Pathophysiology
Cortical spreading depression triggers trigeminovascular activation and CGRP release, causing meningeal vasodilation and neurogenic inflammation.
Sources: ICHD-3 (Cephalalgia 2018;38:1); AHS 2024 (Headache 2024;64:1)
Presentation
Unilateral throbbing headache 4-72 h with nausea, photophobia and phonophobia. 25% have aura (visual scintillations, sensory or aphasic).
Diagnosis
Clinical using ICHD-3 criteria. Neuroimaging only for red flags: thunderclap, focal deficit, new after age 50, immunosuppression.
Management
Acute: triptans, NSAIDs, gepants (rimegepant), lasmiditan. Preventive: propranolol, topiramate, anti-CGRP mAbs (erenumab, fremanezumab), onabotulinumtoxinA for chronic migraine.







