Migraine Explained: Symptoms, Stroke Confusion, Diagnosis, and Best Treatments (Ultimate Guide)

What Is Migraine? Understanding the Basics

Migraine is a common cause of headache with a wide variety of presentations, both in headache location and characteristics.
It is caused by neurochemical disturbances, particularly involving serotonin, leading to abnormal vascular spasms or dilations of blood vessels.

How Migraine Symptoms Mimic Stroke or TIA

Even MRI scans can show ischemic changes in migraine sufferers, making it tricky to differentiate from Transient Ischemic Attack (TIA) or stroke.

Vascular Spasm and Neurological Deficits

Spasm of blood vessels can trigger aura or neurological deficits resembling TIA or stroke.
In Migraine sine qua non, only the spasm phase occurs without headache, leading to diagnostic confusion.

The Journey of Migraine Aura in the Brain

The migraine aura usually starts in the posterior circulation (occipital lobe) and progresses to the parietal and frontal lobes, causing:

Visual symptoms: flashing lights, blurring, photophobia
Sensory symptoms: tingling, numbness
Motor symptoms: weakness or transient paralysis

Key Differences Between Migraine, TIA, and Stroke

ymptoms of migraine can overlap with those of stroke.
Important points to remember:

MRI may show small infarcts (chronic small vessel ischemia).
A young person without stroke risk factors but presenting with neurological symptoms and headache may actually have hemiplegic migraine.
Misdiagnosis can sometimes lead to unnecessary thrombolysis (tPA treatment).
Always rule out vascular events, especially in stroke-suspected patients with headache.

Tip: If stroke risk is high, treat as stroke first, unless you are clinically confident it’s migraine.

Typical and Atypical Presentations of Migraine

Headache Characteristics

May be constant or throbbing.
Worsens with physical activity.
Nausea, vomiting, photophobia are common companions.
Relief comes from resting in a dark, quiet place.

Duration of Migraine Headache

Lasts from 2 hours to 48-72 hours without treatment.
Chronic migraine can persist for weeks but offers headache-free days (unlike tension headaches).

Headache Location in Migraine

Migraine pain can affect:

Frontal area
One side of the scalp
Both sides of the head
Occipital or retro-orbital regions
(Basilar type migraine involves basilar-vertebral circulation.)

Classic Migraine Case

Typically seen in young females:

Unilateral throbbing headache
Nausea, vomiting
Photophobia
Worsens with activity
Feels better in dark, quiet places
Aura may or may not be present

However, only 20-30% fit this “classic” picture.

Other Headaches That Resemble Migraine

Cluster Headaches: Severe orbital/frontal headaches with teary eyes or runny nose, often in males, typically during sleep.
Tension Headaches: Constant, mild-moderate pain without headache-free periods.

Autonomic Disturbances in Migraine

Migraine often disturbs the gastrointestinal system, causing:

Nausea
Vomiting
Abdominal discomfort

Important: Migraine attacks slow gut absorption of oral medications — so take drugs early when warning signs appear.

How to Diagnose Migraine Correctly

Migraine is mainly a clinical diagnosis.
Investigations like MRI are used to:

Rule out stroke
Exclude structural brain lesions

Best Treatment Options for Migraine

Acute Migraine Treatment

NSAIDs: Indomethacin, Ibuprofen

Anti-emetics: Diphenhydramine (offers sedation too)

Hydration therapy

Stomach protection: PPIs like Omeprazole or Ranitidine

Specific Migraine Medications

Triptans (e.g., Sumatriptan): Serotonin agonists effective in aborting acute attacks.
Sumatriptan wafers: Rapid action preferred.

Best Practice:
Take medications at the earliest warning signs to enhance absorption and effectiveness.

Migraine Prophylaxis (Preventive Treatments)

For chronic or frequent migraine sufferers:

First-line: Propranolol (Avoid in hemiplegic migraine due to vasospasm risk)
Second-line: Tricyclic antidepressants (e.g., Amitriptyline)
Third-line: Topiramate ( Teratogenic—avoid in pregnancy)
Other agents: Pizotifen, Pyridoxine (Vitamin B6)

Note:
Preventive medications take several days to show effect.
Acute treatments like Sumatriptan can be used during this adjustment phase.

Caution: Topiramate and Endep (Amitriptyline) can affect driving abilities.