacks or preventatives

Migraine is a complex neurological disorder, so understanding the migraine-related wide range of symptoms, taking an appropriate history and getting a correct diagnosis are important in order to access an appropriate treatment and manage migraine effectively.


Dr Nazeli Manukyan, a GP based in Surrey specialising in headache and migraine management. Dr Manukyan also works at the National Migraine Centre.

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The full module can be found on the Nursing in Practice Learning website.

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