Migraine
A migraine is more than a headache:
What Is Migraine? Symptoms, Causes, Diagnosis, Treatment, and Prevention
Migraine is a neurological disease characterized by repeated episodes of symptoms, called attacks, that usually include headache, often accompanied by nausea; vomiting; sensitivity to light, touch, smell, or sound; dizziness; visual disturbances; and tingling or numbness in the face, hands, or feet.
Migraine attacks may come on suddenly without warning, or they may be preceded by certain known triggers, such as skipping a meal, being exposed to smoke or air pollution, or experiencing a change in hormone levels as part of the menstrual cycle. Most migraine attacks last from 4 to 72 hours, although effective treatment can shorten them to a matter of hours. On the other hand, some migraine attacks can last even longer than 72 hours.
Having a migraine can be disabling and can lead to missing days of school or work, being less productive at school or work, being unable to perform household responsibilities, and missing out on family, social, and leisure activities.
An estimated 1 billion people worldwide, and 39 million Americans, have migraine.
While a variety of triggers can set off migraine attacks, they don’t directly cause the attacks or the underlying disease.
There are still gaps in doctors’ understanding of what causes migraine. However, some doctors describe the migraine brain as hyperactive, or supersensitive, by which they mean that the brain of someone with a migraine reacts more strongly to environmental stimuli such as stress or sleep disturbance than the brain of someone who doesn’t have a migraine, resulting in the symptoms known as a migraine attack.
There is no cure for migraine, but treatments and lifestyle approaches can help minimize the number of attacks a person has and shorten or reduce the severity of those that do occur.
Types of Migraine
There are two main types of migraine: with or without aura. Migraine with aura is further divided into four subtypes: migraine with typical aura, migraine with brain stem aura, hemiplegic migraine, and retinal migraine. And some of these subtypes have sub-subtypes of their own. A person can have more than one type of migraine simultaneously as well as other types of headaches.
Migraine is also categorized as chronic or episodic, based on the number of days per month a person has symptoms. Chronic migraine is defined as migraine pain that is experienced for 15 or more days per month for at least three months. Episodic migraine is defined as fewer than 15 days of migrainous symptoms per month.
An estimated 144 million people worldwide — and 3 to 7 million Americans — have chronic migraine. As with episodic migraine, chronic migraine is up to 3 times more common in women than men.
Identifying what type of migraine you have may help you and your doctor choose the right treatment for you. It can be essential if you want to participate in clinical trials.
Migraine Without Aura
Formerly known as common migraine, migraine without aura is characterized by a headache that’s usually on one side of the head, has a pulsating quality, is worsened by physical activity, and is accompanied by nausea or light and sound sensitivity.
Migraine without aura may have a prodrome, or warning, phase, in which a person experiences symptoms such as depression, food cravings, difficulty focusing, uncontrollable yawning, and others.
It can also have a postdrome phase when the headache pain has receded, but a person feels tired and achy and has trouble concentrating.
Alternatively, a person may feel elated and even euphoric after the headache phase of migraine has passed.
Migraine With Aura
Migraine with aura, formerly called classic migraine, occurs in up to 30 percent of people who have migraine. It usually causes the same symptoms as migraine without aura, except that the headache phase of the migraine attack is preceded by neurologic disturbances that may include visual, speech, or sensory changes.
Examples of visual aura include seeing stars, zigzags, or flashing lights; blurred vision; temporary blind or colored spots; and tunnel vision.
Sensory disturbances may include a feeling of pins and needles or numbness in a part of the body, face, or tongue.
In some cases, aura symptoms occur with no headache accompanying or following them.
Migraine With Brain Stem Aura
This type of migraine, formerly known as basilar-type migraine, is a rare type of migraine with aura. It usually includes neurologic symptoms such as double vision, problems speaking and hearing dizziness, and loss of balance and coordination.
Hemiplegic Migraine
This type of migraine comes in two forms: familial hemiplegic migraine and sporadic hemiplegic migraine. Both are characterized by aura, fever, and hemiplegia (paralysis on one side of the body). Both are relatively rare.
Retinal Migraine
Retinal migraine is an extremely rare cause of temporary vision loss in one eye. It’s diagnosed when a person has repeated attacks of one-sided visual disturbance — including the types of visual symptoms commonly seen in migraine aura — or blindness associated with migraine headaches. These symptoms tend to evolve over five or more minutes, may last as long as an hour, and may be accompanied or followed by a headache.
Chronic Migraine
Chronic migraine is defined as a headache occurring 15 or more days per month for at least three months, with the headache having migraine-like features on at least eight of those days.
Given the frequency of symptoms in chronic migraine, it can be impossible to determine when one migraine attack ends and another begins. It can also be difficult to determine whether an individual in fact has chronic migraine or has another condition, such as medication-overuse headache, that would be expected to cause daily or near-daily head pain.
According to The International Classification of Headache Disorders, keeping a detailed headache diary for at least a month may be necessary to determine what sort of headache — or headaches — a person is experiencing
Syndromes That May Be Associated With Migraine
Certain disorders occur more frequently among people with migraine or people, usually children, at a higher risk of developing migraine:
Cyclical vomiting syndrome In cyclical vomiting syndrome, an individual experiences attacks of severe nausea and vomiting lasting an hour or more for up to 10 days at a time. Between attacks, which occur on a regular cycle, the person has no symptoms of nausea or vomiting.
Abdominal migraine This type of episodic migraine is diagnosed mostly in children. Symptoms include abdominal pain, nausea, and vomiting. Kids who experience abdominal migraine often don’t have attacks involving headaches in adolescence but go on to develop them as adults.
Benign paroxysmal vertigo In this syndrome, otherwise healthy children experience recurrent brief attacks of vertigo that come on without warning and resolve spontaneously without loss of consciousness. During the attacks, a child may have nystagmus (uncontrolled horizontal or vertical eye movement), impaired balance or coordination (called ataxia), vomiting, pale skin, and fearfulness.
Benign paroxysmal torticollis Occurs in infants and small children, this syndrome causes the head to tilt to one side, with or without slight rotation, and stay tilted for minutes to days before spontaneously resuming its normal position. During the attack, the infant or child may be pale and irritable, seem uncomfortable or generally unwell, vomit, or in older children, have impaired balance or coordination.
Other Types of Headaches
Other rare types of headaches include these varieties:
What Is the Difference Between a Headache and Migraine?
Migraine is a type of primary headache disorder, as is a tension-type headache. The cause of neither is fully understood, but both appear to involve a heightened sensitivity to stimuli, whether pain, in the case of tension headache or environmental changes, in the case of migraine.
While head pain is a symptom of both migraine and tension headache, migraine attacks are often accompanied by nausea and are made worse with routine physical activity, while tension-type headache is not.
In addition, headaches caused by migraine typically occur on one side of the head, while tension headaches typically affect both sides.
And migraine tends to have a pulsating or throbbing quality, while the pain of a tension-type headache is described as pressing or tightening.
Having one type of primary headache disorder doesn’t rule out having another. In fact, many people have both migraine and tension-type headaches.
Signs and Symptoms of Migraine
Symptoms of migraine vary depending on the type of migraine and on the person. In general, though, migraine attacks are very painful and can interfere with your daily life.
The most common symptom of migraine is head pain — often characterized as an intense throbbing sensation, usually on one side of the head but sometimes on both sides of the head, and sometimes starting on one side of the head and moving to the other side.
However, migraine attacks have four stages, with somewhat different symptoms at each stage:
Prodrome, or warning, stage You may notice the first signs of a migraine attack one or two days before the onset of aura symptoms or headache. These early warning symptoms can include changes in mood, cravings for certain foods, muscle stiffness, trouble concentrating, sensitivity to sound or light, fatigue and difficulty sleeping, yawning, and frequent urination.
Not everyone who has migraine experiences all four stages, and even those who usually do may not experience all four during every migraine attack.
Generally speaking, these are the most commonly reported migraine signs and symptoms:
Other migraine symptoms may be less common or simply less commonly reported:
Causes and Risk Factors of Migraine
The exact cause of migraine remains unknown. Research suggests that genetic and environmental factors may play a role.
Studies have linked changes in the brain stem and the trigeminal nerve, which mediates pain, to migraine.
Chemical imbalances in the brain may also be involved. Depression and anxiety have long been associated with migraine — depression affects 25 percent of people with migraine, and 50 percent have anxiety, according to the American Migraine Foundation. A study published in Headache found that migraine frequency was associated with the severity of depression and anxiety.
Researchers have found that serotonin levels drop during migraine attacks, causing the trigeminal system to release substances called neuropeptides, which cause headache pain.
A change in the weather or barometric pressure, which can cause imbalances in brain chemicals, may prompt a migraine attack.
Researchers have identified several key risk factors for developing migraine, including the following.
Heredity
The Migraine Research Foundation in New York City reports that approximately 90 percent of people with migraine have a family history of the condition.
Age
People with migraine typically experience their first symptoms during adolescence. Most people who have migraine have their first attack before they reach age 40. But migraine can start at any time in life, depending on other factors.
Gender
During childhood, migraine typically affects boys more than girls, but this trend reverses during adolescence. In adulthood, women are much more likely than men to experience migraine. It seems that hormonal changes, specifically involving estrogen, play a role.
Menstruation and Menopause
Women who experience migraine often do so immediately before or shortly after their menstrual period, when there is a drop in estrogen.
The frequency, severity, and duration of migraine may change during pregnancy or menopause. Some women report that they experience their first migraine attack during pregnancy or that their attacks worsen during pregnancy, while others experience fewer headaches.
How Is Migraine Diagnosed?
There’s no single test that can lead to a diagnosis of migraine. Rather, your doctor will take your medical history, as well as obtain your family history of migraine, and perform a physical and neurological exam. Your healthcare provider may order certain blood tests and imaging tests to rule out other causes of headaches. Keep a detailed log of your symptoms to help with diagnosis.
Prognosis of Migraine
Migraine has a highly variable long-term prognosis. Some people have fewer and less severe migraine attacks over time, while others have more attacks, sometimes transitioning from episodic migraine to chronic migraine. Still others have long periods of remission, during which they have no migraine attacks.
Researchers are still exploring the natural history of migraine, as well as what may contribute to both decreases and increases in migraine attacks over the long term.
In a study published in 2020 in the journal Headache, researchers surveyed 380 people with migraine twice, 10 years apart. Of that group, slightly over 47 percent reported a decrease in migraine attack frequency of 50 percent or more at the 10-year mark. Factors associated with improvement were having a baseline frequency of more than 10 headache days per month at the start of the study, not smoking, and having had a medical follow-up visit for migraine during the study period.
An earlier study, also published in Headache, that followed 374 people over 12 years found that for 29 percent of the group, migraine attacks had ceased entirely at the 12-year mark. Of the 264 people who were still experiencing migraine attacks, 80 percent reported a change in attack frequency (and of those, 80 percent reported fewer attacks), and 66 percent reported a change in pain intensity over time (and of these, 83 percent reported milder pain). Only six people in the study had developed chronic migraine over the study period. The researchers were unsure whether these changes reflected how migraine evolves naturally or better headache management among study participants.
Duration of Migraine
A migraine attack will typically last from 4 to 72 hours. But an attack can go on for several days.
The frequency of attacks varies from person to person. Some people experience migraine several times a month, while others have them much less frequently.
Treatment and Medication Options for Migraine
There’s no cure for migraine, but there have been recent advances in treatment.
Medications to Treat and Prevent Migraine Attacks
Medical treatment options for migraine are twofold: drugs that work to alleviate symptoms once an attack has started, and medications that prevent attacks from happening or reduce their frequency and severity.
Abortive medications Acute, or abortive, treatments include over-the-counter (OTC) pain relievers and prescription medications called triptans. In addition, antinausea medications can help relieve symptoms for those who experience nausea and vomiting with migraine.
It’s important to take antimigraine prescription medications and OTC pain relievers as directed and to follow your healthcare provider's instructions. Overuse of certain medications for migraine, including OTC drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, or prescription drugs such as triptans, can cause medication-overuse headaches (also known as rebound headaches). Frequent use of medications that initially relieve headache pain may end up triggering subsequent headaches. In order to treat these frequent headaches, you find yourself requiring greater amounts of medication for relief, which in turn can bring on more headaches. In other words, you can end up in a vicious cycle of chronic headache
Over-the-counter medications include:
Triptans include:
Triptans are all available in pill form. Zolmitriptan and sumatriptan are also available as nasal sprays. In addition, sumatriptan is available as an injection.
People with rare forms of migraine (hemiplegic and basilar (migraine with brainstem aura) and those with uncontrolled high blood pressure or a history of stroke or certain heart problems should also avoid triptans.
Antinausea medications include:
Metoclopramide and chlorpromazine are available in tablet and liquid form, or by injection. Metoclopramide is also available as a nasal spray. Prochlorperazine is given by tablet, suppository, or injection.
These days, ergots aren’t prescribed as often as the newer triptans, which tend to be more effective and have fewer side effects.
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Ergots include:
Dihydroergotamine can be given by intravenous (IV) injection or taken as a nasal spray. Ergotamine is available as a pill or a suppository.
Dexamethasone (Dexamethasone Intensol) is a steroid medication given by IV or injection that, when given with another acute migraine treatment, can reduce the risk of recurrence. It is also available on a tablet.
Another category of abortive migraine treatments is the calcitonin gene-related peptide (CGRP) receptor antagonists, which suppress pain. They include the oral medicines ubrogepant (Ubrelvy), and rimegepant (Nurtec ODT).
Another abortive migraine treatment is lasmiditan (Reyvow), which is taken as an oral tablet and is the only approved drug in the 5-HT1F receptor agonist class.
Preventive medications Most of the medications that have a preventive, or prophylactic, effect on migraine weren’t developed specifically for migraine; they’re primarily used to treat cardiovascular conditions, seizures, and depression. Preventive treatment is usually recommended for patients who have very severe or frequent long-lasting migraine headaches. Your healthcare provider will usually start you off with a low dose and gradually increase it until you notice an effect. Furthermore, some people may require both preventive treatment and acute treatment in order to control their headaches.
Beta-blockers include:
Metoprolol is available taken by tablet or capsule or given by injection. Propranolol is given by capsule, liquid, or injection. Timolol is instilled as an eye drop.
Antidepressants include:
Amitriptyline and venlafaxine are taken as pills.
Antiseizures include:
Other drugs have been developed to lower the frequency of migraine called CGRP antagonists, which work by blocking the action of CGRP, a protein in the brain and nervous system involved in the transmission of pain.
These drugs, which aim to block pain, are generally prescribed when symptoms don’t improve with standard preventive migraine medications such as beta-blockers, antidepressants, and anti-seizure medications.
These medications have been shown to reduce migraine days in both episodic and chronic migraine.
The CGRP antagonists, rimegepant (Nurtec ODT) and atonement (Qulipta) are available as oral medications.
Four other drugs that were developed specifically to lower the frequency of migraine include erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab-gnlm (Emgality), and eptinezumab (Vyepti). All four are CGRP antibodies, which block the action of CGRP, and all have been shown to reduce migraine days in both episodic and chronic migraine.
Injections of onabotulinumtoxinA (Botox) every 12 weeks may also help prevent migraine in some people with chronic migraine.
Some pharmacological treatments that help with chronic migraine are not effective when it comes to episodic migraine. Treatment will depend on what type of migraine you have.
Nerve Stimulation Devices for Migraine Relief
When medications aren’t providing adequate migraine relief, it may be worth trying a nerve stimulation device. These devices, of which there are several types, reduce pain or help prevent migraine episodes by delivering electrical or magnetic pulses to selected nerves.
They are unlikely to replace medications in a person’s migraine management plan, but they may help control pain when used alongside meds.
The available external devices target, respectively, the upper branch of the trigeminal nerve, on the forehead; the vagus nerve, via the neck; the occipital nerve, on the back of the head; and the peripheral nerves in the upper arm. An implanted device also targets the occipital nerve.
Side effects from nerve stimulation tend to be mild and mainly include redness, irritation, or muscle twitching at the site of the stimulation.
The main drawback of nerve stimulation devices may be that they’re expensive and not always covered by health insurance plans.
Complementary Therapies
In addition to medications, lifestyle changes (such as getting enough sleep, eating right, and managing stress) can help you avoid certain triggers, potentially preventing some migraine attacks. Practicing relaxation exercises, such as yoga and meditation, may ease migraine pain.
While the evidence isn’t definitive, some people with migraine have found that home remedies and alternative therapies such as acupuncture and biofeedback are effective. Consult with your healthcare provider to find an approach that works for you.
According to MedlinePlus, you should see your doctor if there are changes in your headache pattern if treatments you’ve been using stopped working, if your headaches are more severe when you’re lying down, or if you have bothersome side effects from your medication.
You should call 911 if you have problems with speech, vision, movement, paralysis, or loss of balance, particularly if you’ve never had these symptoms before with a migraine. If your headache starts suddenly, it may be an emergency.
Migraine Triggers
While there’s no way to completely prevent migraine, some people are able to control their exposure to certain triggers that can prompt an episode. Often you need several triggers to lead to a migraine attack, not just one.
Common triggers for migraine attacks include the following:
Changes in the Weather
Many people report that changes in the weather, particularly changes in barometric pressure, trigger migraine attacks. Other weather-related migraine triggers include heat, humidity, wind, and reduced light exposure.
Poor air quality, from wildfires or other sources of air pollution, can also be a trigger for some people.
Lights, Sounds, or Smells
Bright lights — whether natural, such as sun glare, or the flickering of a fluorescent bulb — are known to trigger migraine in many people with the condition.
Loud noises and strong smells (from perfume, cleaning products, or secondhand smoke) are also associated with migraine onset.
In some cases, however, heightened sensitivity to light, sound, and smell are the early signs of an oncoming attack — rather than light, sound, or smell triggering the attack.
Medications
Oral contraceptives (birth control pills) and vasodilators, such as nitroglycerin, have been linked to migraine. Overusing certain medications can also lead to headaches.
Dehydration
According to the American Migraine Foundation, about one-third of people cite dehydration as a migraine trigger. Make sure you’re drinking enough water throughout the day.
Disrupted Sleep
Getting too little or too much sleep can trigger migraine in some people, as can changes in your sleep-wake pattern, such as jet lag.
Foods and Food Additives
Certain foods and beverages, particularly alcoholic beverages, can be triggers. The flavor enhancer monosodium glutamate can also be a trigger, as can caffeine.
Foods containing the amino acid tyramine have been associated with migraine onset. Examples include aged cheese, smoked fish, chicken livers, figs, certain beans, and red wine.
The nitrates in cured meats such as bacon, hot dogs, salami, and other lunch meats are a trigger for some.
Research has also suggested that artificial sweeteners such as aspartame and sucralose can be triggers.
And for some people, fruits such as avocados, bananas, and citrus as well as some nuts and seeds can trigger migraine.
Missing or skipping meals can trigger attacks, too.
One approach to discovering migraine food triggers is to try an elimination diet, in which certain foods are eliminated from the diet for a few weeks, then reintroduced one at a time to see whether a migraine attack occurs.
However, a given food does not always trigger a migraine attack; sometimes another trigger, such as a change in the weather, also has to be present for an attack to take place. Or a certain amount of food has to be consumed before it has an effect, according to research.
Elimination diets can deprive you of whole-food groups for an extended period, potentially leading to nutrient shortfalls, and they can be difficult and stressful to follow. What’s more, undernutrition itself can be a migraine trigger, the research found.
For that reason, most experts recommend consulting your physician before trying an elimination diet for migraine and, if you do decide to try it, working with a registered dietitian to maintain good nutrition.
Stress or Relief From Stress
Everyday stress can trigger a migraine attack, as can the relaxation that may occur following stress. The American Migraine Foundation reports that stress is a trigger for 70 percent of individuals with migraine. In turn, the chronic pain of migraine can cause stress. It’s important to find healthy ways to reduce or avoid stressors, at work and at home, when possible
Complications of Migraine
Sometimes, the treatments you take for migraine can cause a complication known as a medication-overuse headache. This happens when the meds stop relieving pain and start causing headaches. Taking drugs to stop a migraine attack, such as Excedrin Migraine (acetaminophen), aspirin, Advil (ibuprofen), Imitrex (sumatriptan), or Maxalt (rizatriptan), too often or in high doses can trigger this phenomenon.
Also, taking a combination of certain migraine medicines, such as triptans and antidepressants, can cause your serotonin levels to rise and lead to a condition called serotonin syndrome. Symptoms include confusion, agitation, sweating, diarrhea, muscle twitching, and rapid heart rate. This condition can be very serious, even life-threatening if it’s not treated.
Rarely, do some people with migraine experience a migrainous infarction, which is a type of stroke that happens at the same time as a migraine with aura?
Research and Statistics: Who Gets Migraine?
The American Migraine Foundation estimates that at least 39 million Americans have migraine. The true number of cases is likely higher because many people have not been formally diagnosed.
Migraine is the third most common disease in the world, according to the Migraine Trust, a research-driven charity based in London. Migraine affects almost 15 percent of the global population.
Migraine disproportionately affects women. About 3 in 4 people with migraine are women, most commonly between ages 20 and 45.
BIPOC Communities and Migraine
The prevalence of migraine among Black, Indigenous, and People of Color (BIPOC) in the United States has not been well studied.
According to an article published in 2018 in the journal Headache, the prevalence of migraine or severe headache in 2015 was highest in American Indian or Alaska Natives (18.4 percent) compared with white, Black, or Hispanic Americans, with the lowest prevalence in Asian Americans (11.3 percent).
These percentages are based on data from the National Health Interview Survey (NHIS), the National Hospital Ambulatory Medical Care Survey, and the National Ambulatory Medical Care Survey. The NHIS performed a separate study on 3,197 households that identified as Native Hawaiian and Pacific Islanders and found that 13.2 percent of respondents experienced migraine or severe headaches.
Of course, the prevalence of a disease doesn’t tell the whole story. A paper in the Journal of the National Medical Association looked into the experience of headaches among Black Americans and found that compared with white people with headaches, “African American headache patients are more likely to (i) be diagnosed with comorbid depressive disorders; (ii) report headaches that are more frequent and severe in nature; (iii) have their headaches underdiagnosed and/or undertreated; and (iv) discontinue treatment prematurely, regardless of socioeconomic status.”
In a 2021 interview with the American Migraine Foundation, Jessica Kiarashi, MD, assistant professor at the University of Texas Southwestern Medical Center in Dallas and chair of the American Headache Society’s Underserved Populations in Headache Medicine Special Interest Section, identified other racial disparities in migraine care:
Dr. Kiarashi also noted that BIPOC communities were underrepresented in migraine and headache research, based on the sample of studies on headaches and migraine that her team reviewed.
Related Conditions
Migraine is associated with other medical conditions:
A note from Dr. Shaymaa Adil - Aesthetic Gp Doctor / MBChB - MFM
The effect of botulinum toxin injection on migraine
Common side effects
It is important not to rub the areas where the injections were done for the first 24 hours. Cleaning the forehead, washing the hair, and applying make-up is best avoided until the drug is fully absorbed during that first day. Minor changes to expression lines in the forehead are possible.