Migraine is one of the most frequently diagnosed ailments in the world. Nearly 1 billion people globally and 39 million Americans suffer from migraines. They are 3 times more common in women than men possibly due to hormonal differences.
What is a migraine?
Migraines are a neurologic condition with a severe headache that lasts for hours or even days. Your forehead, the side of your head, or the area surrounding your eyes is where the pounding pain generally starts.
Migraines share some similarities with headaches, but the key difference is the intensity of the pain. Also, most migraines cause nausea, vomiting and/or blurred vision.
Four phases of migraines
The majority of people experience migraines when they first wake up in the morning. Some get migraines in regular patterns, such as before their periods or on the weekends after a demanding work week.
Migraines have 4 distinct phases: prodrome, aura, attack (headache), and postdrome. Every individual experiences a unique migraine and not everyone experience all 4 phases.
Prodrome
The prodrome symptoms are present hours or 24 hours before a migraine. It affects approximately 60% of people with migraines.
- Becoming hypersensitive to scent, sound, or light
- Tiredness or uncontrollable yawning
- Difficulty concentrating
- Cravings for food or a lack of appetite
- Changes in your mood
- Extreme thirst
- Increased urination
- Bloating
- Constipation or diarrhea
- Muscle stiffness
Aura
The symptoms are nervous system-related and frequently affect your eyesight. They begin gradually over a 5 to 20-minute span and last less than an hour.
15% to 20% of individuals experience aura before a migraine attacke.
- Observe dark spots, light flashes, or objects that aren't there; commonly described as hallucinations
- Possess a narrow focus
- Not being able to see properly or temporarily having no vision at all
- Ringing in your ear(s), otherwise known as tinnitus
- Experiencing difficulties speaking properly
- Experiencing tingling and/or numbness on one side of your body
- Feeling heaviness in your arms and/or legs
Attack or headache
A migraine headache frequently starts off as a dull aching, then intensifies into throbbing pain. Regular activity typically make it worse. The discomfort or pain may radiate from the front of your head, on one side of your head only, or extend throughout your entire head.
The average duration of a migraine attack is approximately 4 hours, although more severe cases can continue for up to 3 days.
- Nausea and/or vomiting
- Neck pain or stiffness
- Insomnia
- Heightened sensitivity to noise, light, and smell
- Pain that becomes worse when you cough, move or sneeze
Postdrome
After a headache, this phase might linger for up to a day.
- Feeling worn out, drained, or irritable
- Being exceptionally energized
- Difficulty concentrating or comprehending
- Aching or weakened muscles
- Cravings for food or a lack of appetite
Keep in mind that it can take approximately 8 to 72 hours to go through the 4 stages.
What causes a migraine?
Although the precise cause of migraines is unknown, it is thought to involve a complex interaction between generic, environmental, and neurochemical factors.
Generic
According to studies, migraines may have a hereditary component, suggesting they may be genetic and run in families. Certain genes linked to migraines have been discovered by researchers.
There is a 50% probability that you will have migraines if one of your parents does. Your likelihood increases to 75% if both of your parents suffer from migraines.
Neurochemical imbalances
Serotonin is a brain chemical (neurotransmitter) that regulates your mood, appetite, and sleep. High serotonin levels cause blood vessels to narrow (shrink) and low serotonin levels cause blood vessels to dilate (swell). During a migraine attack, serotonin levels in your brain decrease, leading to swelling of blood vessels which can cause pain and other migraine symptoms.
Abnormalities in the trigeminal nerve
The trigeminal nerve provide sensation to your face and head. It also transmits pain signals from the head to the brain. Abnormal stimuli in the trigeminal nerve triggers the blood vessels to swell and put pressure on the brain, causing migraines. Ironically migraine pain can cause more stimuli that lead to more swelling.
What are migraine triggers?
There are a number of migraine triggers. Try to identify what your triggers are and avoid them. Some common triggers are:
Hormonal changes in women
- Fluctuations in estrogen may trigger headaches in many women, such as from their menstrual cycle, menopause, or the use of hormonal birth control or hormone replacement therapy.
- A common type of migraine is menstrual-associated migraine (MAM). The exact timing varies person to person. This condition can be treated with oral contraceptives, or the estradiol patch to decrease their frequency.
- Women who have migraines with aura are at a higher risk for stroke and should not use estrogen-containing contraceptives. Due to this risk, progestin-only pills are recommended for women who experience migraine with aura.
Foods
- Common items to avoid include alcohol, especially beer and red wine, aged cheese, chocolate, sweeteners containing aspartame, overuse of caffeine, salty foods, and processed foods.
- It's also possible that your migraine headache may be brought on by skipping a meal.
Caffeine
- Headaches can occur when you consume an excessive amount of caffeine or from caffeine withdrawal. Caffeine can make your blood vessels more sensitive, thus headaches may happen if you don't receive any.
Stress
- Stress is among the most frequent causes of migraine headaches.
- In reaction to stressful situations, your brain releases certain chemicals, commonly referred to as the "flight or fight" response. A migraine may develop as a result of these substances released.
- Other feelings such as fear, nervousness, and excitement can constrict your muscles and widen your blood vessels. Your migraine can become worse as a result.
Usage of painkillers on a regular basis
- A rebound headache might occur if you use headache medications too frequently.
Sensory stimuli
- Bright lights, sun glare, loud noises, and certain scents may be pleasant or unpleasant.
Changes in your wake-sleep cycle
- Either missing sleep or getting too much sleep, including jet lag.
Changes in the environment
- A change in weather or atmospheric pressure, including strong winds, or changes in altitude.
Is it possible for children to get migraines?
Yes, one in 11 children experiences migraines. Pediatric migraines frequently don’t last as long as an adult's, and involve more abdominal symptoms.
What are the risk factors for migraines?
It’s possible for anyone to experience migraines, however, the following factors increase your risk of developing them:
- Sex: migraines are 3 times as common in women than in males. (one in 5 women, one in 16 men)
- Age: most individuals began experiencing migraines between the ages of 10 and 40.
- Family history
- Have additional medical issues, including seizures, bipolar disorder, anxiety, depression, or sleep disorders.
How are migraines diagnosed?
Your doctor will get a complete medical history, including your headache history as well as that of your family, in order to diagnose a migraine.
Migraines are diagnosed when individuals have at least 5 attacks following these criteria:
- Headaches that last 4&mndash;72 hours and recur sporadically
- Headaches that have more than 2 of the following characteristics: unilateral locations, pulsating, moderate-severe pain, and aggravated by, or causing avoidance of routine physical activity
- One of the following occurs during the headache: nausea and/or vomiting, photophobia (sensitivity to light), and phonophobia (sensitivity to sound).
In order to rule out any further causes of your migraine, your doctor may also prescribe blood tests and imaging tests, including a CT scan or an MRI. To exclude any possibility of seizures, your doctor could even recommend an electroencephalogram (EEG).
You may also be required to keep a headache journal/diary as well. This can assist your doctor in determining the potential causes of your migraines and/or identifying your triggers.
How can migraines be treated?
Acute, or “abortive,” treatment is used for a headache that’s already present. Take medication as soon as you think you’re getting a migraine.
Most individuals with mild to moderate migraines might find relief with over-the-counter (OTC) drugs.
- Acetaminophen (brand: Tylenol)
- Advil Migraine (generic: Ibuprofen)
- Excedrin migraine (a brand drug that contains aspirin, acetaminophen, and caffeine)
- Aleve (generic: Naproxen): Nonsteroidal anti-inflammatory drug (NSAID)
You may get more relief from OTC medications, or from prescription medications, such as triptans, and others need to use a combination of both.
Triptans
Selective serotonin receptor agonists that cause narrowing (vasoconstriction) of cranial blood vessels, inhibit neuropeptide release, and decrease pain transmission. This reduces the sensitivity of overactive pain nerves. Triptans reverse the changes in your brain that led to your migraine. This drug class is considered a first-line treatment for acute migraines.
- Almotriptan 6.25–12.5 mg
- Eletriptan (brand: Relpax) 20–40 mg
- Frovatriptan (Frova) 2.5 mg
- Naratriptan (Amerge) 1–2.5 mg
- Rizatriptan (Maxalt, Maxalt-MLT) ODT 5–10 mg
ODT (orally disintegrating tablet): dissolved on the tongue rather than swallowed whole. ODT is useful if nausea is present. - Sumatriptan (Imitrex, Onzetra Xsail) 25, 50, or 100 mg
Imitrex nasal spray: 5, 10, or 20 mg in one nostril. Can repeat 1 time after 2 hours.
Nasal sprays tend to work faster than oral medications.
Onzetra Xsail powder: 11 mg in each nostril using a nosepiece. Can repeat 1 time after 2 hours. - Treximet (brand drug containing active ingredients sumatriptan and naproxen) 85–500 mg
- Zolmitriptan (Zomig) 1.25–5 mg
Available in tablets, ODT, and nasal spray 2.5–5 mg
Triptan side effects
- Paresthesia (tingling/numbness)
- Dizziness
- Hot/cold sensations
- Chest pain/tightness
- Dry mouth
- Nausea
- Sleepiness
- Numbness
- Throat and/or neck pressure
If nausea prevents you from swallowing or holding down your medication, your healthcare provider can prescribe a tablet that dissolves in your mouth (ODT) or a nasal spray.
Ergotamines
Ergotamines (nonselective serotonin receptor agonists) are a group of medications that cause the blood vessels in your bran to narrow and reduce swelling. They may also reduce pain and inflammatory signals in sensory brain nerves.
Ergots work best when taken at the first sign of a migraine attack. However, they cannot stop migraines or lessen the frequency of attacks.
Ergots are not the first line treatmetn for migraines and used for those who can't not take triptans or triptans have failed to treat their migraine.
- Dihydroergotamine (brand: Migranal nasal spray)
- 1 spray (0.5 mg) into each nostril, can repeat after 15 minutes, up to a total of 4 sprays (2 mg)
- The nasal spray should be primed by pumping 4 times. Do not inhale deeply (to let the drug absorb into the skin in your nose).
- Use at the first sign of attack, but can be used at any time during a migraine
- Side effects of the nasal spray include rhinitis (stuffy nose), dysgeusia (altered sense of taste), nausea, and dizziness.
- Ergotamine + caffeine (Cafergot: 1 mg ergotamine + 100 mg caffeine)
- Take 2 tablets at the onset of migraine; then take 1 tablet every 30 minutes as needed to a max of 6 tablets per attack.
Butalbital-containing medications
Butalbital is a barbiturate which is a group of drugs that depress the activity of the central nervous system (CNS) and cause relaxation and sedation.
If your migraine pain won’t go away, strong prescription painkillers containing butalbital are an option.
- Acetaminophen/butalbital/caffeine (brand: Fioricet)
- Aspirin/ butalbital/caffeine (brand: Fiorinal)
These drugs are also available in combinations with codeine.
If your migraine pain won’t go away, strong prescription painkillers containing butalbital are an option.
- Fioricet with codeine
- Fioricet with codeine
These products are federally classified as schedule III (controlled substances), except Fioricet. Use caution when taking these medications as they have the potential to become habit-forming. If necessary your doctor may prescribe these medications only for a brief length of time. However, butalbital-containing products are not recommended for treating acute migraines due to abuse/dependence issues and lower efficacy.
Preventative Drug Treatment
You may require preventative medication to decrease the frequency of migraines. These medications are taken when you feel well and are not effective once a headache is present.
Preventative treatment should be considered if you use acute treatments for more than 2 days a week, more than 3 times per month, if the migraines decrease your quality of life, or if acute treatments are ineffective or contraindicated.
A preventative medication is chosen based on an individual’s characteristics and the side effect profile of the medication because efficacy data is similar for all (approximately 50% reduction in headache days). A full trial, at a reasonable dose, should be 2-6 months. Many individuals try more than one medication before finding one that works well for them.
Beta-Blockers
- Propranolol (brand: Inderal LA) 80-240 mg
Common side effects may include fatigue, decreased heart rate, and possible depression - Timolol 10 mg twice daily
- Metoprolol (Lopressor, Toprol XL) 100-200 mg daily
Anti-epileptic drugs
- Divalproex (Depakote) 250–500 mg twice daily
Black Box Warning: This medication may cause fetal harm, liver failure, pancreatitis
Common side effects: weight gain, thrombocytopenia (low platelet levels in your blood), increased ammonia, alopecia (hair loss), nausea and/or vomiting, tremor, and ovarian syndrome. - Valproic acid (Depakene) 250–500 mg twice daily
Black Box Warning: This medication may cause fetal harm, liver failure, pancreatitis
Common side effects: weight gain, thrombocytopenia (low platelet levels in your blood), increased ammonia, alopecia (hair loss), nausea and/or vomiting, tremor, and ovarian syndrome. - Topiramate (Topamax) starts at 25 mg every night at bedtime, titrate to 50 mg twice a day
Warning: This medication may cause fetal harm, metabolic acidosis (excessive acid accumulation in your body), nephrolithiasis (kidney stone), increased ammonia, open-angle glaucoma, and oligohidrosis (the inability to sweat).
Common side effects:e weight loss, sleepiness, and cognitive impairment.
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists
Calcitonin gene-related peptide is a neuropetide. During a migraine attake, there is an increase of CGRP from the trigeminal nerve, causing the blood vessels to diate and become inflamed. The dilation and inflammation are believed to cause migraine pain and other symptomes.
CGRP receptor antagonist blocks the activity of CGRP to reduce inflammation and swelling of blood vessels. It also decreases the transmission of the pain signals in the brain.
- Nurtec ODT 75 mg daily
Can treat migraines and also prevent them from occurring.
Common side effect: nausea
How can I prevent migraines?
- Stress management, including taking time to relax
- Consume a significant amount of liquids
- Eating regularly and not skipping a meal
- Get lots of sleep
- Exercise regularly
- Keep a migraine notebook or journal to record your triggers and the most effective therapies.
If you get migraines around your menstruation or if lifestyle adjustments are ineffective, speak with your doctor about preventative medications.
Natural products to help prevent migraines
- Magnesium (especially if you already have low magnesium levels)
- According to research, magnesium may be an effective acute (short-term) treatment option for headaches such as migraines, tension-type headaches, and cluster headaches, particularly in certain patient subsets. It’s also well-tolerated, safe, and affordable for migraine prevention.
- Butterbur
- Butterbur is a plant that’s also known as Petasites hybridus
- Petasites are beneficial for preventing migraines when taken in 50-75 mg dosages twice daily
- Feverfew
- An herb that’s also known as Tanacetum parthenium
- Has been used to treat a variety of conditions, such as fever, swelling, and/or inflammation
- Riboflavin
- Also known as vitamin B2, assists your body's process of converting food (carbohydrates) into the fuel (glucose) needed to produce energy.
- Although not enough research has been done, it has been demonstrated that riboflavin decreases the number of migraine attacks individuals encounter monthly.
- Peppermin—can be applied topically
- Menthol, the main component of peppermint oil, is offered in liquid pill form. For simple brewing, tea variants are also available.
- In a 2010 study, menthol in a 10 percent solution was found to be efficient at reducing migraine pain and nausea when applied to the forehead and temples.
- Co-enzyme Q10
- Coenzyme Q10 is an antioxidant that is produced naturally by your body
- Shown to have a positive impact on decreasing migraine attack frequency, headache duration during an attack, and reducing the number of total migraine days per month.
Talk to your primary care physician about your symptoms. They are able to identify and diagnose migraines and begin a treatment plan.