BMJ Best Practice Podcast Migraine
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Mar 2, 2026 Timothy Collins, Associate Professor of Neurology and Chief of the Headache Division at Duke, offers expert clinical perspective. He discusses how migraine is diagnosed by history, core symptom patterns and common diagnostic pitfalls. He compares migraine with cluster headache, reviews acute treatments including triptans and new agents, outlines preventive options including CGRP therapies, and covers imaging red flags and medication overuse.
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Combine Early Acute Treatment With Preventive Therapy
- Use acute medications at headache onset to abort attacks and preventive therapies daily to reduce attack frequency.
- Explain the two-tier strategy clearly to patients: rescue vs ongoing prevention.
Choose Triptans Gepants Or Lasmiditan Based On Risks
- Offer triptans for many patients and consider newer gepants and lasmiditan if triptans fail or are contraindicated.
- Gepants are non-vasoconstrictive; lasmiditan causes marked grogginess and impairs driving.
Confirm History And Treat Early In Attack
- Avoid giving migraine-specific drugs for a first-ever severe headache without prior similar attacks.
- Encourage patients to treat early in an attack because early dosing works better than waiting until pain is severe.