Migraines

Migraines are headaches that involve recurring attacks of moderate to severe pain. The pain is usually a throbbing or pulsing pain, and it is often on one side of the head. During migraines, people are very sensitive to light and sound. They may also become nauseated and vomit.

Many things can trigger a migraine, including stress, anxiety, lack of sleep, hunger, diet changes, exposure to light, or hormonal changes. There may also be a genetic cause of migraine. Migraine headaches often begin in childhood, adolescence, or early adulthood.

Migraine is 3 times more common in women than in men. It affects approximately 1 in 10 people worldwide. Some people can tell when they are about to have a migraine because they see flashing lights or zigzag lines or they temporarily lose their vision. Migraines can last hours to days. Medicines can reduce the severity and frequency of migraines, and lifestyle changes can help avoid triggers that cause migraines.

Migraines may progress through 4 stages, including prodrome, aura, headache and postdrome, though a person may not experience all the stages.

In the prodrome stage, 1 or 2 days before a migraine, subtle changes may signify an oncoming migraine, including:

• constipation
• depression
• food cravings
• hyperactivity
• irritability
• 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)

When untreated, a migraine attack usually lasts from 4 to 72 hours, but the frequency with which headaches occur varies from person to person. Migraines may occur several times a month or much less often. The following symptoms are common during a migraine:

• pain on one side or both sides of your head
• pain that has a pulsating, throbbing quality
• sensitivity to light, sounds and sometimes smells
• mausea and vomiting
• blurred vision
• lightheadedness, sometimes followed by fainting

The final phase, known as postdrome, occurs after a migraine attack. During this time, a person may feel drained and washed out, though some people report feeling mildly euphoric.

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 are older than 50

The exact cause of migraines is not clear, but 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 chemicals found naturally in the brain, including serotonin, which helps regulate pain in your nervous system, may also be involved.

Regardless of the exact mechanism of migraine, many factors may trigger them. Common migraine triggers include:

• hormonal changes, especially 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. Other women have an increased tendency to develop migraines during pregnancy or menopause.
• 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, and secondhand smoke, 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 risk factors increase the likelihood of having migraines.

• family history. Most people with migraines have a family history of migraine attacks.
• age. Migraines can begin at any age, though most people experience their first migraine during adolescence. Most people who have migraines have had their first attack by the age of 40 years old.
• sex. Women are 3 times more likely to have migraines than men. Headaches tend to affect boys more than girls during childhood, but by the time of puberty and beyond, more girls are affected.
• hormonal changes. In women, migraines may begin just before or shortly after onset of menstruation. Migraine patterns may also change during pregnancy or menopause. Generally, migraines improve after menopause.

If you have migraines or a family history of migraine headaches, a 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 and imaging tests can rule out infections, tumors, and damage to the brain or blood vessels as causes of migraine pain.

Self-care measures can help ease the pain of a migraine headache.

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.

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 do not oversleep. Get an adequate amount of sleep each night. It is 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.

Complementary and alternative medicine may also be helpful in preventing or treating migraine pain, including acupuncture, biofeedback, massage therapy, cognitive behavioral therapy, and herbs, vitamins, and minerals.

There is no cure for migraines, but you can manage the condition by avoiding known triggers and using medicines and self-care to relieve or prevent symptoms. 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.

Medications used to combat migraines include:

• 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.

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. Common pain relievers include aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve) and acetaminophen (Tylenol, others), either alone or in combination with each other or caffeine (Excedrin Migraine)

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 in this class 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. A single-tablet combination of sumatriptan and naproxen sodium (Treximet) has been shown to be more effective in relieving migraine symptoms than either medication on its own.

Ergotamine and caffeine combination drugs (Migergot, Cafergot) are less effective than triptans at relieving the symptoms of migraines. Ergots seem most effective in those whose pain lasts for more than 48 hours.
Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine. It is available as a nasal spray and in injection form.

People who have 4 or more debilitating migraine attacks a month, attacks that last more than 12 hours, attacks that are not relieved by pain-relieving medications, or migraine signs and symptoms that include a prolonged aura or numbness and weakness may be a candidate for preventive therapy. Preventive medications can reduce the frequency, severity, and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. Medications that may help prevent migraines 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. Propranolol (Inderal La, Innopran XL, others), metoprolol tartrate (Lopressor), and timolol (Betimol) are effective for preventing migraines. Calcium channel blockers, including verapamil (Calan, Verelan, others), which are also used to treat high blood pressure and keep blood vessels from becoming narrow or wide, may also prevent migraines and relieve symptoms from migraines. The angiotensin-converting enzyme inhibitor lisinopril (Zestril) may reduce the length and severity of migraines.
• antidepressants. Certain antidepressants help to prevent some types of headaches, including migraines. You do not have to have depression to benefit from these drugs. Amitriptyline is the only tricyclic antidepressant proved to effectively prevent migraine headaches, but other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline. One serotonin and norepinephrine reuptake inhibitor, venlafaxine (Effexor XR), may also 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.
• onabotulinumtoxinA (Botox). OnabotulinumtoxinA (Botox) has been shown to be helpful in treating chronic migraine headaches in adults.
• pain relievers. Nonsteroidal anti-inflammatory drugs, especially naproxen (Naprosyn), may help prevent migraines and reduce symptoms.