A 39-year-old female with a severe pulsating headache, vertigo, nausea, and sensitivity to light and sound aggravated by walking or moving was presented. These typical signs and symptoms of headache without any neurological findings and a normal CT scan of the brain lead us to the diagnosis of migraine without aura.

One in ten people have migraine. As shown in our case, the patient’s history is the essential diagnostic tool. From a pathophysiological point of view, spontaneous overactivity and abnormal amplification in pain and other, predominantly sensory, pathways in the brainstem may lead to migraine. Current opinion favors a primarily neural cause, involving feedback loops through innervation of cranial arteries in the trigeminovascular system. Ongoing research is studying the relevance of calcium channel abnormalities and peptides such as calcitonin gene-related peptide, which may be closer than 5-HT to the underlying cause.

Management of lifestyle can appear to be very helpful, though evidence is largely anecdotal. Analgesics and antiemetics are effective for many migraine patients. Some of them prefer a nonsteroidal anti-inflammatory drug (NSAID), aspirin, or paracetamol. Triptans are only slightly more effective than simple analgesics with an antiemetic on the number needed to treat (NNT) basis. These data conceal substantial inter- and intra-patient variation. Ergot alkaloids may still have an occasional place in the acute management of migraine. Daily drug treatment to prevent migraine should be considered after acute treatment has been optimized, medication overuse abolished, lifestyle modification tried, and a migraine diary recorded for a month or three. Comorbid disease may suggest initial drug choice. It is unusual to offer prophylaxis for less than three attacks a month. Treatment should be titrated first for tolerability and then for efficacy.