Migraines Explained: What They Really Are – And How to Treat Them
Episode 29 | Ask the Expert | Guest: Dr James Gratwicke, Consultant Neurologist (MA(Oxon) BMBCh MRCP(Neurology) PhD(Clinical Neurology))
Most people think they know what a migraine is. A banging headache, flashing lights, lying in a darkened room for hours. But according to Dr James Gratwicke, Consultant Neurologist and headache specialist, that picture represents only a tiny fraction of what migraine actually is – and it leaves the vast majority of sufferers unrecognised and undertreated.
In this episode of the London Bridge Sports Medicine podcast, Dr Gratwicke reframes migraine from the ground up – explaining the science, the spectrum of symptoms, the common misdiagnoses, and the genuinely exciting treatment options now available.
Migraine isn’t just a bad headache – it’s a genetic condition
The first thing Dr Gratwicke wants people to understand is that migraine is not simply a severe version of a normal headache. It is a lifelong genetic condition. “When the sperm meets the egg to make you, there are genes that give you your eye colour, your hair colour – and there are several hundred genes that give you cumulatively your genetic liability to migraine,” he explains.
That liability is permanent. What changes throughout life is how often it manifests, and how severely – influenced by hormones, lifestyle, and environment.
More strikingly, Dr Gratwicke argues that the everyday headache most of us dismiss as “normal” is also a migraine – just a mild one. “It’s not normal ever to have a headache,” he says. “All headaches are migraines.” That stress headache that clears with a paracetamol and a glass of water? Migraine. The tension headache after a long day at a screen? Also migraine.
He describes migraine as an iceberg: about two thirds sits below the waterline – people experiencing mild headaches who never seek medical attention and never know they have migraine. The one third above the surface are those with more severe or more chronic symptoms, who present to their GP or a specialist. “That’s why we think of migraine as just the bit above the waves,” he says.
What is actually happening in the brain?
Dr Gratwicke offers a clear framework for understanding the physiology. The brain is an electrical organ, with electrical activity flowing through it constantly. A migraine is a build-up of electrical irritability on the surface of the brain – in an area no bigger than a two-pence piece.
This electrical irritability triggers the release of a chemical called calcitonin gene-related peptide (CGRP), which irritates the meningeal lining surrounding the brain and the optic nerves. It is this irritation that produces the core migraine symptoms: headache, light sensitivity, sound sensitivity, sensitivity to movement, and nausea.
Meanwhile, because different areas of the brain’s surface process different types of information, that electrical disturbance can also scramble the processing of whatever sits beneath it – producing the aura symptoms that many people associate with migraine: visual disturbances, tingling sensations, or other perceptual changes.
Importantly, Dr Gratwicke is clear that the word “migraine” does not mean headache. Headache is simply the most common symptom. The condition is the electrical disturbance itself.
Symptoms: broader than most people think
The core diagnostic symptoms, as defined by the International Headache Classification, are:
• A lateralised headache – usually focused on one side of the head, and typically the same side each time
• Sensitivity to light
• Sensitivity to sound
• Sensitivity to movement
• Nausea, vomiting, or loss of appetite
Not every migraine involves all five – and the milder the episode, the fewer symptoms tend to appear. On top of these core symptoms, some people experience aura: visual disturbances, tingling down one arm or across one side of the face, or a sense of disequilibrium – described as feeling like you’re on the deck of a ship.
Dr Gratwicke also broadens the definition of headache itself. As a neurologist, he defines a headache as “anything above the level of the neck where the head is not crystal clear” – encompassing not just pain, but brain fog, fuzziness, and lack of mental clarity. “It’s not painful, but it’s not crystal clear. That is still a headache to me.”
Triggers: the six big lifestyle factors
Genetic liability is the foundation – but it is triggers that determine whether and when a migraine actually occurs. Dr Gratwicke identifies six major lifestyle triggers that apply to almost everyone with migraine:
- Stress and anxiety
- Poor sleep – both insufficient sleep and irregular sleep timings
- Dehydration
- Delayed or missed meals – not eating at consistent times each day
- Excess screen exposure
- Neck muscle pain and tension – typically postural, particularly relevant for desk workers
Triggers do not act in isolation. They can stack – so a person might tolerate one trigger without incident, but a combination of two or three on the same day pushes the brain over its threshold into a migraine. Understanding this cumulative effect is key to managing the condition day to day.
On the cervical connection, Dr Gratwicke confirms what physiotherapists often observe clinically: pain and tension in the neck muscles can directly trigger secondary migraines. Addressing posture and cervical mobility has a genuine, evidence-supported role in migraine management.
Hormones, women, and migraine
Migraine affects both men and women, but hormonal fluctuations mean that many women experience significant changes in migraine frequency and severity at different life stages.
The mechanism is straightforward: high levels of oestrogen increase the electrical irritability of the brain. This is why many women find their migraines are locked to their menstrual cycle – the point of highest oestrogen concentration in the bloodstream.
The perimenopause is a particularly challenging period. Rather than a smooth drop in oestrogen, perimenopause involves significant hormonal fluctuation – which repeatedly shifts the brain’s electrical threshold, often worsening migraine control. Post-menopause, once hormone levels stabilise at a lower level, migraines typically improve.
Misdiagnosis: the conditions migraine can masquerade as
Because migraine symptoms are so varied, misdiagnosis is common. Dr Gratwicke outlines two main scenarios:
When headache is prominent: migraine can be confused with cluster headache, tension headache, or sinus headache. On that last point – Dr Gratwicke is clear that sinusitis-triggered headaches are, in fact, migraines. Sinusitis is a trigger; the headache itself is a migraine.
When headache is not prominent: this is where diagnosis becomes genuinely difficult. Two particularly common misdiagnoses:
- Stroke: when the aura involves tingling down one arm or one side of the face with only a mild or absent headache, this is frequently misidentified as a TIA or stroke. Dr Gratwicke sees these referrals regularly.
- Benign paroxysmal positional vertigo (BPPV): when dizziness is the dominant symptom, migraine is often overlooked. The distinction lies in the nature of the dizziness – in migraine it is typically disequilibrium (a sense of unsteadiness, as if the world is unstable) rather than true vertigo (a sense of the world spinning or moving).
How is it diagnosed?
Migraine is primarily a clinical diagnosis. A thorough history, combined with a normal neurological examination, is usually all that is needed. “If the symptoms fit and the neurological examination is normal, I will make the diagnosis,” says Dr Gratwicke. “I don’t usually do any tests.”
In practice, many patients do end up having brain scans – largely because of anxiety about more serious causes, particularly brain tumours. While this is understandable, a migraine headache has sufficiently distinct characteristics that an experienced neurologist will generally be confident in the diagnosis from the history alone.
Treatment: the three planks of management
Dr Gratwicke structures migraine management around three distinct areas:
1. Avoid triggers
The most important intervention of all. “Prevention is always better than cure,” says Dr Gratwicke. “If you throw drugs at people but they don’t deal with their poor sleep or the excess glare from their monitors, they won’t get that far.” Identifying and reducing personal triggers – particularly the six big ones – is the foundation of everything else.
2. Acute treatments (for episodic migraine)
These are medications taken at the onset of a migraine to stop it in its tracks. They work well for episodic migraine – where a trigger causes a migraine that burns out within 72 hours, returning the person to a clear-headed baseline. There are two categories:
- Triptans (e.g. Sumatriptan): the established first-line option
- New-generation anti-CGRP oral drugs (e.g. Rimegepant, Atogepant): targeting the CGRP chemical directly
There is a critical caveat: both work only if taken within the first 10 minutes of a migraine beginning, when the electrical irritability is still low. Beyond that window, the irritability snowballs and becomes much harder to stop. Dr Gratwicke notes this timing point is frequently missed – and is a common reason patients report that these medications “didn’t work”.
The other scenario where acute treatments fail is chronic migraine – where triggers stack and keep the brain electrically irritable for days, weeks, months, or even years. In this state, there is no clear beginning to the migraine to treat, so acute medications cannot do their job.
3. Preventative treatments (for chronic migraine)
For those in chronic migraine, the goal is to dampen down the brain’s baseline electrical irritability and break the cycle. There are two generations of preventative medication:
Traditional preventatives: drugs originally developed for other conditions – including propranolol, amitriptyline, and candesartan – that were repurposed for migraine. These are very much trial and error: a drug that works for one person may do nothing for another, each requires around three months at a stable dose to assess properly, and side effects are common.
New-generation anti-CGRP drugs: a genuine paradigm shift. Available in two forms – oral gepants and injectable monoclonal antibodies – these drugs specifically target the CGRP molecule that drives migraine symptoms. They are well tolerated (serious side effects occur in under 1% of patients), and for someone in chronic migraine, an oral anti-CGRP medication will typically break the cycle within six weeks. The injectables, which are only available through specialist headache clinics, are given as depot injections and work by triggering the immune system to neutralise CGRP directly.
When to seek urgent medical attention
Most migraines, while unpleasant, are not medically urgent. However, Dr Gratwicke outlines several red flag symptoms that warrant prompt attention:
- A headache that is strong, persistent, and not rising and falling – one that comes on and stays bad
- Vomiting more than once, or vomiting without feeling better afterwards (in migraine, vomiting typically brings relief)
- A headache that wakes you from sleep (migraines generally improve with sleep; one that disrupts sleep is a different pattern)
- New focal neurological symptoms – loss of vision (rather than visual distortion), or weakness in an arm or leg (rather than tingling)
These features are not consistent with typical migraine and should prompt same-day medical assessment.
The bottom line
Migraine is the most common neurological condition worldwide – and one of the most underdiagnosed. The public image of a migraine as a severe, dramatic headache with visual fireworks obscures the reality: most migraines are mild, most people have them, and most people don’t know.
For those in the more severe or chronic end of the spectrum, the good news is that treatment has genuinely transformed in recent years. Identifying and reducing triggers remains the cornerstone of management – but for those who need medication, the new generation of CGRP-targeting drugs represents a step change from the trial-and-error era.
If you’ve been living with frequent headaches and accepting them as normal, it may be worth asking the question.
Dr James Gratwicke is a Consultant Neurologist specialising in headache and migraine (MA(Oxon) BMBCh MRCP(Neurology) PhD(Clinical Neurology)). He practises at the Harley Street Clinic, London Bridge Hospital, and London International Patient Services at Battersea Power Station.
To book an appointment with a member of the LBSM team, visit lbsm.co.uk/booking/
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