Migraine

What is Migraine?

A migraine is a headache that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with your daily activities.

For some people, a warning symptom known as an aura occurs before or with the headache. An aura can include visual disturbances, such as flashes of light or blind spots, or other disturbances, such as tingling on one side of the face or in an arm or leg and difficulty speaking.

Medications can help prevent some migraines and make them less painful. The right medicines, combined with self-help remedies and lifestyle changes, might help.

Before Migraine Treatment

Symptoms

What are the symptoms of migraines?

The primary symptom of migraine is a headache. Pain is sometimes described as pounding or throbbing. It can begin as a dull ache that develops into pulsing pain that is mild, moderate or severe. If left untreated, your headache pain will become moderate to severe. Pain can shift from one side of your head to the other, or it can affect the front of your head, the back of your head or feel like it’s affecting your whole head. Some people feel pain around their eye or temple, and sometimes in their face, sinuses, jaw or neck.

Other symptoms of migraine headaches include:

. Sensitivity to light, noise and odors.

. Nausea and vomiting, upset stomach and abdominal pain.

. Loss of appetite.

. Feeling very warm (sweating) or cold (chills).

. Pale skin color (pallor).

. Feeling tired.

. Dizziness and blurred vision.

. Tender scalp.

. Diarrhea (rare).

. Fever (rare).

Most migraines last about four hours, although severe ones can last much longer.

Each phase of the migraine attack can come with different symptoms:

Prodrome symptoms:

. Problems concentrating.

. Irritability and/or depression.

. Difficulty speaking and reading.

. Difficulty sleeping. Yawning.

. Nausea.

. Fatigue.

. Sensitivity to light and sound.

. Food cravings.

. Increased urination.

. Muscle stiffness.

Aura symptoms:

. Numbness and tingling.

. Visual disturbances. You might be seeing the world as if through a kaleidoscope, have blurry spots or see sparkles or lines.

. Temporary loss of sight.

. Weakness on one side of the body.

. Speech changes.

Headache symptoms:

. Neck pain, stiffness.

. Depression, giddiness and/or anxiety.

. Sensitivity to light, smell and sound.

. Nasal congestion.

. Insomnia.

. Nausea and vomiting.

Postdrome symptoms:

. Inability to concentrate.

. Depressed mood.

. Fatigue.

. Lack of comprehension.

. Euphoric mood.

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When to see a doctor

Migraines are often undiagnosed and untreated. If you regularly have signs and symptoms of migraine, keep a record of your attacks and how you treated them. Then make an appointment with your doctor to discuss your headaches.

Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.

See your doctor immediately or go to the emergency room if you have any of the following signs and symptoms, which could indicate a more serious medical problem:

. An abrupt, severe headache like a thunderclap

. Headache with fever, stiff neck, confusion, seizures, double vision, numbness or weakness in any part of the body, which could be a sign of a stroke

. Headache after a head injury

. A chronic headache that is worse after coughing, exertion, straining or a sudden movement

. New headache pain after age 50

Causes

Though migraine causes aren't fully understood, genetics and environmental factors appear to play a role.

Changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway, might be involved. So might imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system.

Researchers are studying the role of serotonin in migraines. Other neurotransmitters play a role in the pain of migraine, including calcitonin gene-related peptide (CGRP).

Migraine triggers

What triggers a migraine?

There are a number of migraine triggers, including:

. Hormonal changes in women. Fluctuations in estrogen, such as before or during menstrual periods, pregnancy and menopause, seem to trigger headaches in many women.

Hormonal medications, such as oral contraceptives, also can worsen migraines. Some women, however, find that their migraines occur less often when taking these medications.

. Drinks. These include alcohol, especially wine, and too much caffeine, such as coffee.

. Stress. Stress at work or home can cause migraines.

. Sensory stimuli. Bright or flashing lights can induce migraines, as can loud sounds. Strong smells — such as perfume, paint thinner, secondhand smoke and others — trigger migraines in some people.

. Sleep changes. Missing sleep or getting too much sleep can trigger migraines in some people.

. Physical factors. Intense physical exertion, including sexual activity, might provoke migraines.

. Weather changes. A change of weather or barometric pressure can prompt a migraine.

. Medications. Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines.

. Foods. Aged cheeses and salty and processed foods might trigger migraines. So might skipping meals.

. Food additives. These include the sweetener aspartame and the preservative monosodium glutamate (MSG), found in many foods.

Risk factors

Several factors make you more prone to having migraines, including:

. Family history. If you have a family member with migraines, then you have a good chance of developing them too.

. Age. Migraines can begin at any age, though the first often occurs during adolescence. Migraines tend to peak during your 30s, and gradually become less severe and less frequent in the following decades.

. Sex. Women are three times more likely than men to have migraines.

. Hormonal changes. For women who have migraines, headaches might begin just before or shortly after onset of menstruation. They might also change during pregnancy or menopause. Migraines generally improve after menopause.

Complications

Taking painkillers too often can trigger serious medication-overuse headaches. The risk seems to be highest with aspirin, acetaminophen and caffeine combinations. Overuse headaches may also occur if you take aspirin or ibuprofen (Advil, Motrin IB, others) for more than 14 days a month or triptans, sumatriptan (Imitrex, Tosymra) or rizatriptan (Maxalt, Maxalt-MLT) for more than nine days a month.

Medication-overuse headaches occur when medications stop relieving pain and begin to cause headaches. You then use more pain medication, which continues the cycle.

Diagnosis

If you have migraines or a family history of migraines, a doctor trained in treating headaches (neurologist) will likely diagnose migraines based on your medical history, symptoms, and a physical and neurological examination.

If your condition is unusual, complex or suddenly becomes severe, tests to rule out other causes for your pain might include:

. Magnetic resonance imaging (MRI). An MRI scan uses a powerful magnetic field and radio waves to produce detailed images of the brain and blood vessels. MRI scans help doctors diagnose tumors, strokes, bleeding in the brain, infections, and other brain and nervous system (neurological) conditions.

. Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed cross-sectional images of the brain. This helps doctors diagnose tumors, infections, brain damage, bleeding in the brain and other possible medical problems that may be causing headaches.

Are migraines hereditary?

Migraines tend to run in families. As many as four out of five people with migraines have a family history. If one parent has a history of migraines, their child has a 50% chance of having them. If both parents have a history of migraines, the risk jumps to 75%. Again, up to 80% of people with migraines have a first-degree relative with the disease.

During Migraine Treatment

What are the four stages or phases of a migraine? What’s the timeline?

The four stages in chronological order are the prodrome (pre-monitory), aura, headache and postdrome. About 30% of people experience symptoms before their headache starts.

The phases are:

. Prodrome: The first stage lasts a few hours, or it can last days. You may or may not experience it as it may not happen every time. Some know it as the “preheadache” or “premonitory” phase.

. Aura: The aura phase can last as long as 60 minutes or as little as five. Most people don’t experience an aura, and some have both the aura and the headache at the same time.

. Headache: About four hours to 72 hours is how long the headache lasts. The word “ache” doesn’t do the pain justice because sometimes it’s mild, but usually, it’s described as drilling, throbbing or you may feel the sensation of an icepick in your head. Typically it starts on one side of your head and then spreads to the other side.

. Postdrome: The postdrome stage goes on for a day or two. It’s often called a migraine “hangover” and 80% of those who have migraines experience it.

It can take about eight to 72 hours to go through the four stages.

What are the types of migraines?

There are several types of migraines, and the same type may go by different names:

. Migraine with aura (complicated migraine): Around 15% to 20% of people with migraine headaches experience an aura.

. Migraine without aura (common migraine): This type of migraine headache strikes without the warning an aura may give you. The symptoms are the same, but that phase doesn’t happen.

. Migraine without head pain: “Silent migraine” or “acephalgic migraine,” as this type is also known as, includes the aura symptom but not the headache that typically follows.

. Hemiplegic migraine: You'll have temporary paralysis (hemiplegia) or neurological or sensory changes on one side of your body. The onset of the headache may be associated with temporary numbness, extreme weakness on one side of your body, a tingling sensation, a loss of sensation and dizziness or vision changes. Sometimes it includes head pain and sometimes it doesn’t.

. Retinal migraine (ocular migraine): You may notice temporary, partial or complete loss of vision in one of your eyes, along with a dull ache behind the eye that may spread to the rest of your head. That vision loss may last a minute, or as long as months. You should always report a retinal migraine to a healthcare provider because it could be a sign of a more serious issue.

. Chronic migraine: A chronic migraine is when a migraine occurs at least 15 days per month. The symptoms may change frequently, and so may the severity of the pain. Those who get chronic migraines might be using headache pain medications more than 10 to 15 days a month and that, unfortunately, can lead to headaches that happen even more frequently.

. Migraine with brainstem aura. With this migraine, you'll have vertigo, slurred speech, double vision or loss of balance, which occur before the headache. The headache pain may affect the back of your head. These symptoms usually occur suddenly and can be associated with the inability to speak properly, ringing in the ears and vomiting.

. Status migrainosus. This is a rare and severe type of migraine that can last longer than 72 hours. The headache pain and nausea can be extremely bad. Certain medications, or medication withdrawal, can cause you to have this type of migraine.

Treatment

Migraine treatment is aimed at stopping symptoms and preventing future attacks.

Many medications have been designed to treat migraines. Medications used to combat migraines fall into two broad categories:

. Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms.

. Preventive medications. These types of drugs are taken regularly, often daily, to reduce the severity or frequency of migraines.

Your treatment choices depend on the frequency and severity of your headaches, whether you have nausea and vomiting with your headaches, how disabling your headaches are, and other medical conditions you have.

Medications for relief

Medications used to relieve migraine pain work best when taken at the first sign of an oncoming migraine — as soon as signs and symptoms of a migraine begin. Medications that can be used to treat it include:

. Pain relievers. These over-the-counter or prescription pain relievers include aspirin or ibuprofen (Advil, Motrin IB, others). When taken too long, these might cause medication-overuse headaches, and possibly ulcers and bleeding in the gastrointestinal tract.

Migraine relief medications that combine caffeine, aspirin and acetaminophen (Excedrin Migraine) may be helpful, but usually only against mild migraine pain.

. Triptans. Prescription drugs such as sumatriptan (Imitrex, Tosymra) and rizatriptan (Maxalt, Maxalt-MLT) are used to treat migraine because they block pain pathways in the brain. Taken as pills, shots or nasal sprays, they can relieve many symptoms of migraine. They might not be safe for those at risk of a stroke or heart attack.

. Dihydroergotamine (D.H.E. 45, Migranal). Available as a nasal spray or injection, this drug is most effective when taken shortly after the start of migraine symptoms for migraines that tend to last longer than 24 hours. Side effects can include worsening of migraine-related vomiting and nausea.

People with coronary artery disease, high blood pressure, or kidney or liver disease should avoid dihydroergotamine.

. Lasmiditan (Reyvow). This newer oral tablet is approved for the treatment of migraine with or without aura. In drug trials, lasmiditan significantly improved headache pain. Lasmiditan can have a sedative effect and cause dizziness, so people taking it are advised not to drive or operate machinery for at least eight hours.

. Ubrogepant (Ubrelvy). This oral calcitonin gene-related peptide receptor antagonist is approved for the treatment of acute migraine with or without aura in adults. It's the first drug of this type approved for migraine treatment. In drug trials, ubrogepant was more effective than placebo in relieving pain and other migraine symptoms such as nausea and sensitivity to light and sound two hours after taking it. Common side effects include dry mouth, nausea and excessive sleepiness. Ubrogepant should not be taken with strong CYP3A4 inhibitor drugs.

. CGRP antagonists. Ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) are oral CGRP antagonists recently approved for the treatment of acute migraine with or without aura in adults. In drug trials, drugs from this class were more effective than placebo in relieving pain and other migraine symptoms such as nausea and sensitivity to light and sound two hours after taking it. Common side effects include dry mouth, nausea and excessive sleepiness. Ubrogepant and rimegepant should not be taken with strong CYP3A4 inhibitor drugs.

. Opioid medications. For people who can't take other migraine medications, narcotic opioid medications might help. Because they can be highly addictive, these are usually used only if no other treatments are effective.

. Anti-nausea drugs. These can help if your migraine with aura is accompanied by nausea and vomiting. Anti-nausea drugs include chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro). These are usually taken with pain medications.

Some of these medications are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medications without first talking with your doctor.

Preventive medications

Medications can help prevent frequent migraines. Your doctor might recommend preventive medications if you have frequent, long-lasting or severe headaches that don't respond well to treatment.

Preventive medication is aimed at reducing how often you get a migraine, how severe the attacks are and how long they last. Options include:

. Blood pressure-lowering medications. These include beta blockers such as propranolol (Inderal, InnoPran XL, others) and metoprolol tartrate (Lopressor). Calcium channel blockers such as verapamil (Verelan) can be helpful in preventing migraines with aura.

. Antidepressants. A tricyclic antidepressant (amitriptyline) can prevent migraines. Because of the side effects of amitriptyline, such as sleepiness, other antidepressants might be prescribed instead.

. Anti-seizure drugs. Valproate and topiramate (Topamax, Qudexy XR, others) might help if you have less frequent migraines, but can cause side effects such as dizziness, weight changes, nausea and more. These medications are not recommended for pregnant women or women trying to get pregnant.

. Botox injections. Injections of onabotulinumtoxinA (Botox) about every 12 weeks help prevent migraines in some adults.

. CGRP monoclonal antibodies. Erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), galcanezumab-gnlm (Emgality), and eptinezumab-jjmr (Vyepti) are newer drugs approved by the Food and Drug Administration to treat migraines. They're given monthly or quarterly by injection. The most common side effect is a reaction at the injection site.

Ask your doctor if these medications are right for you. Some of these medications are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medications without first talking with your doctor.

Are there surgical procedures that relieve migraines?

Surgical treatments are not generally recommended for migraine headaches.

What are the treatment options for migraine headaches during pregnancy?

Avoid medications for migraines when you’re pregnant, or if you think you may be pregnant. They can negatively affect your baby. With your healthcare provider’s permission, you may be able to take a mild pain reliever like acetaminophen.

Lifestyle and home remedies

When symptoms of migraine start, try heading to a quiet, darkened room. Close your eyes and rest or take a nap. Place a cool cloth or ice pack wrapped in a towel or cloth on your forehead and drink lots of water.

These practices might also soothe migraine pain:

. Try relaxation techniques. Biofeedback and other forms of relaxation training teach you ways to deal with stressful situations, which might help reduce the number of migraines you have.

. Develop a sleeping and eating routine. Don't sleep too much or too little. Set and follow a consistent sleep and wake schedule daily. Try to eat meals at the same time every day.

. Drink plenty of fluids. Staying hydrated, particularly with water, might help.

. Keep a headache diary. Recording your symptoms in a headache diary will help you learn more about what triggers your migraines and what treatment is most effective. It will also help your doctor diagnose your condition and track your progress in between visits.

. Exercise regularly. Regular aerobic exercise reduces tension and can help prevent a migraine. If your doctor agrees, choose aerobic activity you enjoy, such as walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches.

Regular exercise can also help you lose weight or maintain a healthy body weight, and obesity is thought to be a factor in migraines.

Alternative medicine

Nontraditional therapies might help with chronic migraine pain.

. Acupuncture. Clinical trials have found that acupuncture may be helpful for headache pain. In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin at defined points.

. Biofeedback. Biofeedback appears to be effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses related to stress, such as muscle tension.

. Cognitive behavioral therapy. Cognitive behavioral therapy may benefit some people with migraines. This type of psychotherapy teaches you how behaviors and thoughts affect how you perceive pain.

. Meditation and yoga. Meditation may relieve stress, which is a known trigger of migraines. Done on a regular basis, yoga may reduce the frequency and duration of migraines.

. Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur might prevent migraines or reduce their severity, though study results are mixed. Butterbur isn't recommended because of safety concerns.

A high dose of riboflavin (vitamin B-2) may reduce the frequency and severity of headaches. Coenzyme Q10 supplements might decrease the frequency of migraines, but larger studies are needed.

Magnesium supplements have been used to treat migraines, but with mixed results.

Ask your doctor if these treatments are right for you. If you're pregnant, don't use any of these treatments without first talking with your doctor.

After Migraine Treatment

What is the prognosis (outlook) for people with migraines?

Migraines are unique to each individual. Likewise, how migraines are managed is also unique. The best outcomes are usually achieved by learning and avoiding personal migraine triggers, managing symptoms, practicing preventive methods, following the advice of your healthcare provider and reporting any significant changes as soon as they occur.

Is there a cure for migraines?

Although there isn’t a cure, there are treatments that may help you manage the symptoms.

How long will I have migraine headaches?

You may experience migraine headaches for the rest of your life. If your migraines are caused by your period, you may stop having them when menopause starts.

Sources:

. https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201

. https://my.clevelandclinic.org/health/diseases/5005-migraine-headaches