Also called: Migraine Headaches
A migraine is a severe, debilitating form of headache that typically appears as a throbbing ache near the side of the forehead. Over time, the ache often intensifies to a disabling pain. Migraines are usually a chronic condition, occurring repeatedly throughout a person’s life.
Migraines are considered a type of vascular headache because they involve blood vessels, nerves and chemicals in the brain. Although the exact cause of this type of headache is not fully understood, a number of factors that can trigger the condition have been identified. These include sensory stimulus (e.g., bright lights, loud noises, certain odors), stress and certain foods, such as chocolate or nuts.
A migraine differs from other types of headaches because it is usually more severe and often accompanied by a number of other symptoms, such as nausea or vomiting. In some people, temporary visual changes such as hallucinations or blind spots may occur before the headache appears. Known as aura, these warning symptoms occur in only about one–fifth of migraine suffers. Migraine with aura (classic migraine) and migraine without aura (common migraine) are the two most common types of migraine.
A number of serious conditions, including stroke, blood clot, and brain tumor, can cause severe headaches that may be mistaken for migraines. To rule out these conditions, a physician evaluates the patient by taking a medical history and performing a physical examination. Diagnostic tests such as MRI, CAT scan or electroencephalogram (EEG) may also be performed.
There is no known cure for migraines. However, there are a number of methods used to control symptoms and prevent future episodes. These include headache medications, biofeedback and self–hypnosis. Patients may help prevent migraines by avoiding factors that trigger the headaches.
The National Headache Foundation (NHF) estimates that more than 28 million Americans experience migraine. The disease is more common in women, people between the ages of 15 and 55, and those with a family history of the condition.
People with other conditions are sometimes incorrectly diagnosed with migraines, but because symptoms and onset vary, some migraine sufferers go undiagnosed. The NHF estimates that even among people with complaints of severe disability from the condition, a large percentage do not receive a diagnosis of migraine.
Although they can be debilitating, migraines pose little risk of severe damage to a person’s overall health. However, patients should seek emergency medical treatment when a headache is accompanied by a symptom not experienced with previous migraines, such as speech problems or a loss of balance, as it may indicate a more serious medical condition.
Migraines are a type of vascular headache. They involve blood vessels, as well as nerves and chemicals in the brain. They are most likely caused by an abnormal trigger of chemicals that cause the blood vessels to swell. Migraines differ from other types of headaches because they often are more severe and are accompanied by other symptoms. In patients with aura, they can have unusual symptoms such as nausea or fatigue even two days before the onset of full-blown migraine.
Often described as a throbbing headache, migraines are usually felt on only one side of the head. They typically begin as a dull ache near the side of the forehead. Over a period of several minutes to hours, the ache intensifies to a disabling pain. The pain is often so severe that people may be sensitive to anything touching their head (allodynia).
Without treatment, the headache may last anywhere from four to more than 72 hours. During this time, a person may experience a number of additional symptoms including nausea, vomiting and sensitivity to light. The pain associated with a migraine is referred pain, meaning it is usually felt around the eye or temple area, but it may develop in the face, sinus, jaw or neck.
According to National Headache Foundation (NHF), more than 28 million Americans experience migraines. The frequencies in which migraines are experienced vary from person to person. Some people experience migraines once or twice a year, whereas others will experience them several times a month.
Migraine symptoms appear differently among individuals. None of the symptoms develop in all individuals, making the diagnosis of the condition more difficult. In a large study conducted by the NHF in 1999, 48 percent of the individuals with migraines reported that they had received a medical diagnosis. Even today, the NHF estimates that less than half of the people who suffer with migraines receive a medical diagnosis.
Although migraines pose little risk of long-term damage to a person’s overall health, the debilitating pain can interfere with daily life. In addition, there is a very low risk of stroke associated with severe migraines. This may result from a narrowing of the blood vessels, which reduces blood flow to parts of the brain. Permanent neurological changes, such as muscle weakness, may also occur as the result of complicated migraines.
Severe headaches from a number of serious conditions may be mistaken for migraines. These headaches may be caused by:
- Stroke or intracerebral hemorrhage (bleeding in the brain resulting from the rupture of a blood vessel within the head)
- Blood clot or aneurysm (an abnormal expansion or ballooning of a section of an artery)
- Brain tumor
- Temporal arteritis (inflammation of arteries in the head)
- Cranial neuralgias (pain in nerves of the head)
- Encephalitis or meningitis
- Lyme disease
As a result, patients should discuss all serious or recurring headaches with their physician and seek medical attention when a headache:
- Starts suddenly
- Is severe or persistent
- Disturbs sleep
- Occurs during activity
- Changes in pattern or intensity
- Intensifies after lying down
- Is accompanied by other symptoms, such as drowsiness or vision changes
Emergency medical treatment should be sought when:
- A headache is accompanied by unusual symptoms not experienced with previous migraines, including:
- Speech problems
- Vision abnormalities
- Numbness, weakness or loss of balance
- Difficulty moving a limb
- Stiff neck
- Seizures or mental confusion
- A headache occurs soon after a sore throat or respiratory infection
- A headache occurs after a head injury
- A chronic headache intensifies with coughing, exertion, straining or sudden movement
- A new type of headache pain occurs (in those over age 50 or younger than 8)
- A new type of headache pain occurs that is severe and not contained to just one side of the head
- There is loss of consciousness
Types and differences of migraines
The two major classifications for migraines are:
- Migraine without aura. Also known as common migraine, this type of migraine is characterized by a severe throbbing headache felt usually on only one side of the head. Additional symptoms may include nausea, vomiting, allodynia and sensitivity to light, sound and odors. It is the most common form of migraine.
- Migraine with aura. Also known as classic migraine, this type of migraine is similar to the common migraine except it is preceded by warning symptoms (aura) before the headache occurs. The aura usually presents as a visual disturbance that begins 20 to 60 minutes before the onset of the migraine, but can start up to 48 hours before.
Additional classifications include:
- Complicated migraine. In some cases, warning symptoms (aura) are prolonged, or continue into or through the headache period. This type of migraine is known as a complicated migraine. Forms of complicated migraine include:
- Ophthalmoplegic migraine. During this migraine, patients develop a partial or complete paralysis of the nerves needed for eye movement. The pain typically surrounds the eye. Triggered by weakness of the muscles encasing the eyes, the pain can last anywhere from a few days to a few months. This is a rare form of migraine that most often occurs in children and young adults.
- Retinal migraine. Also known as an ocular or ophthalmic migraine, this type of migraine is characterized by multiple episodes of blind spots or blindness related to a headache. It differs from other forms of headache because the retina (light-sensitive tissue in the back of the eye) is responsible for the visual disturbances, not the brain.
- Hemiplegic migraine. This form of migraine is characterized by numbness or tingling and temporary paralysis on one side of the body. Because of its similarity in symptoms to a stroke, individuals should seek immediate medical attention if they experience these symptoms.
Although they occur rarely, hemiplegic migraines are considered one of the most severe forms of migraine. In some cases, it may take several weeks for a patient to recover completely. In addition, patients may suffer permanent weakness after multiple episodes.
A rare type of hemiplegic migraine can be inherited. Known as familial hemiplegic migraine, this condition has been connected to mutations in genes on several chromosomes. Familial hemiplegic migraine is autosomal dominant, meaning it can be passed on to a child if only one parent has the abnormal gene.
- Basilar migraine. Also known as Bickerstaff’s syndrome, this type of migraine is characterized by neurological symptoms related to the brainstem. It occurs as the result of a migraine affecting circulation in back of the neck or brain. Patients may experience headaches located at the back of the head, accompanied by numbness on both sides of the body and severe vomiting. Additional symptoms may also occur, including dizziness, double vision, loss of balance, confusion, slurred speech, disorientation, fainting and loss of consciousness. This condition occurs most often in children and young women.
- Migraine equivalents. Also known as migraine variants, acephalgic migraine or simply migraine aura without headache, this rare type of migraine presents in a form other than head pain. A patient with a previous history of migraines may be diagnosed with this condition when the headaches have been replaced by an equivalent set of symptoms. A migraine equivalent may present in the form of visual abnormalities (e.g., blind spots), neurologic deficits or psychic disturbances without headache.
A common form of migraine equivalent is the abdominal migraine. Also known as periodic syndrome, this form of migraine most often occurs in children. Patients usually have a family history of migraines, and they often develop typical migraines later on in adulthood. The condition is characterized by recurrent bouts of abdominal pain without headache. These episodes can last for a number of hours. The condition is often accompanied by nausea, vomiting, flushing and pallor (paleness).
Additional terms used to describe migraines include:
- Coexisting migraine and tension headache. Also known as transformed migraine, chronic migraine and chronic daily headache, this condition is characterized by the combination of a chronic tension–type headache and recurrent migraine headaches. In most cases, patients with this condition have a personal history of migraine headaches that can be traced back to adolescence or young adulthood.
- Cyclic migraine syndrome. Patients with this syndrome usually have 10 or more migraines a month, which are accompanied by typical migraine symptoms. These headaches are not classified as cluster headaches because they are long-lasting and do not have symptoms typically associated with cluster headaches.
- Menstrual migraine. This term may be used to describe migraines that occur during ovulation or before, during or immediately after a woman’s menstrual period.
- Nocturnal migraine. This term may be used to describe migraines that occur during the middle of the night or in the early morning. Patients experiencing nocturnal migraines are often awakened by them. They may be caused by changes in the brain’s neurotransmitters that occur during sleep.
- Status migraines. This term may be used to describe a migraine that continues for more than 72 hours.
- Migraine with acute-onset aura. This term may be used to describe aura that fully develops in less than five minutes.
Risk factors and causes of migraines
Migraines are caused by abnormal brain activity. This abnormal activity may be triggered by a number of factors. Although the exact process in which this occurs is unknown, the disorder appears to involve blood vessels, nerve pathways and chemicals in the brain.
Some researchers believe migraines are caused by imbalances in brain chemicals such as serotonin (a neurotransmitter that controls pain signals traveling through the trigeminal nerve) or changes in the trigeminal nerve, which carries sensory stimuli to the brain from the face, teeth and tongue. Others believe that migraines are due to central sensitization, which means that pain centers feel pain without any painful stimulus (allodynia).
Serotonin levels drop during a migraine. Many researchers think this triggers the trigeminal nerve to release substances known as neuropeptides. Once released, the neuropeptides travel to the brain’s surface, where they cause swelling and inflammation of blood vessels. This results in head pain. Low levels of magnesium, a mineral involved in nerve cell function, may also play a role.
Factors that may trigger a migraine include:
- Sensory stimulus, such as bright lights, loud noises or certain odors
- Stress (physical or emotional)
- Changes in sleep patterns, including too little or too much sleep
- Smoking or exposure to secondhand smoke
- Skipping or delaying meals
- Alcohol or caffeine
- Intense physical activity
- Tension headaches
- Medications that cause the blood vessels to swell (vasodilators), including some blood pressure medications
- Frequent use of pain medication (rebound withdrawal headaches)
- Allergic reactions
- Environmental changes, such as changes in weather, altitude level, barometric pressure or time zone
- Hormonal changes, including those caused by menstruation, pregnancy, menopause, birth control pills or hormone replacement therapy
Although responses vary among individuals, certain foods can trigger migraines as well, including:
- Peanut butter and nuts
- Certain fruits (e.g., avocado, banana, citrus fruits)
- Dairy products
- Baked goods
- Fermented foods
- Pickled and marinated foods
- Foods containing monosodium glutamate (MSG) or nitrates (hot dogs, bacon)
- Foods containing the amino acid tyramine (e.g., red wine, aged cheese, smoked fish, chicken livers, figs and some beans)
A number of factors appear to make a person more likely to develop migraines. These risk factors include:
- Age. According to the National Headache Foundation (NHF), migraines occur most often between the ages of 15 and 55.
- Sex. The NHF estimates that women are affected with migraines three times as often as men.
- Family history. Migraines are more likely to occur in people with migraine sufferers in their immediate family, such as a parent or sibling. According to the NHF, between 70 and 80 percent of migraine sufferers have a family history of migraines.
Some studies have found increased prevalence of migraines in people with certain conditions, including epilepsy, insulin resistance, obesity, fibromyalgia and certain cardiovascular conditions (see Ongoing research).
Signs and symptoms of migraines
The main symptom of a migraine is a throbbing, pounding or pulsating headache. The pain, which may be dull or severe, is typically worse on the sides of the forehead. It starts on one side of the head and typically remains contained there. However, it may spread to the other side. For many migraine sufferers, the headaches start on the same side each time.
Exertion often intensifies the pain. In addition, many patients experience pain behind the eye or in the back of the head or neck.
Migraines may be accompanied by a number of other symptoms including:
- Nausea or vomiting
- Sensitivity to light or sound
- Loss of appetite
- Numbness, weakness or tingling
- Dizziness or vertigo (feeling that the room is spinning)
- Increased urination
- Increased sweating
- Swelling of the face
Some people who experience migraines have warning symptoms before the headache appears. Known as aura, these temporary visual disturbances are caused by transient changes in the activity of certain nerve cells. The changes may occur in one eye or in both. Aura most often occurs 20 minutes to one hour before a migraine. However, it can develop anywhere from a few minutes to 24 hours before the headache appears. Warning symptoms may include:
- Visual hallucinations (e.g., flashing lights, zigzag lines, dots)
- Blind spots
- Tunnel vision
- Sensitivity to bright light
- Blurred vision
- Eye pain
Most people, however, do not experience aura. According to the National Headache Foundation (NHF), only around one–fifth of migraine suffers experience aura. Some people also experience difficulty speaking, or a tingling sensation in their arm, leg or face.
Regardless of whether or not a patient has aura, there are a number of symptoms that may appear several hours to a day before a migraine occurs. Known as prodrome symptoms, these include:
- Feelings of elation or extreme energy
- Cravings for sweets
- Increased thirst
In children, a migraine may be preceded by:
- Sleepiness or listlessness
- Cravings for certain foods (e.g., chocolate, hot dogs, sweets, yogurt, bananas)
There are also a number of symptoms that may remain after a migraine has disappeared. These include:
- Mental dullness (unclear or slowed thinking)
- Increased need for sleep
- Neck pain
Diagnosis methods for migraines
During an evaluation for migraines, physicians take the patient’s medical history and perform a physical examination. While collecting a patient’s medical history, physicians may ask the patient about their symptoms. They will ask if there is a family history of migraines. Typically, physical examinations performed on patients with migraines yield no findings.
The patient may be asked to complete a pain assessment form, such as the Migraine Disability Assessment (MIDAS) Questionnaire, which was developed to help physicians identify sufferers most in need of care.
Information provided during the evaluation can help physicians determine whether a patient’s symptoms are the result of an underlying medical condition, such as a brain tumor or aneurysm.
A number of diagnostic tests may be ordered to rule out other potential causes. These may include:
- MRI (magnetic resonance imaging). MRIs use a powerful magnetic field to create images of structures and organs within the body, allowing a computer to produce clear cross-sectional or three-dimensional images. This test may be ordered to rule out sinus inflammation, brain masses and a number of other causes.
- CAT scan (computed axial tomography). This test allows for multiple x-rays to be taken from different angles around the patient. A computer analyzes the “slices” or cross-sectional images. Frequently after the first set of images is taken, the patient receives an intravenous (I.V.) injection of a contrast agent (dye) to better outline the body parts. Then a second set of images is taken. This test may be ordered to rule out sinus inflammation, brain masses and a number of other causes.
- Electroencephalogram (EEG). Electrodes are placed on the head to measure the brain’s electrical activity. This test may be performed to exclude seizures.
- Spinal tap (lumbar puncture). This procedure uses a needle to remove a sample of cerebrospinal fluid (CSF) from between vertebrae in the lower spine. Although this test is rarely performed, it may be ordered to rule out encephalitis, meningitis, subarachnoid hemorrhage or other possible underlying conditions that can cause severe headaches.
No tests are available yet to confirm the diagnosis of a migraine. As a result, migraines are often misdiagnosed as sinus headaches or tension headaches.
Treatment and prevention of migraines
There are a number of treatment options available for migraines. Although migraines cannot be cured, treatments aim to control the symptoms and prevent future episodes. Patients may benefit from immediately treating their migraine as soon as symptoms appear. This may lessen the severity of the headache.
Simple treatment methods for migraines include:
- Resting in a quiet and darkened room. During a migraine, patients are often sensitive to noise and light. Silence and darkness may lessen the severity of migraine symptoms.
- Drinking fluids. This prevents dehydration, especially after vomiting.
- Placing a cool cloth on the head.
Prescription and over–the–counter medications may also be used to prevent migraines, stop the progression of a migraine and relieve symptoms.
Prescription and over–the–counter headache medications may also be used to prevent migraines, stop the progression of a migraine and relieve symptoms:
- Beta blockers. These drugs decrease the workload of the heart and lower blood pressure.
- Calcium channel blockers. These drugs increase the flow of oxygen-rich blood to the heart, lower blood pressure and reduce the workload of the heart.
- Other antihypertensives. These drugs are commonly used to treat high blood pressure.
- Anticonvulsants. These drugs are commonly used to control seizures.
- Selective serotonin reuptake inhibitors (SSRIs). This class of antidepressants is most commonly used to treat depression. Antidepressants, however, may increase the risk of suicidal thinking and behavior in children and adolescents. As a result, the U.S. Food and Drug Administration recommends that people being treated with these drugs be closely monitored for unusual changes in behavior.
- Antihistamines. These drugs are commonly used to treat allergic reactions.
To be effective, these medications must be taken every day. They are frequently recommended for patients who experience three or more migraines a month. Although they may be recommended for some patients, they are less helpful and tolerable in patients with only occasional migraines.
Medications that can stop the progression of migraines or reduce their severity include:
- Ergot alkaloids
Patients who experience migraines with aura (temporary visual changes that precede a migraine) may benefit from taking these medications when warning symptoms occur. However, many of these medications are not safe for everyone. Drugs in this group may cause the blood vessels to constrict. As a result, they should not be taken by patients with heart disease or those at risk for a heart attack, unless recommended by a physician.
A variety of drugs may be recommended to reduce pain, nausea or emotional stress related to migraines. Medications given to treat these symptoms include:
- Anti-emetics to relieve nausea
- Sedatives to reduce anxiety
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen to reduce pain and inflammation
- Acetaminophen to relieve pain and reduce fever
- Narcotic analgesics (opioids) to relieve pain or inflammation
Medications used to treat migraines have variable effectiveness in different people. In many cases, a number of medications may be tried before an effective drug, or combination of drugs, is found.
As an alternative to drug therapy, patients may choose to take feverfew, MIG-99 (an extract of feverfew) or butterbur. These are herbs commonly used to treat migraines. Although their effectiveness has not been proven, some studies support their use. Riboflavin (vitamin B–2) and magnesium sulfate may also be helpful. Patients should receive their physician’s approval before taking herbs, supplements or other complementary and alternative treatments for their migraines.
Additional treatment methods include:
- Biofeedback. This method uses electronic monitoring devices to teach people how to consciously regulate their bodily functions through relaxation or imagery. Migraine suffers may use this technique to stop an attack or reduce its symptoms.
- Self-hypnosis exercises. This method requires a patient to self-induce a state of hypnosis (an altered state of consciousness). It may be used to control muscle contraction and the swelling of blood vessels in patients with migraines.
- Cognitive behavioral therapy. This technique, in which patients identify negative thought patterns and replace them with positive ones, may benefit people with chronic pain.
- Cryotherapy. Application of cold, such as compresses or an ice pack, can numb nerves and increase the patient’s pain threshold.
- Electrical therapy. Techniques such as occipital neurostimulation (ONS), in which electrodes are placed near the base of the skull in minimally invasive surgery, have been used to ease severe migraines.
- Acupuncture or acupressure. Some people have found these Eastern treatments helpful.
People respond differently to treatment. Some may require little or no treatment and others may require the use of several medications or techniques, or in some cases, occasional hospitalization. Patients are encouraged to contact their physician when treatments that were previously effective are no longer helpful.
In addition to taking medications, patients may reduce the frequency of migraines by avoiding factors that trigger the headaches. Patients may identify these triggers by keeping a headache diary. To compile this journal, patients should record certain information after each migraine occurs, including:
- When the migraine occurred
- How severe the migraine was
- Additional symptoms experienced with the migraine
- What was eaten before the migraine occurred
- Sleep patterns
- Menstrual cycles
Other common prevention methods include:
- Avoiding cigarette smoking
- Avoiding caffeine and alcohol
- Avoiding or reducing medications containing estrogen
- Exercising regularly
- Maintaining a regular diet and sleep pattern
- Using relaxation techniques, such as progressive muscle relaxation or meditation
Ongoing research regarding migraines
There is a great deal of research being conducted on migraines, including clinical trials and scientific studies. Many studies are focused on developing more effective treatment methods. Areas of research include:
- Botulinum toxin type A (Botox). This drug is commonly used to reduce the appearance of wrinkles. In clinical studies, however, this form of injection therapy has reduced the frequency and the intensity of migraines in some people. More research is needed to verify the connection.
- Other medications. Many combinations, new drugs and new formulations of older drugs are under study.
- Nerve blocks. Performing an occipital nerve block may abort an attack, but more research is needed.
- Genetics. Because migraines appear to be linked to family history, researchers are studying the possibility of a “migraine gene.”
- Links to other conditions. Scientists are investigating the relationship of migraines to conditions including epilepsy, insulin resistance, obesity, irritable bowel syndrome, fibromyalgia, depression, and cardiovascular disorders such as heart attack, high blood pressure and a fairly common heart defect called patent foramen ovale (PFO).
- Surgery. Nasal surgery to keep surfaces inside sinuses from touching has brought relief to some migraine sufferers. Recent research has found that some migraine patients improved after surgical removal of muscle or a minor nerve to reduce nerve compression and inflammation. Surgical treatment of PFO is being investigated as a way of controlling migraines associated with this heart defect.
Questions for your doctor regarding migraines
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about migraines:
- What could be causing me to have migraines?
- How can I tell whether I’m having a migraine or another type of headache?
- Is there anything about me that makes me prone to migraines or more severe attacks?
- Are migraines likely to run in my family?
- If so, is there any kind of testing or preventive care my children should undergo?
- What is the expected course of my condition? Will it be lifelong?
- Is it likely my attacks will become more or less frequent, or more or less severe?
- How can I determine the cause of my migraines? Should I keep a migraine diary?
- What’s the best way to isolate which foods could trigger my migraines?
- What else besides foods could be my triggers?
- What symptoms of migraines can I expect to see? Will I likely have an aura before an attack? What might I experience in an aura?
- What diagnostic tests for migraine might I have to undergo, and what do they involve?
- What do my test results indicate? What type of migraine do I have?
- Are there ways I can distinguish an attack I can treat from one that needs medical attention?
- What is the best over-the-counter drug for my migraines?
- If I need prescription medication, what do you recommend?
- Can any of my medications interact badly? Are there over-the-counter medications or supplements I should avoid?
- Can anything reduce my need for medication?
- Do you recommend other treatments, such as biofeedback, cognitive behavioral therapy, stress management, exercise therapy, cold therapy, acupuncture or anything else?
- At what point should I call you or seek emergency treatment for a migraine?
- Is there anything I can do to prevent migraines?