Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Migraine

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In one line

·Migraine is a brain disorder where waves of electrical noise and swelling in blood vessels cause headaches that come back again and again, often with warning signs and strange sensory symptoms.

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Normal physiology

·Normally, the cortex (the outer layer of the brain) keeps its electrical signals steady and damped, so no wild waves of activity ripple across it. The trigeminal nerve—the main pain nerve in your head—and the blood vessels around the brain and its covering (the meninges, the protective layers wrapping the brain) stay quiet, signaling pain only if there's real injury. Keep that picture in your head, because the weird findings in migraine only make sense as a change from this calm state.

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What goes wrong

·In migraine, the brain's electrical brake fails, letting a wave of overexcitement—cortical spreading depression—roll across the cortex. That wave flips on the trigeminal nerve like a fire alarm, which then dumps CGRP and other inflammatory chemicals onto the blood vessels and meninges, making them swell and scream pain. Once started, the pain signals spread and amplify (sensitization), so even normal touch or light feels unbearable. Triggers—stress, skipped meals, hormone swings (especially estrogen drops before a period), lack of sleep, certain foods (aged cheese, wine, MSG), weather changes, bright lights—can set off the cascade in people whose brains are wired to overreact.

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Hallmark signs

·Pounding pain on one side of the head that throbs with each heartbeat
·Nausea or vomiting
·Light hurts your eyes (photophobia)
·Sound hurts your ears (phonophobia)
·Physical activity makes the pain worse
·Aura before or during the headache (flashing lights, zigzag lines, blind spots, numbness, or trouble speaking)
·Headache that lasts 4 to 72 hours if untreated
·Sudden, explosive 'thunderclap' headache that peaks in seconds

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Red flags · escalate now

·Sudden thunderclap headache that peaks in seconds (may be bleeding in the brain)
·New weakness, vision loss, numbness, or confusion that does not go away (may be a stroke)
·Fever, stiff neck, or confusion (may be meningitis or encephalitis)
·Headache after age 50 for the first time (may be giant cell arteritis, an inflamed artery in the temple, or a brain tumor)
·Worsening headaches in someone with cancer, HIV, or a weakened immune system (may be infection or spread of cancer to the brain)

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Workup

·MRI or CT of the brain (with and without contrast if red-flag symptoms are present—sudden worst headache of life, new neurologic deficit, fever, age > 50 with new headache)
·Lumbar puncture (spinal tap) with opening pressure measurement
·Complete blood count (CBC) with differential and inflammatory markers (ESR, CRP)
·Thyroid-stimulating hormone (TSH) and complete metabolic panel (sodium, calcium, glucose, kidney and liver function)
·Red blood cell (Erythrocyte) sedimentation rate (ESR) and temporal artery biopsy (if giant cell arteritis is suspected)

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Treatment

·Triptan (sumatriptan 100 mg by mouth, rizatriptan 10 mg, or sumatriptan 6 mg injection) taken at the start of headache pain
·NSAIDs (ibuprofen 400–800 mg, naproxen 500–550 mg) or acetaminophen 1000 mg for mild-to-moderate migraine
·Antiemetic (metoclopramide 10 mg IV or by mouth, or prochlorperazine 10 mg IV or IM) given with acute migraine treatment
·Daily preventive medicine (propranolol 80–240 mg, topiramate 50–200 mg, amitriptyline 25–100 mg at bedtime, or CGRP monoclonal antibody like erenumab 70–140 mg monthly injection) if 4 or more migraines per month or if attacks are disabling
·Trigger avoidance and lifestyle habits—regular sleep schedule, staying hydrated, managing stress, avoiding known food triggers like aged cheese or alcohol, eating regular meals
·OnabotulinumtoxinA (Botox) injections—155 to 195 units across 31 to 39 sites in the head and neck every 12 weeks—if chronic migraine (15 or more headache days per month) persists despite other preventives
·Gepant (ubrogepant 50–100 mg or rimegepant 75 mg by mouth) as acute treatment if triptans fail, cause side effects, or are contraindicated

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NCLEX trap

·Start with ibuprofen, naproxen, acetaminophen, or a triptan like sumatriptan or rizatriptan. Opioids are a trap because they do not calm down the trigeminovascular system — the nerve-and-blood-vessel alarm circuit firing in the head. Instead, they rewrite the brain's pain pathways and cause medication overuse headache (MOH) — a vicious cycle where the headaches come more often and get harder to treat. MOH is a real danger in migraine care, and opioids do not belong in first-line treatment.
·Aura in migraine is cortical spreading depression — a slow wave of nerve cells firing, then going quiet, that marches across the surface of the brain like a ripple on water. It is completely reversible and causes no permanent damage. If the aura goes away within an hour, the brain is fine. Stroke symptoms do not fully reverse — they stick around or worsen. That said, migraine with aura does raise stroke risk slightly over a lifetime, so if attacks happen often (four or more per month), start preventive medication to lower that risk.
·Triggers vary from person to person and change over time. The real problem is cortical excitability — the brain's nerve cells are set to fire too easily, like a smoke alarm that goes off when you toast bread. Triggers are just the spark. Preventive drugs like propranolol (a beta-blocker that steadies brain signals), topiramate (an anti-seizure medicine that quiets overactive nerves), or CGRP monoclonal antibodies like erenumab (which block the pain peptide CGRP that fuels migraines) lower the brain's firing threshold itself. That is more powerful than trigger avoidance alone. Use both together.
·Frequent triptan use — more than ten days per month, or even more than two days per week over time — causes medication overuse headache (MOH), a trap that turns occasional migraine into chronic daily headache. If a patient needs rescue medicine more than twice a week on average, start preventive therapy like propranolol, topiramate, amitriptyline (a tricyclic antidepressant that raises serotonin and steadies pain signals), or a CGRP antibody like fremanezumab to reduce attack frequency and lower MOH risk.
·Thunderclap headache — pain that hits peak intensity within seconds to a minute — is a red flag for subarachnoid bleeding (hemorrhage) (bleeding into the space around the brain), not migraine. Migraine builds over minutes to an hour. Thunderclap is a medical emergency. Go to the ER for a CT scan and, if CT is negative, a lumbar puncture (spinal tap) to look for blood in the spinal fluid. Do not assume it is migraine.
·Fever and neck stiffness are red flags for meningitis — infection of the lining around the brain and spinal cord — not migraine. Migraine does not cause fever. This patient needs urgent CT to rule out swelling or mass before the spinal tap, then lumbar puncture to check for bacteria or white blood cells in the spinal fluid. Work up the dangerous cause first, then treat.

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