What is a migraine?
A migraine is a specific type of headache that is severe, persistent, and often occurs in conjunction with other symptoms. Researchers believe migraines are the result of abnormal brain activity that leads to constriction and subsequent dilation (widening) of the arteries in the brain. This process results in the classic symptoms of migraine that include nausea and vomiting, sensitivity to sound and light, and severe, throbbing headache that lasts several hours to several days.
Contributing factors—sometimes called headache or migraine triggers—may include muscle tension, stress, certain foods, odors, medications, dehydration, or changing levels of hormones. These triggers vary greatly from person to person.
Migraine is a common disorder in the United States, affecting as much as 12% of the population. Migraines are more common among women, adults between the ages of 30 and 39, people with a family history or migraine, and people with other medical conditions, such as anxiety, bipolar disorder, depression, epilepsy, or a sleep disorder.
Many effective medical treatments are available to reduce the frequency of migraines and control symptoms of migraine to a degree that allows a person to live a productive, active life. Treatment plans include lifestyle changes, medications, and avoiding substances and situations that can trigger a migraine.
In some cases, migraine headaches can be so severe or frequent that they are disabling and result in serious disruption of work, school, relationships, and social activities. Seek prompt medical care if you have symptoms of migraine, such as nausea and vomiting, and a severe, throbbing headache.
Symptoms of migraine can also mimic symptoms of more serious conditions, such as a stroke, meningitis, or retinal detachment. Seek immediate medical care (call 911) if you, or someone you are with, have a stiff neck and fever or sensory disturbances, such as numbness or vision changes.
What are the phases of migraines?
Migraines are also unique in that they have distinct phases. Not all individuals experience each phase, however. The phases of a migraine headache may include:
- Premonition phase (prodrome), a change in mood or behavior that may occur hours or days before the headache
- Aura phase, a group of visual, sensory, or motor symptoms that immediately precede the headache, including hallucinations, numbness, changes in speech, and muscle weakness
- Headache phase, a period during the actual headache when the sufferer may be sensitive to light and motion and experience depression, fatigue and anxiety
- Headache resolution phase (postdrome), a period when pain lessens but may be replaced with fatigue, irritability, and difficulty concentrating
There are four different types of migraine aura that may overlap but generally occur in the following order:
- Visual aura, usually begins as either a bright spot or small area of vision loss near the center of vision and expands out to peripheral vision over time
- Sensory aura, typically follows the visual aura and begins as a tingling in a limb or on one side of the face that leads to numbness
- Language aura, causes temporary speech impairments and difficulty understanding language
- Motor aura, the least common among the four auras, characterized by weakening of the limbs, and possibly face, on one side of the body
What are the types of migraine?
Migraine has several distinct subtypes differentiated by their specific symptoms, triggers and frequency:
- Chronic migraine, headache occurring 15 or more days per month for more than three months with features of migraine headache on at least eight days each month
- Episodic migraine, also referred to as ‘acute migraine,’ occurs fewer than 14 days per month
- Hemiplegic migraine, with similarities to the “motor aura” phase of some migraines, hemiplegic migraine is distinguished by weakened mobility and may sometimes include temporary vision loss, numbness, a burning sensation of the skin, communication and comprehension difficulties, fever, lethargy, and seizures
- Menstrual migraine, typically occurring within two days of the start of a woman’s menstrual period and lasting for the duration, menstrual migraine is closely associated with “hormonal migraine” or “estrogen-associated migraine”
- Retinal migraine, also called ocular migraine, characterized by repeated visual phenomena, vision impairment or blindness in one eye that lasts less than an hour, followed by a headache
- Vestibular migraine, includes vertigo associated with headaches and clinical features of migraine, such as sensitivity to light and sound
What are the symptoms of a migraine?
Symptoms of migraines vary between individuals. The length of a migraine can vary greatly, from several hours to several days or more. Some people may only have one migraine in their lifetime, but migraines often recur. Repeat migraines can happen often or there may be years between migraines.
Symptoms of migraines are the result of constriction and dilation, or widening of arteries in the brain. The symptoms may include:
- Difficulty concentrating
- Mild confusion
- Numbness or tingling in different parts of the body
- Sensitivity to light
- Sensitivity to sound
- Severe, throbbing or persistent headache that increases in intensity. The headache generally starts on one side of the head and can spread to the other side. However, migraines can vary greatly in character and intensity.
- Sudden, overwhelming fatigue and need to lie down in a dark, quiet room to sleep
Some people with migraines experience an aura, which consists of sensory disturbances that occur just before a migraine headache. Sometimes an aura is described as an inspirational or religious experience. Symptoms of an aura may include:
- Having a passing blind spot
- Seeing flashing lights, stars, or a zigzag pattern of distorted colors and lights
- Surging emotions
Serious symptoms that might indicate a life-threatening condition
Symptoms of a migraine can mimic symptoms of more serious, even life-threatening conditions, such as a stroke, meningitis, or retinal detachment. Only your healthcare provider can diagnose whether your symptoms are due to a migraine or other type of headache, such as a cluster headache, or a more serious condition.
Seek immediate medical care (call 911) if you have any of the following symptoms:
- Change in level of consciousness or alertness, such as passing out or unresponsivenes
- Headache that is extremely severe, or if you have been diagnosed with migraines, a headache that is different in nature from your usual migraine headache
- Headache that starts very suddenly
- Severe headache that was preceded by a head injury
- Stiff neck and fever
If you have been diagnosed with migraine, seek immediate medical care if these symptoms have not happened before with your migraines: symptoms that affect vision, mental functioning, balance, or cause numbness or trouble speaking.
What causes and triggers migraine?
Current research suggests migraine headaches may be caused by activation of certain brain chemicals and nerve pathways that lead to changes in blood flow. Specifically, blood flow to the brain is reduced by constriction of the arteries in the brain. This is followed by dilation or widening of these arteries.
The exact cause of this process is not known, but researchers have found some connections between neuron dysfunction in the brain and the pain sensitivity associated with migraine headaches. The release of calcitonin gene-related peptide (CGRP), a neurotransmitter that leads to blood vessel dilation, is thought to play a role in triggering migraine attacks, but additional research is needed to confirm.
Migraines are often triggered by one or more specific substances or situations. Triggers can vary greatly from person to person.
Physical migraine triggers
- Hormonal changes due to the menstrual cycle
- Not eating
- Disrupted sleep
- Neck pain
- Extreme exertion
Environmental migraine triggers
- Bright lights and fluorescent lights
- Extreme changes in weather, especially sudden onset of unusually warm weather
- High altitudes
Food-related migraine triggers
- Aged foods, such as aged cheeses and sausages
- Alcohol, especially red wine
- Certain food additives, such as monosodium glutamate, nitrates, and nitrites
If you have recurring migraines, it is a good idea to keep a migraine log or diary. This involves recording the timing, symptoms, and the types of situations that occurred or what you ate before the migraine occurred. This will help you determine triggers that can be avoided to minimize your migraines.
What are the risk factors for migraine?
Healthcare professionals have identified certain risk factors that can make you more prone to migraines. However, having these risk factors does not mean that you will have migraines. The typical risk factors include:
- Family history of migraine
- Female sex
- Female hormonal changes
- Younger than 40 years old
In most cases, migraine is an inherited condition. The risk of migraine for relatives of a patient diagnosed with migraine is three times greater than for those without a family member who suffers from migraines.
What are some conditions related to migraine?
Differentiating between migraine and other headache types can be difficult. While other types of headache may include some of the same symptoms as migraine, they generally have no associated auras. Other conditions related to migraine include:
- Cluster headache, groupings of headaches that occur in relatively quick succession, followed by periods without headache; patients most often experience pain on one side of the head, describing it as a hot poker piercing the eye
- Tension headache, the most general form of headache with dull, generalized pain caused by muscle contractions in the head and neck; usually described as a tight band around the forehead
- Secondary headache, a headache caused by another condition, such as a head or neck injury
How do doctors diagnose migraines?
Doctors consider the patient’s history, a physical examination, patient reported symptoms, and diagnostic criteria that satisfies The International Classification of Headache Disorders, 3rd edition (ICHD-3) to diagnose migraine.
These criteria separate diagnoses into migraine with aura and migraine without aura:
- Migraine with aura is having two or more attacks of headache at the same time as aura or following aura symptoms within 60 minutes. Aura symptoms include flashing light, zigzag lines, or other visual disturbances. Fewer migraine sufferers have this type of migraine.
- Migraine without aura is having five or more attacks of headache and additional symptoms, which may include nausea, vomiting, and sensitivity to light and/or sound. This more common type of migraine does not include an aura phase—the visual, sensory, or motor symptoms before the headache.
Benefits of keeping a headache journal
Tracking and sharing information about your headache with your doctor helps with making an accurate diagnosis and modifying your treatment plan as needed. It is helpful to track migraine occurrences (dates and times) and the details associated with migraines.
Consider keeping a headache journal to write down the following information and take to your doctor visit:
- Specific location of your headaches
- How your headaches feel
- How long your headaches last
- Any changes in behavior or personality
- Effect of changes in position on the headache
- Trouble sleeping
- History of stress
- History of head trauma
Diagnostic tests and imaging
In addition to the information you provide, your doctor may order computed tomography (CT) scans, magnetic resonance imaging (MRI), and a spinal tap to confirm a migraine diagnosis. These tests help to rule out other problems, such as tumors, infection, or blood vessel irregularities that may cause migraine-like symptoms.
Most migraine patients will not require brain imaging as part of their diagnosis. However, brain MRI or CT scan is typically used in the following cases:
- Patient describes headache as their “first” or “worst.”
- Headaches always occur on the same side.
- Prescribed treatment for headaches is not controlling frequency or relieving symptoms.
- Headaches change in frequency or severity from what is typical for the patient.
- Headaches begin happening for the first time after age 50.
How are migraine headaches treated?
As there is not currently a cure for migraine, treatment efforts focus on migraine prevention and symptom relief. The most effective treatment plan for migraine headaches is multifaceted. Treatment plans are also individualized to best address the specific triggers and severity of the migraine, your age, medical history, and other factors.
Many people with migraines report sudden, overwhelming fatigue and need to lie down in a dark, quiet room to sleep. In many people, a nap combined with taking an over-the-counter pain medication might be all it takes to minimize or even eliminate a migraine.
Effective migraine treatment involves lifestyle changes and drug therapies that prevent migraines from occurring as often and acute therapies to relieve migraines as they develop.
Lifestyle changes to reduce frequency of migraines
Patients suffering from migraine can take initial steps to help reduce the frequency of migraine headaches by making certain lifestyle changes:
- Establish a regular sleep pattern and get enough sleep.
- Eat meals on a routine schedule.
- Stay active and exercise regularly.
- Avoid or limit exposure to migraine triggers.
Medications to prevent migraines
Depending on the specific patient and their symptoms, a neurologist who specializes in migraine may recommend medications to prevent migraine. These preventive migraine medications fall under the following drug classes:
- Beta blockers (such as propranolol), meant to treat high blood pressure and coronary artery disease
- Antidepressants (such as amitriptyline), which affect the levels of serotonin and other brain chemicals
- Anticonvulsants (such as topiramate or valproic acid), which prevent or reduce seizures also prevent migraines in adults
- CGRP antagonists, drugs that interfere with the release of CGRP into the brain. CGRP blockers like erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality) target a molecule thought to instigate and intensify migraines
Medications to treat a migraine attack
To increase the effectiveness of treatment for a migraine attack, it is best to take the prescribed medicine soon after symptoms begin. The medications used in treating a migraine attack include the following drug types:
- Analgesics, such as nonsteroidal anti-inflammatory drugs (ibuprofen and others) and acetaminophen, help relieve pain
- Triptans, such as sumatriptan (Imitrex, Alsuma) and zolmitriptan (Zomig), reverse the changes in the brain that caused the migraine
- Antiemetics, administered by nasal spray, rectal suppository or intravenously (IV) to combat nausea and vomiting during a migraine attack
- Ergots, such as dihydroergotamine (Migranol) and ergotamine (Ergomar), relieve pain specifically for throbbing headaches
- Vasoconstrictors, which constrict dilated blood vessels in the brain. These include ergot alkaloids and sumatriptan (Imitrex), and other serotonin receptor agonists
Narcotics, such as morphine or Dilaudid, are generally not recommended for long-term treatment of migraines because of the potential for dependence.
Keeping a migraine log or diary helps you recognize an oncoming migraine and begin early treatment. Keep track of the type of treatment and its effect to help pinpoint the most effective treatment for you.
How does migraine affect quality of life?
Classified as the sixth most disabling illness worldwide, migraine can be incredibly debilitating. Here are just a few statistics that capture the considerable impact of migraine on quality of life:
- More than 90% of migraine patients are unable to work or function normally during a migraine attack.
- Healthcare costs are 70% higher for families affected by migraine compared to those without.
- On average, 1.2 million emergency room visits each year are for acute migraine attacks.
- Combined annual healthcare and lost productivity costs due to migraine in the United States are estimated at $36 billion.
- American employers report a combined 113 million missed work days due to migraine each year.
Additionally, more than half of those who suffer from migraine are never diagnosed and an even greater number never seek medical care for their pain.
Migraine is not fatal. However, it often occurs alongside—and worsens—other medical conditions, such as bipolar disorder and depression. Migraine patients often live in constant fear of migraine attacks disrupting their daily lives.
While symptoms can be extremely painful and disorienting, untreated migraines will last anywhere from a few hours to several days and eventually resolve on their own, often with sleep.
What are the possible complications of migraine headaches?
Migraine headaches are generally not a serious health threat. However, if migraine headaches are frequent (chronic migraine) and severe, it may be difficult for you to function normally or effectively in everyday life. Migraines headaches are also a risk factor for stroke. In severe cases, migraine headaches can result in disability.
You can help minimize your risk of recurring migraine headaches and serious complications by following the treatment plan you and your health care professional design specifically for you.
Although there isn’t a cure for migraine, research for a cure is underway. As awareness of migraine and its effects on people’s lives grows, so should funding into migraine research. June is National Migraine and Headache Awareness Month. Learn about current efforts to find a cure and provide support through the Migraine Research Foundation.