Migraine in Canada — how it's diagnosed, and the treatments a GP can start vs what needs a neurologist

You've had headaches for a while now — bad enough to stop you working, lie down in the dark, maybe feel sick with them. You've started to wonder whether this is "just headaches" or something with a name and a treatment. The good news is that recurrent, disabling headaches like these usually do have a name — migraine — and that migraine is diagnosed from the pattern of your attacks, not from an expensive scan or a long specialist queue. This article explains how doctors tell migraine apart from other headaches, when imaging is actually warranted, and the treatment ladder from what your GP can start today to what typically needs a neurologist. If your main worry is the wait to be seen, read this alongside our companion pieces on migraine specialist wait times and what to do while you wait and general neurologist wait times in Canada.

Migraine vs other headaches — how to tell them apart

The word "headache" covers several very different conditions, and getting the label right is what unlocks the right treatment. The three most common primary headache types — migraine, tension-type, and cluster — feel different and respond to different things.

Migraine

Migraine attacks are typically moderate to severe, often (though not always) one-sided and throbbing or pulsating, and characteristically worse with routine physical activity — climbing stairs, bending over, moving your head. They come with nausea and/or vomiting and sensitivity to light and sound (which is why lying in a dark, quiet room helps). Untreated, an attack lasts anywhere from 4 to 72 hours. Some people get an aura beforehand — usually visual, such as shimmering zig-zag lines, blind spots, or flashing lights, lasting 5 to 60 minutes and then fading as the headache begins. Aura affects a minority of migraine sufferers; most migraine has no aura at all.

Tension-type headache

Tension-type headaches feel different: usually mild to moderate, a pressing or tightening "band" around the head rather than a throb, on both sides, and not made worse by activity. There's usually no nausea, and at most only mild light or sound sensitivity — not both. People often carry on with their day. This is the everyday headache most of us recognise.

Cluster headache

Cluster headache is rarer and unmistakable to those who have it: excruciating, strictly one-sided pain around or behind one eye, coming in bouts (clusters) of attacks lasting 15 minutes to 3 hours, often at the same time each day or night. On the affected side the eye may go red and water and the nostril may run or block. Unlike a migraine sufferer who wants to be still in the dark, someone in a cluster attack is typically restless and paces. Cluster headache warrants prompt medical attention and specialist input.

Migraine is a clinical diagnosis — usually no scan needed

This surprises many people: in typical migraine, you do not need a CT or MRI to be diagnosed. Migraine is a clinical diagnosis — a doctor makes it by taking your history (the pattern, frequency, and features of your attacks) and finding a normal neurological examination between attacks. Imaging in a straightforward, long-standing migraine picture almost never changes the diagnosis or the plan, which is why guidelines actively discourage routine scanning.

The practical implication is liberating: you don't have to wait for a scan to start getting better. The most useful "test" you can bring to any appointment isn't imaging — it's a headache diary (more on that below), because the pattern is the diagnosis.

When imaging is warranted — red flags

Scans are reserved for headaches that don't behave like ordinary migraine. A doctor will consider a CT or MRI when there are "red flag" features, including:

• A sudden thunderclap headache that reaches maximum intensity within seconds to a minute (this is an emergency).
• Headache with fever and a stiff neck, or with a rash, suggesting infection.
• New neurological signs — weakness, numbness, persistent visual loss, confusion, difficulty speaking, or an abnormal exam.
• A new or clearly changed headache after age 50.
• Headache that is progressively worsening, or is triggered by coughing, straining, or lying down.
• New headache in someone with cancer, HIV, or a weakened immune system, or in pregnancy.

If none of these apply and your attacks fit the migraine pattern, a normal exam plus a clear history is genuinely enough to make the diagnosis and start treatment.

Chronic migraine — when attacks take over the calendar

Migraine is described by how often it strikes. Chronic migraine is defined as 15 or more headache days per month (with migraine features on at least 8 of them) for more than three months; fewer than that is called episodic migraine. The distinction matters because chronic migraine changes what treatments you qualify for — Botox and some of the newer preventives are specifically approved for chronic migraine. A frequent, unrecognised driver of the shift from episodic to chronic is medication-overuse headache, covered next.

The treatment ladder — acute and preventive

Migraine treatment has two distinct jobs, and it helps to keep them separate in your mind: acute treatment stops an attack that has already started, and preventive treatment reduces how often attacks happen in the first place.

Acute (attack) treatment

Taken at the first sign of an attack, acute options include:

• NSAIDs (such as ibuprofen or naproxen) or plain analgesics for milder attacks.
• Triptans (sumatriptan, rizatriptan, and others) — migraine-specific medications that are the mainstay for moderate-to-severe attacks. Taken early, they abort the attack for many people.
• Anti-nausea medication (an antiemetic), which both settles the nausea and helps other medication absorb.

The critical caution: avoid medication-overuse headache. Using acute medication too often — roughly 10 or more days per month for triptans or combination painkillers, or 15+ days for simple NSAIDs — can paradoxically turn occasional migraine into a daily headache. If you're reaching for acute treatment that often, it's a signal you need preventive treatment, not more painkillers.

Preventive treatment — when attacks are frequent

Prevention is considered when attacks are frequent (a common threshold is roughly four or more migraine days a month), disabling, or when acute medication isn't working or is being overused. Preventives are taken daily to make attacks less frequent and less severe — they're judged over 8 to 12 weeks, not overnight.

What your GP can start now vs what needs a neurologist

Here is the part that saves people months of waiting: most migraine can be started — and often well controlled — by your family doctor, long before a neurologist is involved.

What a GP can start

Your GP can prescribe the full range of acute treatment (including triptans and an antiemetic) and can initiate the first-line preventive medications, all of which are well within family-practice scope:

• Beta-blockers — propranolol, metoprolol (also helpful if you have high blood pressure).
• Candesartan — a blood-pressure medication with good evidence in migraine prevention.
• Amitriptyline — a low-dose tricyclic, especially useful if you also have poor sleep or coexisting tension-type headache.
• Topiramate — an anti-seizure medication with strong migraine-prevention evidence.

A GP will usually try one first-line preventive at an adequate dose for 8 to 12 weeks, and if it doesn't help enough or isn't tolerated, switch to another. Going through two or three of these properly is the expected path — and it's a path your family doctor can walk with you.

What typically needs a neurologist or special authority

The newer, more advanced treatments generally sit at the specialist level, both clinically and because provincial drug plans usually require special-authority approval that documents first-line preventives were tried first:

• CGRP monoclonal antibodies — erenumab, galcanezumab, and fremanezumab. These injectable, migraine-specific preventives are typically reserved for people who've failed multiple first-line preventives, and are usually specialist-initiated with special-authority coverage.
• Gepants — oral CGRP-receptor blockers used for acute treatment and, for some, prevention. Access and coverage often route through a specialist.
• Botox (onabotulinumtoxinA) — approved specifically for chronic migraine (15+ headache days a month), delivered as a series of injections, and generally initiated by a neurologist or headache specialist after first-line preventives have failed.

So the honest map is this: your GP can and should start the acute triptans and the first-line preventives now; the neurologist's role is to confirm the diagnosis when it's uncertain, and to open the door to CGRP therapies, gepants, and Botox once the first-line ladder has been climbed.

The South Asian angle — access and expertise

For many South Asian Canadians, the barrier isn't recognising the problem — it's access. Long specialist waits, time off work, and sometimes a cultural tendency to "push through" pain mean migraine goes under-treated for years. It's worth knowing that neurology is a deep strength of Indian academic medicine: institutions like PGIMER Chandigarh and AIIMS run large, high-volume headache and neurology services, and their neurologists manage migraine to the same international standards used in Canada. For patients whose families are treated at these very hospitals back home, that expertise is both familiar and trusted — and now accessible without leaving Canada.

How a specialist opinion from Ginie Health works

If you're unsure whether your headaches are migraine, or you've been on a first-line preventive that isn't working and you want to know what to push for next, a written specialist opinion can give you clarity now rather than in six months. You upload your headache diary and history and describe your attacks. Within 6 hours, for $45 CAD, you receive a written clinical opinion from a neurologist trained at PGIMER or AIIMS. It tells you whether your pattern fits migraine, which acute and preventive treatments are appropriate to start, and exactly what to say to your GP — or when it's genuinely time to push for a neurology referral for CGRP therapy or Botox. It doesn't replace your Canadian care; it makes every appointment count. If you'd rather talk it through, a live video consultation is available for $75 CAD. No referral needed for either.