Migraine Headache

Learn what causes migraines and how to prevent and treat migraine symptoms.

• Migraine headache is a result of specific changes within the brain. It causes severe head pain that is often accompanied by sensitivity to light, sound, or smells.
• Common symptoms and signs include the following:
  • Eye pain
  • Sensitivity to light or sound
  • Nausea
  • Vomiting
  • Severe pain, often only on one side of the head, that some individuals describe as "pounding" or throbbing
• The following are types of migraines:
  • Common migraine has no "aura." About 80% of migraines are common.
  • Classic migraines (migraine with aura) present with an aura before the headache and are more severe than common migraines.
  • A silent or acephalgic migraine is a migraine without head pain but with aura and other aspects of migraine.
  • Hemiplegic migraine can have symptoms that mimic a stroke, such as weakness on one side of the body, loss of sensation, or feeling "pins and needles."
  • A retinal migraine causes temporary vision loss in one eye, which can last from minutes to months, but it is usually reversible. This is often a sign of a more serious medical problem, and patients should seek medical care.
  • Chronic migraine is a migraine headache that lasts for more than 15 days per month for three consecutive months.
  • Status migrainosus is a constant migraine attack that lasts more than 72 hours.
• Other types of headaches can also cause intense pain, and not all headaches are migraines. For example, some describe the pain of cluster headaches as the worst pain they have experienced. Sinus headaches can also cause pain and inflammation.
• While the specific cause of migraines is not known, changes in neurotransmitter levels within the brain are thought to influence migraine pain. Over the past several years, the impact of CGRP, or calcitonin gene-related protein, has been recognized. Although located throughout the body, this neuropeptide is involved in the dilation of the blood vessels of the brain, inflammation of brain tissues, and trigger of sensory receptors in the meninges (covering of the brain) during a migraine attack.
• The presence of typical clinical signs and symptoms helps diagnose migraines.
• Migraine attacks can be triggered by many factors, for example:
  • Hormonal changes
  • Stress
  • Strong stimuli like loud noises
  • Certain foods
• Migraine treatment usually is with over-the-counter (OTC) migraine medication or prescription drugs.
• Prescription medications used to relieve the pain of migraine include triptans (a class of drugs), for example:
  • sumatriptan (Imitrex, Alsuma, Imitrex STATdose System, Sumavel DosePro, Zecuity, Treximet)
  • rizatriptan (Maxalt, Maxalt-MLT)
  • eletriptan (Relpax)
  • zolmitriptan (Zomig, Zomig-ZMT)
  • naratriptan Amerge)
  • almotriptan (Axert)
  • frovatriptan (Frova)

Three newly approved medications for the treatment of acute migraine include lasmiditan (Reyvow), a serotonin 5-HT1F receptor agonist (also known as a ditan) which doesn't cause vasoconstriction. Ubrogepant (Ubrelvy) and rimegepant (Nurtec) are oral calcitonin gene-related peptide antagonists used primarily for the acute treatment of occasional migraine headaches. Rimegepant may be used for preventative therapy, as well.

Calcitonin gene-related peptide receptor (CGRP-R) antagonists can also be used to treat chronic migraine. These medications are given by periodic injection, given monthly or quarterly, to prevent migraines. This class of medication includes erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality), all of which are injected subcutaneously, and eptinezumab (Vyepti), which is given intravenously every 3 months. Oral versions of CGRP-R antagonists include rimegepant (Nurtec), which is taken every other day, and atogepant (Qulipta), which is taken daily to prevent migraine.

• Some patients with chronic migraine receive botulinum toxin (Botox) injections every three months to help treat their headaches.
• Lifestyle changes like eating a healthy diet and getting exercise may help reduce the frequency of migraine attacks.
  • Avoid foods that trigger migraines. This also may reduce the frequency of attacks.
  • Some may find exercises, for example, yoga, that promotes muscle relaxation helpful in managing severe pain.
  • Most people with migraines usually are able to manage their condition with a combination of medications and lifestyle changes.
  • Some people may need prescription medications to decrease the frequency of headaches.
• Up to 25% of people will have a migraine at some point. Most sufferers are female. It is estimated that after adolescence, the ratio of female to male patients who experience migraines is about 3:1. There seems to be a genetic predisposition, as there is often a strong family history of migraine in patients with this disorder.

Migraines usually are associated with sensitivity to sound, light, and smells.

Although the term "migraine" is often used to describe any severe headache, a migraine headache is the result of specific physiologic changes that occur within the brain, and lead to the characteristic pain and associated symptoms of a migraine.

Migraines usually are associated with sensitivity to sound, light, and smells. A migraine attack may be accompanied by nausea or vomiting. This type of headache often involves only one side of the head, but in some cases, patients may have pain bilaterally or on both sides. The pain is often described as throbbing or pounding and it may be made worse with physical exertion.

Not all headaches represent migraines, and migraine is not the only condition that can cause severe and debilitating headaches. For example, cluster headaches are very severe headaches that affect one side of the head in a recurrent manner (occurring in a "cluster" over time). The pain is sometimes described as "drilling," and can be worse than migraine pain in some cases. Cluster headaches are less common than migraine.

Tension headaches are a more common cause of headaches. These occur due to the contraction of the muscles of the scalp, face, and neck.

For patients who have never had an aura, it can be frightening and can mimic the symptoms of a stroke.

In some cases, people with migraines have specific warning symptoms, or an aura, prior to the onset of their headache. These warning signs can range from flashing lights or a blind spot in one eye to numbness or weakness involving one side of the body. The migraine aura may last for several minutes and then resolves as the head pain begins or may last until the headache resolves. For patients who have never had an aura, it can be frightening and can mimic the symptoms of a stroke.

The most common symptoms of migraine are:

• Severe, often "pounding," pain, usually on one side of the head
• Nausea and/or vomiting
• Sensitivity to light
• Sensitivity to sound
• Eye pain

What is an episodic migraine?

The International Headache Society defines episodic migraine as being unilateral (meaning on one side of the head), pulsing discomfort of moderate-to-severe intensity, which is aggravated by physical activity and associated with nausea and/or vomiting as well as photophobia and/or phonophobia (sensitivity to light and sound).

Other migraine headache symptoms and signs of migraines

• Many people describe their headache as a one-sided, pounding type of pain, with nausea and sensitivity to light, sound, or smells (known as photophobia, phonophobia, and osmophobia). In some cases, the discomfort may be bilateral (both sides of the head). The pain of a migraine is often graded as moderate to severe in intensity. Physical activity or exertion (walking upstairs, rushing to catch a bus or train) will worsen the symptoms.
• Up to one-third of people with migraines have an aura, or a specific neurologic symptom, before their headache begins. Frequently, the aura is a visual disturbance described as temporary blindness that obscures part of the visual field. Some describe flashing lights in one or both eyes, sometimes surrounding a blind spot. Other symptoms, including numbness or weakness along one side, or speech disturbances, occur rarely.
• Some people describe visual symptoms of loss of vision, which lasts for less than an hour, and may or may not be associated with head pain once the vision returns, as an ocular migraine. This is also known as retinal migraine and may be associated with symptoms similar to those described as an aura, such as blind spots, complete loss of vision in one eye, or flashing lights. Patients who experience these symptoms regularly need evaluation to exclude a primary retinal problem.
• Eye pain, which is different from sensitivity to light, is not a common component of migraine. If eye pain is persistent, or if eye pain is present and accompanied by blurred vision or loss of vision, then seek prompt evaluation.

What is the difference between a migraine vs. tension headache?

A tension headache is described as being bilateral and the pain is not pulsating but feels like pressure or tightness. While severity can be mild-to-moderate, the headache is not disabling and there is no worsening of the pain with routine physical activity; additionally, there is no associated nausea, vomiting, photophobia, or phonophobia.

How long does a migraine last?

A migraine headache typically lasts for several hours up to several days.

The specific cause of migraines is not known, but there may be fluctuations in certain neurotransmitters, which are chemicals that send messages between brain cells. These changes may predispose some people to develop migraine headaches.

Calcitonin gene-related peptide is a neuropeptide, or protein, which is released when migraines occur. The release of this protein can cause inflammation of the blood vessels and sensory receptors of the brain and contributes to the pounding pain associated with migraines.

Many factors have been identified as migraine triggers.

• Normal hormone fluctuations, which occur with regular menstrual cycles, and some types of oral contraceptives (birth control pills)
• Various foods such as:
  • Red wines
  • Aged cheeses
  • Preservatives used in smoked meats (nitrates)
  • Monosodium glutamate
  • Artificial sweeteners
  • Chocolate
  • Dairy products
  • Alcoholic beverages
• Stress
• Oversleeping
• Exposure to strong stimuli such as bright lights, loud noises, or strong smells

Changes in barometric pressure have been described as leading to migraine headaches.

Not every individual who has migraine attacks will experience one when exposed to these triggers. If a person is unsure what specific triggers might cause a migraine, maintaining a headache diary can be beneficial to identify those individual factors that lead to migraine.

No specific physical findings are found when patients are experiencing a routine migraine headache. If an abnormality is identified on physical examination, there should be suspicious of other possible causes for the headache.

According to the International Classification of Headache Disorders 3 (ICHD) criteria for migraine without aura, a patient must have had at least five headache attacks fulfilling the following criteria:

• Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
• The headache has at least two of the following characteristics:
  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity (for example, walking or climbing stairs)
• During the headache, at least one of the following characteristics:
  • Nausea and/or vomiting
  • Photophobia and/or phonophobia
• The headache cannot be attributed to another disorder.

Imaging the brain with MRI and CT scans or performing a brain wave test (electroencephalogram [EEG]) is not necessary if the patient's physical examination is normal.

Migraine headache treatment can vary due to several factors. Usually, the treatment for migraines depends upon how frequently they occur, the type of medicine prescribed to prevent triggers and attacks or provide pain relief, and how long they last.

The treatment of an acute migraine headache may vary from over-the-counter (OTC) medicines, like acetaminophen (Tylenol and others), ibuprofen (Advil, Motrin, etc.), naproxen sodium (Aleve) to prescription medications.

Triptans

• Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, naratriptan, almotriptan, and frovatriptan), may be extremely effective in treating migraines and may be prescribed to help patients treat their migraines at home. A combination of naproxen and sumatriptan is available. Additionally, sumatriptan is now available as a patch, which delivers the medication through the skin.
• Not every patient can take these medications, and there are specific limitations regarding how often these medications can be used.

Other migraine treatments

• Lasmiditan (Reyvow), a selective serotonin 1F receptor agonist, is effective for treating acute migraine and may be a good alternative for patients who are unable to use triptan.
• Ubrogepant (Ulbrevy) and rimegepant (Nurtec) are oral calcitonin-gene-related peptide antagonists that can be used to treat acute migraines.
• Some medications are appropriate for home use and others require a visit to the doctor's office or emergency department.
• Dihydroergotamine (DHE 45) can be administered intravenously or by nasal spray; this medication cannot be used if a triptan has been used within the preceding 24 hours.
• Diclofenac potassium for oral solution (Cambia) is a potent nonsteroidal anti-inflammatory medication approved for the treatment of migraine.
• Antiemetic medications, including intravenous (IV) metoclopramide, and IV or intramuscular (IM) chlorpromazine and prochlorperazine can be used both to relieve nausea and vomiting and to rid migraine pain.
• Non-medicinal treatment options are available. These include external nerve stimulators worn on the head that target supraorbital nerves, occipital nerves, or trigeminal nerves and a stimulator worn on the arm to impact pain centers in the brain through peripheral nerves in the upper arm. Transcranial magnetic stimulation has shown promise as a preventative treatment and acute therapy for migraine. The therapy is administered through a device used at home. Implantable stimulators, including vagal nerve or occipital nerve stimulators, have also been beneficial in relieving migraine frequency and may be used for acute pain management, as well. The majority of these devices require a prescription.

Narcotics

Narcotic pain medications are not necessarily appropriate for the treatment of migraine headaches and are associated with the phenomenon of rebound headache, where the headache returns -- sometimes more intensely -- when the narcotics wear off. In all cases of migraine, the use of acute pain therapies must be watched closely so that a patient does not develop medication overuse headache.

Too frequent use of many of the medications used to treat migraine headaches, even over-the-counter medications, can lead to increased headache occurrence, or even daily headaches. This type of headache phenomenon is known as medication overuse headache.

If an individual experiences frequent headaches, or if the headaches routinely last for several days, then preventive medications may be indicated. These may be prescribed on a daily basis in an effort to decrease the frequency, severity, and duration of migraine headaches. There are many different medications that have been shown to be effective in this role, including:

• blood pressure medications, for example, propranolol (Inderal), nadolol (Corgard), verapamil (Calan, Covera, Isoptin, Verelan), and flunarizine),
• anti-seizure medications, for example, divalproex sodium (Depakote and others), topiramate (Topamax), and gabapentin (Neurontin, Gralise),
• antidepressant medications (amitriptyline, nortriptyline, and venlafaxine) and
• other supplements (magnesium, butterbur, and riboflavin).

The specific migraine headache treatment that is selected for a patient is dependent on many other factors, including age, sex, blood pressure, and other pre-existing medical conditions.

Some patients who experience more than 15 headache days every month might benefit from onabotulinum toxin A (Botox) injections.

Other patients may find that the use of one of the new calcitonin gene-related peptide (CGRP) receptor antagonists, including erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), or eptinezumab (Vyepti), is beneficial to decrease their migraine frequency. These medications are injected monthly or quarterly (every 3 months) to treat migraine. There are two oral versions of CGRP receptor antagonists, rimegepant (Nurtec) and atogepant (Qulipta), which are approved for migraine prevention.

Migraine patients can play a significant role in managing their headache frequency and severity.

Keep track of when migraines occur by using a headache diary or log to track pain levels, triggers, and symptoms. In addition, patients should keep track of the migraine types they experience (an individual can experience more than one type of migraine). This can help identify patterns that precede a migraine, as well as help, identify factors that contribute to the development of the headache. Once these contributing factors are known, lifestyle modifications can lessen their impact. These modifications may include:

• Maintain a regular schedule for eating and sleeping.
  • Avoid certain foods that might cause a migraine.
  • Keep well hydrated since dehydration has been identified as a migraine trigger for some people.
  • Exercise regularly.
• Relaxation strategies and meditation also have been recognized as effective strategies to prevent migraines and decrease their severity.

Exercise and migraine

Some people find that physical exercises and exercises that promote muscle relaxation can help manage the pain of migraines. Examples of types of mind-body exercises that can help encourage relaxation are:

• Meditation
• Progressive muscle relaxation
• Guided imagery
• Yoga

Diet and Migraine

There is no specific diet for people with migraines that will help relieve symptoms. However, certain foods can be triggers for migraines in susceptible people. These foods include:

• Red wines
• Aged cheeses
• Preservatives used in smoked meats (nitrates)
• Monosodium glutamate
• Artificial sweeteners
• Chocolate
• Alcoholic beverages
• Dairy products

Understanding the particular triggers of your migraines and avoiding them may help some sufferers decrease the frequency of attacks. For some patients, missing a meal may trigger migraine, and eating regularly can help eliminate recurrent attacks.

Alternative therapies for migraine management

• Coenzyme Q10: Some patients seem to have decreased headache frequency when taking this supplement.
• Riboflavin: Longer-term use may decrease migraine frequency or severity.
• Magnesium, melatonin, and feverfew haven't been shown to be beneficial for migraine in studies.
• Butterbur has been identified as having components that may lead to liver injury or cause cancer and is not recommended.

Many women find their headaches stabilize or even resolve during pregnancy. This may be related to more consistent hormone levels that occur during pregnancy. To decrease the risk of birth defects, certain medications used to prevent migraines may need to be discontinued prior to pregnancy.

There are limited studies of drugs used to treat migraines during pregnancy. Acetaminophen is relatively safe when used in recommended doses. If you are pregnant and are experiencing frequent headaches, your doctor or other health care professional may provide treatment alternatives. Many migraine medicines, including triptans, are not well studied in pregnancy, so the doctor needs to weigh the potential benefits to the patient against the risks to the fetus before prescribing these medications.

Migraines may occur in children. Treatment is similar to the treatment of migraines in adults, but drug dosages may need to be adjusted because of the smaller size of the patients.

• Acetaminophen and ibuprofen are often effective in controlling acute headaches.
• For more severe or refractory headaches, some of the triptans have been identified as being beneficial.
• If headaches occur frequently, daily medication may be needed for prevention.
• Diet, regular sleep patterns, routine exercise, and biofeedback, are all potentially beneficial in decreasing the frequency and severity of migraines in children.
• The use of a headache diary is a helpful tool to identify and avoid migraine triggers.

Most people who have migraines find that their headaches may be controlled with preventive medications and lifestyle changes. Those with a diagnosis of migraine need to be aware of how their lifestyle may directly affect the frequency and severity of their headache. Controlling triggers may provide substantial benefits. It has been identified that as patients get older, there may be a decrease in the frequency of this type of headache and they may disappear after a number of years.

If you are susceptible to migraines, you will always have some component of risk, but daily use of medications and avoiding triggers often are effective in preventing them.