Definition of Migraine
A migraine headache can cause intense throbbing or a pulsing sensation in one area of the head and is commonly accompanied by nausea, vomiting, and extreme sensitivity to light and sound.
Migraine attacks can cause significant pain for hours to days and be so severe that all you can think about is finding a dark, quiet place to lie down.
Some migraines are preceded or accompanied by sensory warning symptoms (aura), such as flashes of light, blind spots, or tingling in your arm or leg.
Medications can help reduce the frequency and severity of migraines. If treatment hasn’t worked for you in the past, talk to your doctor about trying a different migraine headache medication. The right medicines, combined with self-help remedies and lifestyle changes, may make a big difference.
Symptoms of Migraine
Migraine headaches often begin in childhood, adolescence or early adulthood. Migraines may progress through four stages, including prodrome, aura, headache and postdrome, though you may not experience all the stages.
One or two days before a migraine, you may notice subtle changes that signify an oncoming migraine, including:
- Food cravings
- Neck stiffness
- Uncontrollable yawning
Aura may occur before or during migraine headaches. Auras are nervous system symptoms that are usually visual disturbances, such as flashes of light. Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Most people experience migraine headaches without aura. Each of these symptoms usually begins gradually, builds up over several minutes, and then commonly lasts for 20 to 60 minutes. Examples of aura include:
- Visual phenomena, such as seeing various shapes, bright spots or flashes of light
- Vision loss
- Pins and needles sensations in an arm or leg
- Speech or language problems (aphasia)
Less commonly, an aura may be associated with limb weakness (hemiplegic migraine).
When untreated, a migraine usually lasts from four to 72 hours, but the frequency with which headaches occur varies from person to person. You may have migraines several times a month or much less often. During a migraine, you may experience the following symptoms:
- Pain on one side or both sides of your head
- Pain that has a pulsating, throbbing quality
- Sensitivity to light, sounds and sometimes smells
- Nausea and vomiting
- Blurred vision
- Lightheadedness, sometimes followed by fainting
The final phase, known as postdrome, occurs after a migraine attack. During this time you may feel drained and washed out, though some people report feeling mildly euphoric.
When to see a doctor
Migraine headaches are often undiagnosed and untreated. If you regularly experience signs and symptoms of migraine attacks, 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 may indicate other, more serious medical problems:
- An abrupt, severe headache like a thunderclap
- Headache with fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or trouble speaking
- Headache after a head injury, especially if the headache gets worse
- A chronic headache that is worse after coughing, exertion, straining or a sudden movement
- New headache pain if you’re older than 50
Although much about the cause of migraines isn’t understood, genetics and environmental factors appear to play a role.
Migraines may be caused by changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway.
Imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system — also may be involved. Researchers continue to study the role of serotonin in migraines.
Serotonin levels drop during migraine attacks. This may cause your trigeminal system to release substances called neuropeptides, which travel to your brain’s outer covering (meninges). The result is headache pain.
Migraine headache triggers
Whatever the exact mechanism of the headaches, a number of things may trigger them. Common migraine triggers include:
- Hormonal changes in women. Fluctuations in estrogen seem to trigger headaches in many women with known migraines. Women with a history of migraines often report headaches immediately before or during their periods, when they have a major drop in estrogen.
Others have an increased tendency to develop migraines during pregnancy or menopause.
Hormonal medications, such as oral contraceptives and hormone replacement therapy, also may worsen migraines. Some women, however, may find their migraines occur less often when taking these medications.
- Foods. Aged cheeses, salty foods and processed foods may trigger migraines. Skipping meals or fasting also can trigger attacks.
- Food additives. The sweetener aspartame and the preservative monosodium glutamate, found in many foods, may trigger migraines.
- Drinks. Alcohol, especially wine, and highly caffeinated beverages may trigger migraines.
- Stress. Stress at work or home can cause migraines.
- Sensory stimuli. Bright lights and sun glare can induce migraines, as can loud sounds. Unusual smells — including perfume, paint thinner, secondhand smoke and others — can trigger migraines in some people.
- Changes in wake-sleep pattern. Missing sleep or getting too much sleep may trigger migraines in some people, as can jet lag.
- Physical factors. Intense physical exertion, including sexual activity, may provoke migraines.
- Changes in the environment. A change of weather or barometric pressure can prompt a migraine.
- Medications. Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines.
Several factors make you more prone to having migraines.
- Family history. Up to 90 percent of people with migraines have a family history of migraine attacks. If one or both of your parents have migraines, then you have a good chance of having migraines too.
- Age. Migraines can begin at any age, though most people experience their first migraine during adolescence. By age 40, most people who have migraines have had their first attack.
- Sex. Women are three times more likely to have migraines. Headaches tend to affect boys more than girls during childhood, but by the time of puberty and beyond, more girls are affected.
- Hormonal changes. If you’re a woman who has migraines, you may find that your headaches begin just before or shortly after onset of menstruation.
They may also change during pregnancy or menopause. Generally migraines improve after menopause.
Some women report that migraine attacks begin during pregnancy, or the attacks may get worse. However, for many, the attacks improved or didn’t occur during later stages in the pregnancy.
Complications of Migraine
Sometimes your efforts to control your pain cause problems.
- Abdominal problems. Certain pain relievers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others), may cause abdominal pain, bleeding, ulcers and other complications, especially if taken in large doses or for a long period of time.
- Medication-overuse headaches. If you take over-the-counter or prescription headache medications more than 10 days a month for three months, or in high doses, you may be setting yourself up for a serious complication known as medication-overuse headaches.
Medication-overuse headaches occur when medications not only stop relieving pain but also cause headaches. You then use more pain medication, which continues the cycle.
- Serotonin syndrome. Serotonin syndrome is a rare, potentially life-threatening condition that occurs when your body has too much serotonin, which is a chemical found in your nervous system. It may occur if you take migraine medications called triptans and antidepressants known as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs).
These medications naturally raise serotonin levels. When combined, they cause increased serotonin levels in your system, more than if you were taking one of these medications.
Triptans include medications such as sumatriptan (Imitrex) or zolmitriptan (Zomig). Some common SSRIs include sertraline (Zoloft), fluoxetine (Sarafem, Prozac) and paroxetine (Paxil). SNRIs include duloxetine (Cymbalta) and venlafaxine (Effexor XR).
Also, some people experience complications from migraines such as:
- Chronic migraine. If your migraine lasted for 15 or more days a month for more than three months, you had a chronic migraine.
- Status migrainosus. People with this complication have migraine attacks that last for more than three days.
- Persistent aura without infarction. Usually an aura goes away after the migraine attack. However, some people have an aura that lasts for more than one week after a migraine attack has finished. A prolonged aura may have similar symptoms to bleeding in the brain (stroke). In this condition, though, you have a prolonged aura without signs of bleeding in the brain or other problems.
- Migrainous infarction. Some people who have a migraine with aura may have aura symptoms that last longer than one hour. This can be a sign of bleeding in the brain (stroke). If you have a migraine with aura, and your aura symptoms last longer than one hour, you should have it evaluated. Doctors can conduct neuroimaging tests to determine if you have bleeding in the brain.
Preparing for your appointment
You’re likely to start by seeing your primary care provider, but you may be referred to a doctor trained in evaluating and treating headaches (neurologist).
Because appointments can be brief, and because there’s often a lot to talk about, it’s a good idea to be well prepared for your appointment. Here’s some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
- Write down symptoms you’re experiencing, even if they seem unrelated to your migraines.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, vitamins or supplements that you’re taking. It’s particularly important to list all medications, as well as the dosages you have used to treat your headaches.
- Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important, in case time runs out. For migraine headaches, some basic questions to ask your doctor include:
- What is likely triggering my migraine headaches?
- Are there other possible causes for my symptoms?
- What kinds of tests do I need?
- Is my condition likely temporary or chronic?
- What is the best course of action?
- What are the alternatives to the primary approach that you’re suggesting?
- What changes to my lifestyle or diet do you suggest I make?
- I have these other health conditions. How can I best manage them together?
- Is there a generic alternative to the medicine you’re prescribing for me?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend?
In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
- When did you first begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
- Has anyone in your family experienced migraines?
What you can do in the meantime
- Keep a headache diary. A diary can help you and your doctor determine what triggers your migraines. Note when your headaches start, how long they last and what, if anything, provides relief.
Be sure to record your response to any headache medications you take. Also note the foods you ate in the 24 hours preceding attacks, any unusual stress, and how you feel and what you’re doing when headaches strike.
- Reduce stress. Because stress triggers migraines for many people, try to avoid overly stressful situations, or use stress-reduction techniques like meditation.
- Get enough sleep. Aim for a regular sleep schedule and get an adequate amount of sleep.
Tests and diagnosis
If you have migraines or a family history of migraine headaches, your doctor trained in treating headaches (neurologist) will likely diagnose the condition on the basis of your medical history, a review of your symptoms, and a physical and neurological examination.
Your doctor may also recommend a variety of tests to rule out other possible causes for your pain if your condition is unusual, complex or suddenly becomes severe.
- Blood tests. Your doctor may order blood tests to test for blood vessel problems, infections in your spinal cord or brain, and toxins in your system.
- Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed cross-sectional images of your brain. This helps doctors diagnose tumors, infections, brain damage, bleeding in your brain and other possible medical problems that may be causing your headaches.
- Magnetic resonance imaging (MRI). An MRI uses a powerful magnetic field and radio waves to produce detailed images of your brain and blood vessels.
MRI scans help doctors diagnose tumors, strokes, bleeding in your brain, infections, and other brain and nervous system (neurological) conditions.
- Spinal tap (lumbar puncture). If your doctor suspects an underlying condition, such as infections or bleeding in your brain, he or she may recommend a spinal tap (lumbar puncture).
In this procedure, a thin needle is inserted between two vertebrae in your lower back to extract a sample of cerebrospinal fluid for laboratory analysis.
Treatments and drugs
Migraines can’t be cured, but doctors will work with you to help you manage your condition.
A variety of medications have been specifically designed to treat migraines. In addition, some drugs commonly used to treat other conditions also may help relieve or prevent 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 that have already begun.
- Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.
Choosing a strategy to manage your migraines depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions.
Some medications aren’t recommended if you’re pregnant or breast-feeding. Some medications aren’t given to children. Your doctor can help find the right medication for you.
For the most effective results, take pain-relieving drugs as soon as you experience signs or symptoms of a migraine. It may help if you rest or sleep in a dark room after taking them. Medications include:
- Pain relievers. Aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, others), may help relieve mild migraines.
Pain relievers, such as acetaminophen (Tylenol, others), also may help relieve mild migraines in some people.
Drugs marketed specifically for migraines, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraine pain, but aren’t effective alone for severe migraines.
If taken too often or for long periods of time, these medications can lead to ulcers, gastrointestinal bleeding and medication-overuse headaches.
The prescription pain reliever indomethacin may help thwart a migraine headache and is available in suppository form, which may be helpful if you’re nauseated.
- Triptans. Many people with migraine attacks use triptans to treat their migraines. Triptans work by promoting constriction of blood vessels and blocking pain pathways in the brain.
Triptans effectively relieve the pain and other symptoms that are associated with migraines.
Medications include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax). Some triptans are available as nasal sprays and injections, in addition to tablets.
Side effects of triptans include nausea, dizziness, drowsiness and muscle weakness. They aren’t recommended for people at risk of strokes and heart attacks.
A single-tablet combination of sumatriptan and naproxen sodium (Treximet) has proved to be more effective in relieving migraine symptoms than either medication on its own.
- Ergots. Ergotamine and caffeine combination drugs (Migergot, Cafergot) are less effective than triptans. Ergots seem most effective in those whose pain lasts for more than 48 hours.
Ergotamine may cause worsened nausea and vomiting related to your migraines and other side effects, and it may also lead to medication-overuse headaches.
Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine. It’s available as a nasal spray and in injection form. This medication may cause fewer side effects than ergotamine and is less likely to lead to medication-overuse headaches.
- Anti-nausea medications. Because migraines are often accompanied by nausea, with or without vomiting, medication for nausea is appropriate and is usually combined with other medications. Frequently prescribed medications are chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro).
- Opioid medications. Opioid medications containing narcotics, particularly codeine, are sometimes used to treat migraine headache pain for people who can’t take triptans or ergot. Narcotics are habit-forming and are usually used only as a last resort.
- Glucocorticoids (prednisone, dexamethasone). A glucocorticoid may be used in conjunction with other medications to improve pain relief. Because of the risk of steroid toxicity, glucocorticoids shouldn’t be used frequently.
You may be a candidate for preventive therapy if you have four or more debilitating attacks a month, if attacks last more than 12 hours, if pain-relieving medications aren’t helping, or if your migraine signs and symptoms include a prolonged aura or numbness and weakness.
Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks.
Your doctor may recommend that you take preventive medications daily, or only when a predictable trigger, such as menstruation, is approaching.
In most cases, preventive medications don’t stop headaches completely, and some drugs cause serious side effects. If you have had good results from preventive medicine and your migraines are well controlled, your doctor may recommend tapering off the medication to see if your migraines return without it.
To prevent or reduce the frequency of your migraines, take these medications as your doctor recommends:
- Cardiovascular drugs. Beta blockers, which are commonly used to treat high blood pressure and coronary artery disease, may reduce the frequency and severity of migraines.
The beta blockers propranolol (Inderal La, Innopran XL, others), metoprolol tartrate (Lopressor) and timolol (Betimol) have proved effective for preventing migraines. Other beta blockers are also sometimes used for treatment of migraine. You may not notice improvement in symptoms for several weeks after taking these medications.
If you’re older than age 60, use tobacco, or have certain heart or blood vessel conditions, doctors may recommend you take alternate medications instead of beta blockers.
Another class of cardiovascular medications (calcium channel blockers) used to treat high blood pressure and keep blood vessels from becoming narrow or wide, also may be helpful in preventing migraines and relieving symptoms from migraines. Verapamil (Calan, Verelan, others) is a calcium channel blocker that may help you.
In addition, the angiotensin-converting enzyme inhibitor lisinopril (Zestril) may be useful in reducing the length and severity of migraines.
Researchers don’t understand exactly why these cardiovascular medications prevent migraine attacks.
- Antidepressants. Certain antidepressants help to prevent some types of headaches, including migraines. Tricyclic antidepressants may be effective in preventing migraines. You don’t have to have depression to benefit from these drugs.
Tricyclic antidepressants may reduce the frequency of migraine headaches by affecting the level of serotonin and other brain chemicals. Amitriptyline is the only tricyclic antidepressant proved to effectively prevent migraine headaches. Other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline.
These medications can cause dryness of mouth, constipation, weight gain and other side effects.
Another class of antidepressants called selective serotonin reuptake inhibitors hasn’t been proved to be effective for migraine headache prevention.
However, research suggests that one serotonin and norepinephrine reuptake inhibitor, venlafaxine (Effexor XR), may be helpful in preventing migraines.
- Anti-seizure drugs. Some anti-seizure drugs, such as valproate sodium (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraine headaches.
In high doses, however, these anti-seizure drugs may cause side effects. Valproate sodium may cause nausea, tremor, weight gain, hair loss and dizziness. Valproate products should not be used in pregnant women for prevention of migraine headaches. Topiramate may cause diarrhea, nausea, weight loss, memory difficulties and concentration problems.
- OnabotulinumtoxinA (Botox). OnabotulinumtoxinA (Botox) has been shown to be helpful in treating chronic migraine headaches in adults.
During this procedure, injections are made in muscles of the forehead and neck. When this is effective, the treatment usually needs to be repeated every 12 weeks.
- Pain relievers. Taking nonsteroidal anti-inflammatory drugs, especially naproxen (Naprosyn), may help prevent migraines and reduce symptoms.
Lifestyle and home remedies
Self-care measures can help ease the pain of a migraine headache.
- Try muscle relaxation exercises. Relaxation may help ease the pain of a migraine headache.
Relaxation techniques may include progressive muscle relaxation, meditation or yoga.
- Get enough sleep, but don’t oversleep. Get an adequate amount of sleep each night. It’s best to go to bed and wake up at regular times, as well.
- Rest and relax. If possible, rest in a dark, quiet room when you feel a headache coming on. Place an ice pack wrapped in a cloth on the back of your neck and apply gentle pressure to painful areas on your scalp.
- Keep a headache diary. Continue keeping your headache diary even after you see your doctor. It will help you learn more about what triggers your migraines and what treatment is most effective.
Nontraditional therapies may be helpful if you have chronic migraine pain:
- Acupuncture. In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin at defined points. Clinical trials have found that acupuncture may be helpful for headache pain.
- 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.
- Massage therapy. Massage therapy may help reduce the frequency of migraines. Researchers continue to study the effectiveness of massage therapy in preventing migraines.
- Cognitive behavioral therapy. Cognitive behavioral therapy may benefit some people with migraines.
Herbs, vitamins and minerals. There is some evidence that the herb butterbur may prevent migraines or reduce their severity.
Another herb, feverfew, may help prevent migraines, but it has shown mixed results in studies.
A high dose of riboflavin (vitamin B-2) also may prevent migraines or reduce the frequency of headaches.
Coenzyme Q10 supplements may decrease the frequency of migraines, but they have little effect on the severity of the headache.
Due to low magnesium levels in some people with migraines, magnesium supplements have been used to treat migraines, but with mixed results.
Ask your doctor if these treatments are right for you. Don’t use feverfew, riboflavin or butterbur if you’re pregnant or without first talking with your doctor.
Whether or not you take preventive medications, you may benefit from lifestyle changes that can help reduce the number and severity of migraines. One or more of these suggestions may be helpful for you:
Avoid triggers. If certain foods or odors seem to have triggered your migraines in the past, avoid them.
Your doctor may recommend you reduce your caffeine and alcohol intake and avoid tobacco.
In general, establish a daily routine with regular sleep patterns and regular meals. In addition, try to control stress.
Exercise regularly. Regular aerobic exercise reduces tension and can help prevent migraines. If your doctor agrees, choose any aerobic exercise you enjoy, including walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches.
Obesity is also thought to be a factor in migraine headaches, and regular exercise can help you maintain a healthy weight or lose weight.
Reduce the effects of estrogen. If you’re a woman who has migraines and estrogen seems to trigger or make your headaches worse, you may want to avoid or reduce the medications you take that contain estrogen.
These medications include birth control pills and hormone replacement therapy. Talk with your doctor about the appropriate alternatives or dosages for you.