Condition · ICD-11 8A80
Migraine
Reviewed by Dr. Placeholder D (HPCSA MP0XXXXX · Neurology) · Last updated · Published
Migraine is a primary headache disorder characterised by recurrent moderate-to-severe headaches, often unilateral and pulsatile, frequently with nausea, photophobia, or phonophobia. Most patients respond adequately to standard care — acute triptans plus a preventive (propranolol, topiramate, amitriptyline, or a CGRP inhibitor in chronic migraine). Cannabinoids are sometimes considered for chronic migraine (≥15 headache days per month) where multiple preventive classes have failed or caused intolerable side effects. They are not first-line, not second-line, and are unlikely to be appropriate for patients who have not yet had a structured neurology workup.
What the evidence says
Cuttler et al (2020) analysed app-based real-world data from over 1,300 patients reporting headache or migraine and found cannabis reduced acute headache and migraine ratings by approximately 47% and 49% respectively — though without placebo control. Lochte et al (2017) reviewed the existing pre-clinical and small clinical evidence and concluded the case for further controlled trials is reasonable but not yet conclusive. American Headache Society guidance does not endorse cannabinoids as standard therapy. The honest summary: real-world signal is consistent, but the controlled-trial evidence base remains thin, and doctors generally limit Section 21 cannabinoid prescribing to refractory chronic-migraine cases under specialist input.
How the doctor will evaluate you
You will need a current neurology assessment with a confirmed migraine diagnosis (preferably distinguished from medication-overuse headache, which is treated differently), a 3-month headache diary documenting frequency and severity, a list of all preventives tried with reasons for discontinuation, and a record of acute-medication usage. The doctor will look explicitly for medication-overuse headache before considering cannabinoid therapy — adding a daily cannabinoid to chronic over-use of triptans or NSAIDs typically worsens the rebound pattern. A balanced or CBD-leaning oil with conservative dosing is the usual starting point; THC-heavy formulations may aggravate migraine in some patients.
When to see a doctor urgently
- Medication-overuse headache (acute analgesic use ≥10–15 days/month) — treat the over-use first
- Sudden change in headache pattern, focal neurological signs, or "thunderclap" onset — neurology referral, not cannabinoid initiation
- Pregnancy or pregnancy planning — cannabinoid therapy is deferred
- Active psychotic illness or strong family history — THC components are unsuitable
If any of the above apply, seek in-person medical care — do not wait for a remote Section 21 consultation.
The South African Section 21 pathway
Refractory chronic migraine is reviewed under the SA Section 21 pathway, typically requiring documented failure of at least two preventive classes and ideally specialist (neurology) involvement. SAHPRA applications are stronger when accompanied by a recent headache-diary summary and a clear statement that medication-overuse headache has been excluded. Authorisations are time-limited; renewal hinges on documented frequency reduction or functional improvement, not just symptom self-report.
Frequently asked
- Will medical cannabis replace my triptans?
- No — acute triptans for breakthrough attacks usually remain in place. The cannabinoid trial is preventive, aimed at reducing attack frequency over weeks to months. If frequency does drop, triptan use naturally falls; the doctor does not stop them outright.
- Can it cause headaches?
- Yes, in some patients THC-heavy formulations can trigger or worsen migraine, particularly during titration or at higher doses. The doctor will start low and may pivot to a CBD-leaning regimen if THC consistently triggers attacks. Honest reporting of attack patterns during the trial is essential.
- How long is a fair trial for chronic migraine?
- Typically 8–12 weeks of stable dosing. Migraine prevention takes time to assess because the natural attack frequency varies week to week. The doctor will compare a 4-week pre-treatment headache-diary baseline against 4 weeks at stable cannabinoid dosing — measurable reduction is the threshold for continuing.
- Should I keep my preventive (e.g. propranolol or topiramate) running?
- Almost certainly yes during the trial. The cannabinoid is added on top — not in place of — your existing preventive. Only after the cannabinoid effect is established and stable will the doctor consider tapering an existing preventive, and that decision is made jointly with your neurologist.
- Can I use it as an acute attack abortive?
- Generally no. Cannabinoid prescribing for migraine is preventive — daily or scheduled dosing aimed at reducing attack frequency over weeks. Aborting an acute migraine still relies on triptans, NSAIDs, or anti-emetics. Inhaled cannabis is sometimes reported by patients as helping acute attacks, but this is outside the typical Section 21 framework.
Related conditions
Glossary — terms used on this page
Quick definitions for terminology referenced above. Each links to a fuller entry.
- THC (Δ⁹-tetrahydrocannabinol)The principal psychoactive cannabinoid in the cannabis plant.
- CBD (cannabidiol)Non-psychoactive cannabinoid with established use in some seizure disorders and emerging use in anxiety.
- CYP3A4Most abundant hepatic CYP450 isoform; affected by both THC and CBD.
- Dosage titrationGradual stepwise dose-adjustment to find the minimum effective dose with tolerable side effects.
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