As opposed to the common, genetically complex types of migraine, there are a few rare monogenic migraine variants. The prototype is familial hemiplegic migraine (FHM), a severe subtype of migraine with aura, for which three causative genes (FHM1–3), all of which are involved in ion translocation in the CNS, have been identified. This review summarizes the current knowledge about the clinical symptomatology, (differential) diagnosis, treatment, genetics, and pathophysiology of FHM. Clinically and genetically overlapping disorders, such as episodic ataxia type 2 (EA-2), spinocerebellar ataxia type 6 (SCA-6) and alternating hemiplegia of childhood (AHC) are briefly discussed, and novel genes which have been occasionally associated with HM or migraine are critically evaluated. Finally, monogenic (vascular) syndromes, in which migraine is part of the phenotypic spectrum, are discussed.