Confirm migraine before escalating treatment
Charité and Heidelberg both emphasize diagnostic classification of headache and facial-pain disorders. Migraine can coexist with tension-type headache, medication-overuse headache or other neurological conditions, while secondary headache requires a different work-up. Additional imaging or testing should be driven by the history, examination and red flags rather than ordered automatically for every migraine patient.
- Age at onset and evolution of the headache pattern
- Attack frequency, duration and associated symptoms
- Aura or focal neurological symptoms
- Triggers and menstrual or hormonal pattern when relevant
- Neurological examination
- Review of previous MRI/CT or other testing when already performed
A headache diary makes treatment decisions more objective
Before a specialist second opinion, document headache days, migraine days and days using acute medication. This helps distinguish episodic from chronic migraine, identify medication overuse and measure whether preventive treatment is actually reducing burden over time.
Acute treatment should be reviewed before simply adding more prevention
Charité’s Headache Center explicitly includes optimisation of acute treatment and prevention while considering adverse effects. The review should cover what the patient takes at the beginning of an attack, timing, response, recurrence, contraindications and the number of medication days per month.
Preventive treatment is individualized
Preventive therapy is considered according to migraine frequency, disability, attack severity, comorbidity and previous treatment response. The goal is not necessarily zero headaches but a meaningful reduction in attack burden, acute-medication use and disruption of work or daily life. A German headache-center review is particularly useful after several adequately tried preventive options have failed or caused unacceptable adverse effects.
CGRP-targeted therapy is a specialist option for selected patients
Charité documents treatment of migraine with CGRP or CGRP-receptor antibodies. These are preventive therapies rather than rescue treatment for a single attack. Eligibility, previous preventive-treatment history, contraindications, expected benefit and the plan for assessing response should be reviewed before starting a recurring treatment pathway.
Botulinum toxin is used for chronic migraine, not every migraine pattern
Charité, Freiburg and Heidelberg all document botulinum-toxin treatment for chronic migraine. This is a repeated preventive procedure rather than a one-time cure. Freiburg describes regular outpatient treatment intervals, and specialist assessment should first confirm that the headache pattern meets the chronic-migraine pathway and address medication overuse when present.
Medication overuse can maintain chronic headache
Charité offers intensified outpatient treatment for chronic headache, chronic migraine and medication overuse, while Freiburg separately describes medication-induced headache. A useful review therefore counts acute-medication days and distinguishes necessary rescue treatment from a pattern that may be perpetuating headache frequency.
What to send for a German migraine second opinion
A concise treatment history is often more useful than a long list of drug names without dose, duration or response.
- Headache diary covering at least several recent weeks when possible
- Headache days, migraine days and acute-medication days per month
- List of previous acute medicines with response and adverse effects
- List of preventive medicines with dose, duration and reason for stopping
- History of CGRP therapy or botulinum toxin if already tried
- Relevant MRI/CT reports and images if performed
- Other neurological, cardiovascular, psychiatric and pregnancy-related history relevant to treatment selection
- A specific question: confirm diagnosis, reduce attack burden, review medication overuse, assess CGRP therapy or assess chronic-migraine Botox
Official sources
Sources last checked 2026-09-01. Clinical pathways, eligibility and hospital procedures can change; confirm current requirements directly with the treating center.