Migraine Treatment in Sydney
Comprehensive specialist neurology care for migraine — from the occasional severe attack through to chronic daily migraine. Dr Ron Granot, FRACP, Bondi Junction.
Book a ConsultationMigraine — More Than a Bad Headache
Migraine is a neurological disorder, not just a severe headache. It affects approximately 12% of adults — more than diabetes and asthma combined — and is one of the leading causes of disability worldwide, particularly in women aged 25–55. A typical attack lasts 4–72 hours and brings moderate to severe head pain, often one-sided and throbbing, with nausea, vomiting and sensitivity to light and sound. Many patients also experience visual aura, vertigo, brain fog, fatigue and food cravings as part of the attack.
The biology of migraine is now well understood as a brain-based disorder of sensory processing — not muscle tension, sinus pressure or "just stress". It involves cycles of cortical hyperexcitability, trigeminovascular activation, and release of pain-signalling molecules including CGRP. Understanding this matters because it shapes treatment: today we have migraine-specific acute medications (triptans, gepants) and preventatives (Botox, CGRP monoclonal antibodies) that target the actual disorder.
The Phases of a Migraine Attack
A migraine attack often unfolds in distinct phases. Not every patient experiences every phase, and the timing varies — but recognising the pattern helps with both diagnosis and treatment timing.
1. Prodrome
Hours to days before head pain. Yawning, mood changes, food cravings, neck stiffness, fatigue, irritability. Often unrecognised until pattern is noticed.
2. Aura (some patients)
Visual disturbance (zigzag lines, blind spots), sensory changes (tingling), speech disturbance, or weakness. Typically 5–60 minutes before head pain.
3. Headache
4–72 hours of moderate–severe pain, often unilateral and throbbing. Worse with movement. Nausea, photophobia, phonophobia.
4. Postdrome
Hours to a day or two after. "Migraine hangover" — tired, washed out, mild residual ache, cognitive slowing.
Migraine Variants — Not All Migraines Look the Same
Several distinct migraine variants exist. Recognising them is important because some have specific treatment implications, and some can mimic other neurological problems (or be mimicked by them).
Migraine without aura
The most common form. Recurrent attacks of moderate–severe headache, often with nausea and light/sound sensitivity, but no preceding aura.
Migraine with aura
Up to a third of migraine sufferers experience aura — usually visual (zigzag lines, fortification spectra, scotomata). Some have sensory or speech aura. Aura raises specific considerations including stroke risk and contraceptive choice.
Chronic migraine
≥15 headache days per month, with ≥8 being migraine, for ≥3 months. Specific treatment pathway including PBS-listed Botox and CGRP medications.
Vestibular migraine
Recurrent vertigo or imbalance with migraine features — sometimes without head pain. Commonly misdiagnosed as inner ear disease. See MAV / vestibular migraine.
Hemiplegic migraine
Rare migraine variant with motor weakness as part of the aura. Can mimic stroke. Familial or sporadic forms. Specific medications are avoided.
Menstrual migraine
Attacks tightly linked to the menstrual cycle, often around the perimenstrual window. Often more severe and longer-lasting. Specific treatment strategies including short-cycle prevention can help.
Migraine vs Other Headaches — Quick Differentiation
Several common headache types share features with migraine but call for different treatment. This table gives a quick framework — but the diagnosis is clinical and individual.
| Type | Typical features | Treatment direction |
|---|---|---|
| Migraine | 4–72 h, often one-sided, throbbing, nausea, photophobia, phonophobia, worsens with movement | Acute triptans/NSAIDs/gepants + preventative as needed |
| Tension-type | Bilateral, pressing/tightening, mild–moderate, no nausea, not worsened by routine activity | Simple analgesia, stress management, sometimes amitriptyline |
| Cluster | Severe one-sided around the eye, autonomic symptoms (red eye, tearing, nasal congestion), 15 min–3 h, often nocturnal, cyclical "cluster periods" | Oxygen, subcutaneous sumatriptan; verapamil prevention — see cluster headache |
| Trigeminal neuralgia | Brief (seconds), severe lancinating face pain, triggered by touch/chewing/cold air | Carbamazepine, oxcarbazepine; neurosurgical referral if refractory — see trigeminal neuralgia |
| Medication overuse | Chronic daily headache developing in someone who frequently uses acute medications (≥10 days/month of triptans/codeine; ≥15 days/month simple analgesia) | Structured withdrawal + bridging — see medication overuse headache |
| Cervicogenic | Headache referred from neck structures, often unilateral, made worse by neck movement, restricted neck motion | Physiotherapy, occipital nerve blocks, sometimes facet joint injections |
Red Flags — When to Worry
Most headaches are primary disorders (migraine, tension, cluster). But a small proportion are secondary — caused by another medical problem. The following features should prompt urgent assessment, often in an emergency department rather than an outpatient clinic.
Seek urgent assessment if any of these are present
- Thunderclap onset — worst-ever headache, peaking within a minute (rule out subarachnoid haemorrhage)
- New headache with fever, neck stiffness or rash (consider meningitis)
- Persistent focal neurological deficit beyond typical migraine aura
- Altered consciousness, persistent vomiting, or seizures with headache
- Headache after head trauma in the preceding 30 days
- New headache >50 years with systemic symptoms (consider giant cell arteritis)
- Pregnancy or postpartum with new severe headache
- Visual obscurations suggesting raised intracranial pressure
How We Approach Migraine Treatment
Effective migraine care combines several layers — acute treatment for individual attacks, preventative strategies to reduce frequency, trigger and lifestyle management, and a sustained commitment to finding what works for the individual patient. There is no single "best" treatment, and patience matters.
Layered approach to treatment
- Headache diary — the foundation. Without baseline data we cannot assess response or qualify for specialist treatments.
- Acute treatment — triptans (sumatriptan, rizatriptan, eletriptan, etc.), NSAIDs, gepants (newer, increasingly available), antiemetics for nausea. Used early in the attack and not on too many days per month.
- Preventative oral medications — propranolol, topiramate, amitriptyline, candesartan, sodium valproate, flunarizine. Trial each for 8–12 weeks at adequate dose before judging response.
- Specialist preventatives for refractory/chronic migraine — PBS-listed Botox and CGRP monoclonal antibodies (Emgality, Ajovy, Vyepti).
- Trigger and lifestyle — sleep hygiene, regular meals, hydration, exercise, identification of personal triggers via diary, stress management.
- Comorbidity management — depression, anxiety, sleep disorders, medication-overuse headache all need attention as they amplify migraine impact.
Frequently Asked Questions
Considering Migraine Specialist Care?
Book a consultation with Dr Ron Granot — FRACP consultant neurologist, trained at Prince of Wales, Bondi Junction.
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