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Migraine

Overview

A migraine can cause severe throbbing pain or a pulsing sensation, usually on just one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound.

Migraine attacks can cause significant pain for hours to days and can be so severe that the pain is disabling.

Warning symptoms known as aura may occur before or with the headache. These can include flashes of light, blind spots, or tingling on one side of the face or in your arm or leg.

Medications can help prevent some migraines and make them less painful. Talk to your doctor about different migraine treatment options if you can't find relief. The right medicines, combined with self-help remedies and lifestyle changes, may help.

Symptoms

Migraines often begin in childhood, adolescence or early adulthood. Migraines may progress through four stages: prodrome, aura, headache and post-drome, though you may not experience all stages.

Prodrome

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

  • Constipation
  • Mood changes, from depression to euphoria
  • Food cravings
  • Neck stiffness
  • Increased thirst and urination
  • Frequent yawning

Aura

Aura may occur before or during migraines. Most people experience migraines without aura.

Auras are symptoms of the nervous system. They are usually visual disturbances, such as flashes of light or wavy, zigzag vision.

Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Your muscles may get weak, or you may feel as though someone is touching you.

Each of these symptoms usually begins gradually, builds up over several minutes and lasts for 20 to 60 minutes. Examples of migraine 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
  • Weakness or numbness in the face or one side of the body
  • Difficulty speaking
  • Hearing noises or music
  • Uncontrollable jerking or other movements

Sometimes, a migraine with aura may be associated with limb weakness (hemiplegic migraine).

Attack

A migraine usually lasts from four to 72 hours if untreated. The frequency with which headaches occur varies from person to person. Migraines may be rare, or strike several times a month. During a migraine, you may experience:

  • Pain on one side or both sides of your head
  • Pain that feels throbbing or pulsing
  • Sensitivity to light, sounds, and sometimes smells and touch
  • Nausea and vomiting
  • Blurred vision
  • Lightheadedness, sometimes followed by fainting

Post-drome

The final phase, known as post-drome, occurs after a migraine attack. You may feel drained and washed out, while some people feel elated. For about 24 hours, you may also experience:

  • Confusion
  • Moodiness
  • Dizziness
  • Weakness
  • Sensitivity to light and sound

When to see a doctor

Migraines 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 a more serious medical problem:

  • 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

Causes

Though migraine causes aren'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 are still studying the role of serotonin in migraines.

Serotonin levels drop during migraine attacks. This may cause your trigeminal nerve to release substances called neuropeptides, which travel to your brain's outer covering (meninges). The result is migraine pain. Other neurotransmitters play a role in the pain of migraine, including calcitonin gene-related peptide (CGRP).

Migraine triggers

A number of factors may trigger migraines, including:

  • Hormonal changes in women. Fluctuations in estrogen seem to trigger headaches in many women. 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, 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 (MSG), 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. Strong 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.

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 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 are 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. Migraines generally improve after menopause.

    Some women report that migraine attacks begin during pregnancy, or their attacks worsen. For many, the attacks improved or didn't occur during later stages in the pregnancy. Migraines often return during the postpartum period.

Complications

Sometimes your efforts to control your migraine pain cause problems, such as:

  • 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. Taking over-the-counter or prescription headache medications more than 10 days a month for three months or in high doses may trigger serious medication-overuse headaches.

    Medication-overuse headaches occur when medications stop relieving pain and begin to 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 of the nervous system chemical called serotonin.

    While the risk is considered extremely low, taking migraine medications called triptans and antidepressants known as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) may increase the risk of serotonin syndrome. These medications naturally raise serotonin levels, and it is possible that combining them could cause levels that are too high.

    Triptans and SSRIs or SNRIs may be used together, but it's important to watch out for possible symptoms of serotonin syndrome such as changes in cognition, behavior and muscle control (such as involuntary jerking).

    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 lasts for 15 or more days a month for more than three months, you have chronic migraine.
  • Status migrainosus. People with this complication have severe migraine attacks that last for longer than three days.
  • Persistent aura without infarction. Usually an aura goes away after the migraine attack, but sometimes aura lasts for more than one week afterward. A persistent aura may have similar symptoms to bleeding in the brain (stroke), but without signs of bleeding in the brain, tissue damage or other problems.
  • Migrainous infarction. Aura symptoms that last longer than one hour can signal a loss of blood supply to an area of the brain (stroke), and should be evaluated. Doctors can conduct neuroimaging tests to identify bleeding in the brain.

Prevention

Until recently, experts recommended avoiding common migraine triggers. Some triggers can't be avoided, and avoidance isn't always effective. But some of these lifestyle changes and coping strategies may help you reduce the number and severity of your migraines:

  • Transcutaneous supraorbital nerve stimulation (t-SNS). This device (Cefaly), similar to a headband with attached electrodes, was recently approved by the Food and Drug Administration as a preventive therapy for migraines. In research, those that used the device experienced fewer migraines.
  • Learn to cope. Recent research shows that a strategy called learning to cope (LTC) may help prevent migraines. In this practice, you are gradually exposed to headache triggers to help desensitize you to them. LTC may also be combined with cognitive behavioral therapy. More research is needed to better understand the effectiveness of LTC.
  • Create a consistent daily schedule. 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. Regular exercise can also help you lose weight or maintain a healthy body weight, and obesity is thought to be a factor in migraines.
  • Reduce the effects of estrogen. If you are 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.

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.

Your doctor may also recommend more 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 these to test for blood vessel problems, infections in your spinal cord or brain, and toxins in your system.
  • Magnetic resonance imaging (MRI). An MRI 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.
  • Spinal tap (lumbar puncture). Your doctor may recommend a spinal tap (lumbar puncture) if he or she suspects infections, bleeding in the brain or another underlying condition.

    In this procedure, a thin needle is inserted between two vertebrae in the lower back to remove a sample of cerebrospinal fluid for analysis in a lab.

Treatment

Migraine treatments can help stop symptoms and prevent future attacks.

Many medications have been designed to treat migraines. Some drugs often 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.
  • Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.

Your treatment strategy 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.

Pain-relieving medications

Take pain-relieving drugs as soon as you experience signs or symptoms of a migraine for the best results. It may help if you rest or sleep in a dark room after taking them. Medications include:

  • Pain relievers. Aspirin or ibuprofen (Advil, Motrin IB, others) may help relieve mild migraines.

    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. They 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 and is available in suppository form, which may be helpful if you're nauseated.

  • Triptans. These medications are often used in treating migraines. Triptans make blood vessels constrict and block pain pathways in the brain.

    Triptans effectively relieve the pain and other symptoms that are associated with migraines. They are available in pill, nasal spray and injection form.

    Triptan medications include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax).

    Side effects of triptans include reactions at the injection site, 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. Ergots are most effective when taken soon after migraine symptoms start.

    Ergotamine may worsen nausea and vomiting related to your migraines, 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 also less likely to lead to medication-overuse headaches. It's available as a nasal spray and in injection form.

  • Anti-nausea medications. Medication for nausea 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 pain for people who can't take triptans or ergots. Narcotics are habit-forming and are usually used only if no other treatments provide relief.
  • Glucocorticoids (prednisone, dexamethasone). A glucocorticoid may be used with other medications to improve pain relief. Glucocorticoids shouldn't be used frequently to avoid side effects.

Preventive medications

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
  • 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. It may take several weeks to see improvements in your symptoms.

Your doctor may recommend daily preventive medications, or only when a predictable trigger, such as menstruation, is approaching.

Preventive medications don't always 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.

The most common medications for migraine prevention include:

  • 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 a different medication.

    Another class of cardiovascular medications (calcium channel blockers) used to treat high blood pressure also may be helpful in preventing migraines and relieving symptoms. Verapamil (Calan, Verelan, others) is a calcium channel blocker that may help prevent migraines with aura.

    In addition, the angiotensin-converting enzyme inhibitor lisinopril (Zestril) may be useful in reducing the length and severity of migraines.

  • Antidepressants. Tricyclic antidepressants may be effective in preventing migraines, even in people without depression.

    Tricyclic antidepressants may reduce the frequency of migraines by affecting the level of serotonin and other brain chemicals. Amitriptyline is the only tricyclic antidepressant proved to effectively prevent migraines. Other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline.

    These medications can cause sleepiness, dry 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 prevention. These drugs may even worsen or trigger headaches.

    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 (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraines.

    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 or women who may become pregnant.

    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 migraines in adults.

    During this procedure, onabotulinumtoxinA is injected into the 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.

Alternative medicine

Nontraditional therapies may be helpful if you have 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.
  • 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. This type of psychotherapy teaches you how behaviors and thoughts affect how you perceive pain.
  • Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur may prevent migraines or reduce their severity, though study results are mixed. Butterbur isn't recommended because of long-term safety concerns.

    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 larger studies are needed.

    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.

Lifestyle and home remedies

Self-care measures can help ease migraine pain.

  • Practice muscle relaxation exercises. Relaxation techniques may include progressive muscle relaxation, meditation or yoga.
  • Get enough sleep, but don't oversleep. Get the right balance of sleep each night, making sure to go to bed and wake up at consistent times.
  • Rest and relax. Try to 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 recording in 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.

Preparing for an appointment

You'll probably first see a primary care provider, but you may be referred to a doctor trained in evaluating and treating headaches (neurologist).

Because appointments can be brief and there's often a lot to discuss, prepare for your appointment. Here's some information to help you get ready, 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.
  • Make a note of key personal information, including things like recent life changes, or major stresses.
  • 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 a list of 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 migraines, some basic questions to ask your doctor include:

  • What is likely triggering my migraines?
  • Are there other possible causes for my migraine symptoms?
  • What kinds of 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?
  • 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, so be ready to answer them to save time for your questions. 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 spot your migraine triggers. Note when your headaches start, how long they last and anything that 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 such as meditation.
  • Get enough sleep. Aim for a regular sleep schedule and get an adequate amount of sleep.

Last updated: April 26th, 2017

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