Playbook
What should I actually do about migraine?
Migraine is a real neurological disease, about three times more common in women, and it is often shrugged off as "just a headache". It also interacts with your hormones and with birth control in ways that matter. This helps you pin down your type, spot the safety issues, and choose treatment.
Migraine · reviewed July 2026 · 14 cited papers
See a clinician promptly if
- !A sudden "worst headache of my life" (thunderclap), or headache with fever, stiff neck, confusion, or weakness. These can signal a bleed, infection, or stroke and need emergency assessment, not migraine treatment.
- !A clearly new or different headache pattern, especially after age 50 or with a new aura. A change in pattern warrants evaluation to exclude a secondary cause.
- !Using acute migraine medication on more than about 10 to 15 days a month. Frequent use can cause medication-overuse headache, which makes migraine worse and needs a different plan.
Step 1
Which kind of migraine do you have?
Migraine comes in patterns, and two distinctions really change your plan: whether you get aura, and whether attacks track your cycle.
Step 2
What to get checked
Migraine is usually a clinical diagnosis; tests are mainly to catch red flags and guide safe treatment. Scans are not routine without warning signs.
A headache diary (days per month, aura, cycle timing, medication use)
It confirms the pattern, reveals menstrual timing, flags medication overuse, and is the single most useful thing to bring.
Blood pressure and cardiovascular risk review
It shapes safe options, especially whether triptans and estrogen contraception are appropriate.
Brain imaging only if there are red flags
Routine scans are not needed for typical migraine, but new, changing, or alarming features warrant one.
Step 3
What actually works
Two tracks: treat attacks quickly when they come, and if you get them often, prevent them. Menstrual attacks can get their own timed approach.
Acute treatment: triptans or gepants
Take an effective acute drug early in the attack. Triptans relieve many attacks within two hours, and some work better or faster than others so switching is worthwhile. Gepants (like rimegepant) are an option that avoid the vascular cautions of triptans.
TimelineWithin the attack; judge over a few attacks.
How to get itPrescription (NSAIDs over the counter).
CautionsTriptans are avoided with certain cardiovascular disease; cap acute-drug use to avoid medication-overuse headache.
Perimenstrual short-term prevention
If attacks reliably track your period, taking a longer-acting triptan (or an NSAID) on a schedule for a few days around menstruation can head them off.
Preventive medication when attacks are frequent
For frequent or disabling migraine, daily prevention cuts attack days. Options range from older drugs like topiramate to CGRP-targeted therapies: monthly injectable antibodies (erenumab, galcanezumab) and daily oral gepants (atogepant).
TimelineWeeks to a few months to judge.
How to get itPrescription.
CautionsTopiramate can affect cognition and harm a pregnancy, so it needs care in anyone who may conceive.
Manage triggers and protect the basics
Consistent sleep and meals and managing stress target the most commonly reported triggers. Track your own triggers rather than over-restricting your life on a generic list.
Estrogen-containing contraception if you have aura
Because migraine with aura already raises stroke risk, combined estrogen contraception is generally avoided; progestogen-only or non-hormonal methods are preferred.
Set your expectations
- Migraine is treatable: the aim is fewer, less severe attacks and effective rescue when they come, not a cure.
- Treat attacks early and cap acute-medication days to avoid medication-overuse headache.
- Preventives take weeks to months, so give one a fair trial before judging it.
- Migraine often eases during pregnancy, but drug choices narrow, so plan ahead.
Step 4
Take this to your doctor
“I get migraines and want a proper plan for both stopping attacks and preventing them, and I want to make sure my contraception is safe given my migraine type.”
Questions to ask
- Do I get aura, and does that change which contraception is safe for me?
- Which acute medication should I try, and how many days a month can I safely use it?
- Am I having enough attacks to warrant a preventive, and which one fits me?
- Do my period-related attacks call for timed short-term prevention?
What to bring
- A headache diary with attack days, aura, and how they map to your cycle
- A list of acute and preventive treatments already tried and how they worked
- Your blood pressure, smoking status, and any pregnancy plans
When to push. Seek urgent care for a thunderclap headache or headache with fever or neurological signs, and ask for neurology referral if attacks stay frequent despite prevention or you are overusing acute medication.
Step 5
Where the science is going
The CGRP era
Drugs targeting CGRP, both injectable antibodies and oral gepants used acutely and preventively, have given migraine its first purpose-built treatment class in decades and expanded options for people who failed older drugs.
All sources
Every claim above links to peer-reviewed research. Full list below.
- Migraine: integrated approaches to clinical management and emerging treatments (2021). Lancet. doi.org/10.1016/S0140-6736(20)32342-4
- Incidence of migraine relative to menstrual cycle phases of rising and falling estrogen (2006). Neurology. doi.org/10.1212/01.wnl.0000233888.18228.19
- Menstrual migraine: a distinct disorder needing greater recognition (2021). Lancet Neurol. doi.org/10.1016/S1474-4422(20)30482-8
- A randomized trial of frovatriptan for the intermittent prevention of menstrual migraine (2004). Neurology. doi.org/10.1212/01.wnl.0000134620.30129.d6
- Hormonal contraceptives and risk of ischemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESC) (2017). J Headache Pain. doi.org/10.1186/s10194-017-0815-1
- Migraine and cardiovascular disease: systematic review and meta-analysis (2009). BMJ. doi.org/10.1136/bmj.b3914
- Triptans in the Acute Treatment of Migraine: A Systematic Review and Network Meta-Analysis (2015). Headache. doi.org/10.1111/head.12601
- A Controlled Trial of Erenumab for Episodic Migraine (2017). N Engl J Med. doi.org/10.1056/NEJMoa1705848
- Evaluation of Galcanezumab for the Prevention of Episodic Migraine: The EVOLVE-1 Randomized Clinical Trial (2018). JAMA Neurol. doi.org/10.1001/jamaneurol.2018.1212
- Efficacy, safety, and tolerability of rimegepant orally disintegrating tablet for the acute treatment of migraine: a randomised, phase 3, double-blind, placebo-controlled trial (2019). Lancet. doi.org/10.1016/S0140-6736(19)31606-X
- Atogepant for the Preventive Treatment of Migraine (2021). N Engl J Med. doi.org/10.1056/NEJMoa2035908
- Topiramate for migraine prevention: a randomized controlled trial (2004). JAMA. doi.org/10.1001/jama.291.8.965
- Headache and pregnancy: a systematic review (2017). J Headache Pain. doi.org/10.1186/s10194-017-0816-0
- Perceived triggers of primary headache disorders: A meta-analysis (2018). Cephalalgia. doi.org/10.1177/0333102417727535
This playbook is educational and is not medical advice. Hair loss has many causes and individual treatment decisions belong with a clinician who can examine you.