Migraine

Overview

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 bad 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.

Symptoms

Migraines, which affect children and teenagers as well as adults, can progress through four stages: prodrome, aura, attack and post-drome. Not everyone who has migraines goes through all stages.

Prodrome

One or two days before a migraine, you might notice subtle changes that warn of an upcoming migraine, including:

• Constipation.
• Mood changes, from depression to euphoria.
• Food cravings.
• Neck stiffness.
• Increased urination.
• Fluid retention.
• Frequent yawning.

Aura

For some people, an aura might occur before or during migraines. Auras are reversible symptoms of the nervous system. They're usually visual but can also include other disturbances. Each symptom usually begins gradually, builds up over several minutes and can last up to 60 minutes.

Examples of migraine auras 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.
• Weakness or numbness in the face or one side of the body.
• Difficulty speaking.

Attack

A migraine usually lasts from 4 to 72 hours if untreated. How often migraines occur varies from person to person. Migraines might occur rarely or strike several times a month.

During a migraine, you might have:

• Pain usually on one side of your head, but often on both sides.
• Pain that throbs or pulses.
• Sensitivity to light, sound, and sometimes smell and touch.
• Nausea and vomiting.

Post-drome

After a migraine attack, you might feel drained, confused and washed out for up to a day. Some people report feeling elated. Sudden head movement might bring on the pain again briefly.

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 health care provider to discuss your headaches.

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

See your health care provider 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

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 strain. 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 (Tylenol, others) 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) 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 specialist trained in treating headaches, known as a 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:

• An MRI scan. A magnetic resonance imaging (MRI) scan uses a powerful magnetic field and radio waves to produce detailed images of the brain and blood vessels. MRI scans help diagnose tumors, strokes, bleeding in the brain, infections, and other brain and nervous system, known as neurological, conditions.
• A CT scan. A computerized tomography (CT) scan uses a series of X-rays to create detailed cross-sectional images of the brain. This helps diagnose tumors, infections, brain damage, bleeding in the brain and other possible medical problems that may be causing headaches.

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 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 (Migranal, Trudhesa). 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.
• Oral calcitonin gene-related peptides antagonists, known as gepants. Ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) are oral gepants approved for the treatment of migraine in adults. In drug trials, medicines from this class were more effective than placebo at relieving pain two hours after taking them. They also were effective at treating migraine symptoms such as nausea and sensitivity to light and sound. Common side effects include dry mouth, nausea and too much sleepiness. Ubrogepant and rimegepant should not be taken with strong CYP3A4 inhibitor medicines such as some medicines used to treat cancer.

• Intranasal zavegepant (Zavzpret). The Food and Drug Administration recently approved this nasal spray to treat migraines. Zavegepant is a gepant and the only migraine medicine that comes as a nasal spray. It brings migraine pain relief within 15 minutes to 2 hours after taking a single dose. The medicine continues working for up to 48 hours. It also can improve other symptoms related to migraine, such as nausea and sensitivity to light and sound.

  Common side effects of zavegepant include a change in sense of taste, nasal discomfort and throat irritation.

• 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 (Gimoti, Reglan) or prochlorperazine (Compro, Compazine). 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 health care provider.

Preventive medications

Medications can help prevent frequent migraines. Your health care provider 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), Hemangeol) and metoprolol (Lopressor). Calcium channel blockers such as verapamil (Verelan, Calan) 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, 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.
• Calcitonin gene-related peptides (CGRP) monoclonal antibodies. Erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), galcanezumab-gnlm (Emgality), and eptinezumab-jjmr (Vyepti) are newer medicines 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.
• Atogepant (Qulipta). This medicine is a gepant that helps prevent migraines. It's a tablet taken by mouth daily. Potential side effects of the medicine may include nausea, constipation and fatigue.
• Rimegepant (Nurtec ODT). This medicine is unique in that it's a gepant that helps prevent migraines in addition to treating migraines as needed.

Ask your health care provider 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 provider.

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

Preparing for an appointment

You'll probably first see a primary care provider, who might then refer you to a provider trained in evaluating and treating headaches, called a neurologist.

Here's some information to help you get ready for your appointment.

What you can do

• Keep track of your symptoms. Keep a headache diary by writing a description of each incident of visual disturbances or unusual sensations, including when they occurred, how long they lasted and what triggered them. A headache diary can help diagnose your condition.
• Write down key personal information, including major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements you take, including doses. It's particularly important to list all medications you've used to treat your headaches.
• Write down questions to ask your health care provider.

Take a family member or friend along, if possible, to help you remember the information you receive.

For migraines, questions to ask your care provider include:

• What is likely triggering my migraines?
• Are there other possible causes for my migraine symptoms?
• What tests do I need?
• Are my migraines 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?
• Are there printed materials you can give me? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your health care provider is likely to ask you a number of questions, including:

• How often do your headaches occur?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Does anyone else in your family have migraines?