Reviewed by the Evolve Health clinical team · 2026-10-17 · 8 min read
Clinically reviewed by the Evolve Health clinical team — October 2026
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Quick answer
A migraine is a throbbing, often one-sided headache that lasts 4 to 72 hours untreated, usually with nausea and sensitivity to light and sound — and it is treatable in primary care. A visit focuses on your pattern: how often attacks come, what triggers them, and whether the headache medicine itself is now causing rebound headaches. Treatment has two parts — an acute plan to stop an attack early, and a preventive plan when attacks are frequent. Most migraine needs neither a scan nor a specialist. The exceptions matter: a sudden thunderclap headache, one with fever and a stiff neck, or one with weakness or vision changes means the emergency room, not a clinic — call 911.
The questions we hear every week follow a pattern: "Is this a migraine or just a bad headache?" "My headache medicine used to work — why does it barely touch it now?" "I lose a whole day every month around my period — is that connected?" Usually, the answer is the same: migraine is a pattern, and patterns can be mapped, treated, and often made much less frequent. Migraine care rarely starts with a scan. It starts with your history.
Migraine, tension, or sinus? How the three compare
Most recurring headaches are one of three types, treated differently — which is why the label matters. Migraine is a neurological condition in which the brain becomes temporarily oversensitive; tension headaches are the common muscle-and-stress headache; true sinus headaches come with an actual sinus infection. Many headaches blamed on sinuses turn out to be migraine, because migraine can cause facial pressure and a stuffy nose too.
| Migraine | Tension headache | Sinus headache | |
|---|---|---|---|
| How it feels | Throbbing or pulsing, moderate to severe; movement worsens it | Dull, steady pressure, like a tight band; mild to moderate | Aching pressure over the cheeks, forehead, or bridge of the nose |
| Where | Often one side (can switch sides between attacks) | Both sides, forehead, or back of head and neck | Face and forehead; worse bending over or lying down |
| Comes with | Nausea, light and sound sensitivity; some get aura first | Tight neck and shoulders; no nausea | Congestion, thick discharge, fever, reduced smell |
| How long | 4 to 72 hours untreated | 30 minutes to several hours | Days, tracking with the sinus infection itself |
About one in four people with migraine get an aura — most often visual: flashing lights, shimmering zigzags, or a blind spot that grows over 5 to 60 minutes, then clears. Aura can also be tingling that creeps up an arm, or brief trouble finding words. Aura that behaves the same way every time is a migraine feature; aura that is new, different, or leaves weakness behind needs prompt evaluation.
Headaches that mean the emergency room, not a clinic
Most headaches are miserable but not dangerous. A short list is different — these need emergency care first:
- A thunderclap headache — pain that peaks within a minute, often the worst headache of your life.
- Headache with fever and a stiff neck, confusion, or a rash — possible meningitis.
- A headache after a head injury, especially if it worsens or comes with vomiting or drowsiness.
- Headache with vision loss, weakness, facial droop, or trouble speaking — stroke signs until proven otherwise.
- A brand-new headache pattern after age 50, or one that steadily worsens over days to weeks.
If any of these fit, call 911 or go to the nearest emergency room. Do not book a sick visit and wait it out.
What a primary care visit does for migraine
For a typical migraine pattern, the most useful diagnostic tool is not a machine — it is a headache diary. For a month or two, note when each attack starts, how long it lasts, symptoms, possible triggers, and what you took and whether it worked. Patterns hide in ordinary life — skipped meals, poor sleep, a weather front, the let-down after a stressful week, hormonal shifts — and the diary finds them.
The visit also includes a check patients rarely expect: medication overuse. Acute headache medicine — including over-the-counter painkillers — taken on too many days each month can itself cause a near-daily rebound headache, so the treatment quietly becomes the problem. As a general guide, triptans or combination painkillers on 10 or more days a month, or simple painkillers on 15 or more, can keep that cycle alive. Finding it is good news: it is one of the most fixable reasons migraines worsen. The clinician finishes with a basic neurological exam and a red-flag screen, and most patients leave with two written plans — one for the attack, one for prevention.
Treating the attack itself
Acute treatment works best early — at the first sign of an attack, not after the pain is fully established. In class terms, the usual ladder looks like this:
- Anti-inflammatory painkillers (NSAIDs) such as ibuprofen or naproxen — often enough for milder attacks, especially taken early.
- Triptans — migraine-specific prescription medicines that target the migraine process itself, for when NSAIDs are not enough. Several forms exist, including nasal sprays for people who vomit early in an attack.
- Anti-nausea medicines — migraine slows the stomach, so these ease nausea and help the other medicines absorb.
Resting in a dark, quiet room, a cold pack, and fluids genuinely help while medicine takes effect. What does not help is rotating through three or four different painkillers in one attack — that is how medication-overuse headaches start.
When attacks come often: prevention
If migraine steals several days a month, the goal shifts from rescue to prevention. Preventive treatment is usually considered when attacks come four or more days a month, last a long time, or respond poorly to acute medicine. Options, again in class terms, include certain blood-pressure medicines, certain anti-seizure medicines, and certain antidepressants that also calm migraine pathways — reviewed over two to three months, because preventives work gradually. Newer migraine-specific preventives exist as well and can be part of the conversation. Supplements are a smaller piece: some patients discuss magnesium or riboflavin (vitamin B2) with their clinician as an add-on — evidence is modest, they are no substitute for a real preventive plan, and "natural" products still deserve a clinician's review.
Prevention is also behavioral, and it is unglamorous because it works: regular sleep (same wake time, even on weekends — sleeping in is a classic trigger), regular meals, steady caffeine rather than weekday floods and weekend withdrawal, and a plan for known triggers. Your diary tells you which of these actually matters for you.
Hormones and migraine: the monthly pattern
Many women notice attacks clustering around a period — falling estrogen is a well-known trigger — and the same sensitivity can change migraine's character during the hormonal swings of the forties. Attacks that become more frequent, longer, or harder to treat deserve a visit that looks at the whole picture: our guide to whether this is perimenopause walks through how clinicians sort migraine changes from thyroid, iron, and other look-alikes. Note cycle timing in your diary — hormonal patterns affect treatment choices.
When we refer to neurology
Primary care manages most migraine well. We refer to a neurologist when the pattern is atypical or changes without explanation, when a first-line preventive or two has not helped, when aura involves weakness (hemiplegic migraine) or brainstem symptoms such as double vision or slurred speech, or when the presentation needs a specialist's exam or imaging. A referral is not a dismissal — your primary care clinician stays your home base and coordinates whatever the specialist recommends.
Migraine care at Evolve Health
A migraine evaluation at Evolve Health is a sick visit: $75 flat if you are self-pay — in person in Denton or by video anywhere in Texas — with the price told before you are seen. With insurance, we verify your coverage free before the visit from your insurance card, photo ID, and date of birth. We are a clinic, not insurance agents: we verify, we do not enroll or recommend plans. Migraine treatment is part of our regular practice, in English, Nepali, and Hindi.
Once your pattern is established, follow-ups are a natural fit for telehealth — diary review, preventive adjustments, and refills without the drive. Our guide to what telehealth in Texas can and can't treat explains how those visits work. The exception is a first-time or changed headache: that deserves an in-person evaluation, and a red-flag headache the emergency room.
Frequently asked questions
How do I know if my headache is a migraine?
The pattern is the clue. A migraine attack typically throbs or pulses, often on one side of the head, builds over an hour or two, and lasts 4 to 72 hours if untreated. Nausea, sensitivity to light and sound, and wanting to lie still in a dark room are classic. Some people get an aura first — flashing lights, zigzag lines, or tingling that spreads slowly and fades within the hour. Tension headaches feel like a dull band of pressure on both sides, without nausea; sinus pain centers on the face and worsens when you bend over. If your attacks keep repeating in the same pattern, a clinician can usually identify migraine from the history alone.
Can taking headache medicine too often make headaches worse?
Yes — this is called medication-overuse headache, or rebound headache, and it is one of the most common reasons migraines spiral. Using acute headache medicine on too many days each month sets up a cycle — a new headache arrives as the last dose wears off. As a general guide, taking triptans or combination painkillers on 10 or more days a month, or simple painkillers like ibuprofen or acetaminophen on 15 or more days a month, can keep the cycle going. The fix is a clinician-guided plan that usually pairs a limit on acute medicine days with a preventive treatment. Never stop a daily prescribed medicine suddenly on your own — bring your list to the visit and sort it out together.
What will the clinician actually do at a migraine visit?
Most of the visit is detective work: how often attacks come, how long they last, what triggers them, and what you have already tried. You will be asked to keep a simple headache diary — date, duration, symptoms, medicine taken — because two months of entries beat any single test for typical migraine. The clinician also checks for medication overuse, screens for red-flag symptoms, and does a basic neurological exam. Most patients leave with two plans: an acute plan for stopping an attack early, and, if attacks are frequent, a preventive plan for having fewer of them.
Do I need a brain scan or a neurologist for migraine?
Usually not. A classic migraine pattern with a normal neurological exam rarely needs imaging, and most migraine is managed well in primary care. Referral to neurology makes sense when the pattern is atypical or changes, when standard preventive treatments have not worked, when attacks come with unusual features such as weakness on one side (hemiplegic migraine) or aura symptoms from the brainstem, or when a new headache pattern starts after age 50. And some headaches skip the clinic entirely — thunderclap headache, headache with fever and a stiff neck, one after a head injury, or one with vision loss, weakness, or trouble speaking means the emergency room: call 911.
Can migraine follow-ups happen by telehealth?
Yes — once your migraine pattern is established, follow-up visits work well by video: reviewing your headache diary, adjusting preventive medicines, and refilling acute prescriptions when appropriate. Evolve Health offers telehealth visits to patients who are physically located in Texas at the time of the visit, and a self-pay video sick visit is the same $75 flat as an in-person one. A first evaluation of a new pattern is usually better in person, and any headache with red-flag symptoms — sudden worst-ever pain, weakness, vision changes, fever with a stiff neck — needs emergency care, not a video call.
How much does a migraine visit cost at Evolve Health?
A migraine evaluation is a sick visit. If you are paying out of pocket, it is $75 flat — in person at our Denton clinic or by video anywhere in Texas — and the price is told to you before you are seen. That covers the clinician exam, diagnosis, treatment plan, and prescriptions sent to your pharmacy when appropriate. If you have insurance, we verify your coverage free before the visit, using your insurance card, a photo ID, and your date of birth, so you know before you come in whether the visit is covered.
Sources
- MedlinePlus (U.S. National Library of Medicine) — Migraine (symptoms, aura, emergency care)
- National Institute of Neurological Disorders and Stroke — Migraine (phases, duration, triggers, treatment classes)
- American Migraine Foundation — Resource Library (medication-overuse headache, diaries, prevention)
General education only — not medical advice: This article explains how migraine is commonly evaluated and treated in primary care; your clinician's plan may differ. Any headache with the red-flag symptoms above needs emergency care — call 911.
Losing whole days to migraine? Let's map the pattern
Book a sick visit — $75 flat self-pay, in Denton or by video anywhere in Texas — and leave with an acute plan for the next attack and a preventive plan if attacks are frequent. Insurance? We verify your coverage free from your card, photo ID, and date of birth before your visit.