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Migraines

By

Stephen D. Silberstein

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Last full review/revision Jul 2021| Content last modified Jul 2021
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A migraine headache is typically a pulsating or throbbing pain that ranges from moderate to severe. It can affect one or both sides of the head. It is often worsened by physical activity, light, sounds, or odors and accompanied by nausea, vomiting, and sensitivity to sounds, light, and/or odors.

  • Migraines may be triggered by lack of sleep, changes in the weather, hunger, excessive stimulation of the senses, stress, or other factors.

  • They can be made worse by physical activity, light, sounds, or odors.

  • Doctors base the diagnosis on typical symptoms.

  • There is no cure for migraines, but drugs are used to stop the migraine as it is starting, to relieve pain, and to reduce the number and severity of migraines attacks.

Migraines are the most common cause of recurring moderate to severe headaches.

Although migraines can start at any age, they usually begin during puberty or young adulthood. In most people, migraines recur periodically (fewer than 15 days a month). After age 50, headaches often become significantly less severe or resolve entirely. Migraines are 3 times more common among women. In the United States, about 18% of women and 6% of men have a migraine at some time each year.

Migraines may become chronic. That is, they occur 15 or more days a month. Chronic migraines often develop in people who overuse drugs to treat migraines.

Migraines tend to run in families. More than half the people who have migraines have close relatives who also have them.

Causes of Migraine

Migraines occur in people whose nervous system is more sensitive than that of other people. In these people, nerve cells in the brain are easily stimulated, producing electrical activity. As electrical activity spreads over the brain, various functions, such as vision, sensation, balance, muscle coordination, and speech, are temporarily disturbed. These disturbances cause the symptoms that occur before the headache (called the aura). The headache occurs when the 5th cranial (trigeminal) nerve is stimulated. This nerve sends impulses (including pain impulses) from the eyes, scalp, forehead, upper eyelids, mouth, and jaw to the brain. When stimulated, the nerve may release substances that cause painful inflammation in the blood vessels of the brain (cerebral blood vessels) and the layers of tissues that cover the brain (meninges). The inflammation accounts for the throbbing headache, nausea, vomiting, and sensitivity to light and sound.

Estrogen, the main female hormone, appears to trigger migraines, possibly explaining why migraines are more common among women. Migraines can probably be triggered when estrogen levels increase or fluctuate. During puberty (when estrogen levels increase), migraines become much more common among girls than among boys. Some women have migraines just before, during, or just after menstrual periods. Migraines often occur less often and become less severe in the last trimester of pregnancy when estrogen levels are relatively stable, and they worsen after childbirth when estrogen levels decrease rapidly. As menopause approaches (when estrogen levels are fluctuating), migraines become particularly difficult to control.

Oral contraceptives (which contain estrogen) and estrogen therapy may make migraines worse and may increase the risk of stroke in women who have migraines with an aura.

Other triggers include the following:

  • Lack of sleep, including insomnia

  • Changes in the weather, particularly barometric pressure

  • Red wine

  • Certain foods

  • Hunger (as when meals are skipped)

  • Excessive stimulation of the senses (for example, by flashing lights or strong odors)

  • Stress

Various foods have been associated with migraines, but whether they trigger migraines is unclear. These foods include

  • Foods that contain tyramine, such as aged cheeses, soy products, fava beans, hard sausages, smoked or dried fish, and some nuts

  • Foods that contain nitrates, such as hot dogs and lunch meats

  • Foods that contain MSG (monosodium glutamate), a flavor enhancer found in fast foods, broths, seasonings, and spices

  • Caffeine (including that in chocolate)

Which foods trigger migraines varies from person to person.

Familial hemiplegic migraine, a rare subtype of migraine, causes weakness on one side of the body. It is associated with genetic defects on chromosome 1, 2, or 19. The role of genes in the more common forms of migraine is under study.

In some families, family members have different migraine symptoms. Some have mainly headache. Some have mainly vertigo Dizziness and Vertigo Dizziness is an inexact term people often use to describe various related sensations, including Faintness (feeling about to pass out) Light-headedness Dysequilibrium (feeling off balance or... read more (a type of dizziness) or weakness on one side of the body. Some have only a migraine aura with no headache. These findings suggest that migraine may be more than just a headache disorder.

Symptoms of Migraine

In a migraine, pulsating or throbbing pain is usually felt on one side of the head, but it may occur on both sides. The pain may be moderate but is often severe and incapacitating. Physical activity, bright light, loud noises, and certain odors may make the headache worse. This increased sensitivity makes many people retreat to a dark, quiet room, lie down, and sleep if possible. Typically, migraines subside during sleep.

The headache is frequently accompanied by nausea, sometimes with vomiting, and sensitivity to light, sounds, and/or odors. People have difficulty concentrating during an attack.

Attacks vary greatly in frequency and severity. Many people have several types of headache, including mild attacks without nausea or sensitivity to light. These attacks may resemble a tension-type headache Tension-Type Headaches A tension-type headache is usually mild to moderate pain that feels like a band tightening around the head. Stress, sleep disturbances, neck or jaw pain, or eye strain may trigger these headaches... read more but are a mild form of migraine.

Migraine attacks may last for hours to a few days (typically 4 hours to several days). Severe attacks can be incapacitating and disrupt family and work life.

A prodrome often occurs before a migraine. The prodrome is sensations that warn people that an attack is about to begin. These sensations may include mood changes, neck pain, food cravings, loss of appetite, and nausea.

An aura precedes migraines in about 25% of people. The aura involves temporary, reversible disturbances in vision, sensation, balance, muscle coordination, or speech. People may see jagged, shimmering, or flashing lights or develop a blind spot with flickering edges. Less commonly, people experience tingling sensations, loss of balance, weakness in an arm or a leg, or difficulty talking. The aura lasts minutes to an hour before and may continue after the headache begins. Some people experience an aura but have only a mild or no headache.

Migraines usually become less severe as people age. However, auras that affect vision without a headache occur more frequently in older people.

Did You Know...

  • Sometimes migraines cause symptoms such as disturbances in vision or balance without causing a headache.

  • Taking pain relievers too often can make migraines worse.

Diagnosis of Migraine

  • A doctor's evaluation

  • Sometimes computed tomography or magnetic resonance imaging

No test or procedure can confirm the diagnosis.

Certain findings are warning signs that suggest that the headaches may be caused by a serious disorder. These findings include the following:

  • A sudden headache that becomes most severe within a few seconds or less (thunderclap headache)

  • Headaches that begin after age 50

  • Headaches that increase in intensity or frequency for weeks or longer

  • Headaches that occur in people who have had cancer or have a weakened immune system (due to a disorder or drug)

  • A severe headache accompanied by a fever, a stiff neck, and/or confusion

  • Persistent problems that suggest a brain disorder, such abnormalities in sensation or vision, weakness, loss of coordination, and drowsiness or confusion

  • A clear change in the established headache pattern

If headaches have developed recently or if certain warning signs are present, magnetic resonance imaging (MRI) of the head is often done, and a spinal tap (lumbar puncture) is sometimes done to exclude other disorders.

If people who are known to have migraines develop a headache that is similar to their previous migraines, doctors rarely do tests. However, if the headache is different, particularly if warning signs are present, a doctor's examination and often tests are needed.

Prevention of Migraine

The choice of a preventive drug is based on the side effects of the drug and on other disorders present, as in the following examples:

Monoclonal antibodies, given by injection, block the action of a substance that can trigger migraines.

Other drugs that can be used to prevent migraines include calcium channel blockers.

Devices that stimulate certain nerves, held to certain parts of the body, can also help prevent migraine attacks. One such device, held to the forehead, can reduce the frequency of migraines. Another device, held to the back of the skull, can relieve migraines as they start and help prevent them. These devices have no significant side effects.

Treatment of Migraine

  • Behavioral interventions, yoga, or relaxation techniques

  • Drugs to stop a migraine as it starts or keep it from progressing

  • Drugs to control pain and nausea

  • Drugs to prevent migraines

Migraines cannot be cured, but they can be controlled.

Doctors encourage people to keep a headache diary. In it, people write down the number and timing of attacks, possible triggers, and their response to treatment. With this information, triggers may be identified and eliminated when possible. Then, people can participate in their treatment by avoiding triggers, and doctors can better plan and adjust treatment.

Doctors also recommend using behavioral interventions (such as relaxation, biofeedback, and stress management) to control migraine attacks, especially when stress is a trigger or when people are taking too many drugs to control the migraines. Relaxation techniques can help control stress, ease muscle tension, and alter brain wave activity.

Yoga can reduce the intensity and frequency of migraines. Yoga combines physical poses that strengthen and stretch muscles with deep breathing, meditation, and relaxation.

Drugs

Some drugs stop (abort) a migraine as it is starting or keep it from progressing. Some are taken to control the pain. Others are taken to prevent migraines.

For mild to moderate migraines, pain relievers (analgesics Treatment of Pain In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more ) can help control the pain. Often, nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen is used. They can be taken as needed during a migraine, with or instead of a triptan. For occasional mild migraines, analgesics that contain caffeine, an opioid, or butalbital (a barbiturate) may help. However, overuse of analgesics, caffeine (in analgesic preparations or in caffeinated beverages), or triptans can lead to daily, more severe migraines. Such headaches, called medication overuse headaches Medication Overuse Headache A medication overuse (rebound) headache occurs when people who take too many headache drugs have a headache for more than 15 days a month for more than 3 months. Medication overuse headache... read more , occur when these drugs are taken more than 15 days a month for more than 3 months.

When migraines are or become severe, drugs that can abort the migraine are used. They are taken as soon as people sense a migraine is starting. They include the following:

  • Triptans (5-hydroxytryptamine [5-HT], or serotonin, agonists) are usually used. Triptans prevent nerves from releasing substances that can trigger migraines. Triptans are most effective when taken as soon as the migraine begins. They may be taken by mouth or by nasal spray or be injected under the skin (subcutaneously).

  • Ditans are a new class of drugs that can abort headaches. They work like triptans but may have fewer side effects that involve the heart (such as changes in blood pressure or heart rate). Lasmiditan, taken by mouth, is currently the only ditan being used. No more than one dose of lasmiditan should be taken in 24 hours.

  • Gepants are another new class of drugs that can abort headaches. Gepants block a protein in the blood that triggers migraine. These drugs (rimegepant and ubrogepant) are taken by mouth.

  • Dihydroergotamine is given intravenously, subcutaneously, and by nasal spray to stop severe, persistent migraines. It is usually given with a drug used to relieve nausea (antiemetic drug), such as prochlorperazine, given intravenously.

  • Certain antiemetic drugs (such as prochlorperazine or metoclopramide) may be used to relieve mild to moderate migraines. Prochlorperazine, taken by mouth or given as a suppository, is also used to stop migraines when people cannot tolerate triptans or dihydroergotamine.

Because triptans and dihydroergotamine may cause blood vessels to narrow (constrict), they are not recommended for people who have angina, coronary artery disease, or uncontrolled high blood pressure. If older people or people with risk factors for coronary artery disease need to take these drugs, they must be monitored closely. However, people with one of these disorders can take lasmiditan, rimegepant, or ubrogepant.

If migraines are usually accompanied by nausea, taking an antiemetic with a triptan when symptoms begin is effective. Antiemetics (such as prochlorperazine or metoclopramide), taken alone, may also stop mild or moderate migraines from progressing.

When migraines are severe, fluids given intravenously can help relieve headache and make people feel better, especially if people are dehydrated from vomiting.

Other drugs are used to prevent migraine and can decrease the frequency and severity of symptoms. They include the following:

  • Antiseizure drugs

  • Beta-blockers

  • Calcium channel blockers

  • Monoclonal antibodies (erenumab, fremanezumab, and galcanezumab)

  • Tricyclic antidepressants

OnabotulinumtoxinA (which is injected into the scalp, forehead, and neck) or monoclonal antibodies can be used to treat chronic migraines.

Missing or reducing a dose of a drug used to prevent migraines or taking it late may trigger or worsen a migraine.

Table
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Devices that stimulate certain nerves, held to certain parts of the body, can help treat migraine attacks, as well as prevent them. One such device, held to the forehead, can reduce the frequency of migraines. Another device, held to the back of the skull, can relieve migraines as they start. A device that uses an armband to stimulate nerves in the skin can relieve migraine pain. These devices have no significant side effects.

Drugs Mentioned In This Article

Generic Name Select Brand Names
BOTOX
D.H.E. 45, MIGRANAL
COMPRO
REGLAN
TYLENOL
No US brand name
FROVA
INDOCIN
ZOMIG
Galcanezumab
Fremanezumab
IMITREX
AXERT
INDERAL
AMERGE
MAXALT
RELPAX
LOPRESSOR, TOPROL-XL
Butalbital
Lasmiditan
TOPAMAX
Ubrogepant
DEMEROL
ADVIL, MOTRIN IB
OXYCONTIN
CALAN
SPRIX
ALEVE, NAPROSYN
TENORMIN
Erenumab
CORGARD
TIMOPTIC
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