Migraine

A migraine is a headache that can cause intense throbbing pain or a pulsing feeling, usually on one side of the head. It often happens with nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so bad that it interferes with your daily activities.

For some people, a warning symptom known as an aura occurs before or with a migraine. An aura can include visual changes, such as flashes of light or blind spots. The aura also can cause tingling on one side of the face or in an arm or leg and trouble speaking.

Medicines can help prevent some migraines and make them less painful. Combining medicines with self-help remedies and lifestyle changes also might help.

Migraines can affect children and teenagers as well as adults. A migraine can progress through four stages that have different symptoms: prodrome, aura, attack and postdrome. Not everyone who has migraines goes through all stages.

Prodrome

One or two days before a migraine, you might notice subtle changes that warn of an upcoming migraine, including:

• Constipation.
• Mood changes, from depression to elation.
• Food cravings.
• Neck stiffness.
• Increased urination.
• Fluid retention.
• Frequent yawning.

Aura

An aura might occur before or during migraines for some people. Auras are reversible symptoms of the nervous system. They’re usually visual but also can include other disturbances. Each symptom usually begins gradually and builds up over several minutes, up to 60 minutes.

Examples of migraine auras include:

• Visual changes, such as seeing shapes, bright spots or flashes of light.
• Vision loss.
• A feeling of pins and needles in an arm or leg.
• Weakness or numbness in the face or one side of the body.
• Trouble speaking.

Attack

A migraine usually lasts 4 to 72 hours if it’s not treated. How often migraines occur varies from person to person. Migraines might occur rarely or strike several times a month.

During a migraine, you might have:

• Pain that’s usually on one side of your head, although it can occur on both sides.
• Pain that throbs or pulses.
• Sensitivity to light, sound, and sometimes smell and touch.
• Nausea and vomiting.

Postdrome

After a migraine attack, you might feel drained, confused and worn out for up to a day. Some people report feeling elated. Sudden head movement might briefly bring on the pain again.

When to see a doctor

Migraines are often not diagnosed or treated. If you regularly have symptoms of migraines, keep a record of your attacks and how you treated them. Then make an appointment with your healthcare professional to discuss your headaches.

If you have a history of headaches, see your healthcare professional if the pattern changes or your headaches suddenly feel different.

See your healthcare professional right away or go to the emergency room if you have any of the following symptoms. They could be caused by a more serious medical issue.

• An abrupt, very bad headache like a thunderclap.
• Headache with a fever, stiff neck, confusion, seizures, double vision, or numbness or weakness in any part of the body. These symptoms could be a sign of a stroke.
• Headache after a head injury.
• A chronic headache that is worse after coughing, exertion, straining or sudden movement.
• New headache pain after age 50.

Though migraine causes aren’t fully understood, genetics and environmental factors appear to play a role.

Changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway, might be involved. Imbalances in brain chemicals also might be involved — including serotonin, which helps regulate pain in your nervous system. Researchers are studying the role of serotonin in migraines.

Other chemical messengers play a role in migraine pain, including calcitonin gene-related peptide, also known as CGRP.

Migraine triggers

There are a number of things that can bring on a migraine, including:

• Hormonal changes. Fluctuation in estrogen levels seems to trigger headaches in many people. This can happen before or during menstrual periods or during pregnancy and menopause. Hormonal medicines, such as oral contraceptives, also can worsen migraines. Some people, however, find that their migraines occur less often when taking hormonal contraceptives.
• Alcohol and caffeine. Alcohol, especially wine, and too much caffeine, such as in coffee, can trigger a migraine.
• Stress. Stress at work or home can cause migraines.
• Sensory stimuli. Bright or flashing lights can induce migraines, as can loud sounds. Strong smells can trigger migraines in some people. These smells can include perfume, paint thinner, secondhand smoke and other triggers.
• Sleep changes. Missing sleep or getting too much sleep can trigger migraines in some people.
• Physical strain. Intense physical exertion, including sexual activity, might provoke migraines.
• Weather changes. A change of weather or barometric pressure can prompt a migraine.
• Medicines. Oral contraceptives and vasodilators, such as nitroglycerin (Nitrostat, Nitro-Dur, others), can aggravate migraines.
• Foods. Aged cheeses and salty and processed foods might trigger migraines. Skipping meals also can bring on a migraine.
• Food additives. These include the sweetener aspartame and the preservative monosodium glutamate, also called MSG. These additives are found in many foods.

Several risk factors make you more prone to having migraines, including:

• Family history. Having a family member with migraines means you have a higher chance of developing them yourself.
• Age. Migraines can begin at any age, though the first often occurs when you’re a teenager. Migraines tend to peak during your 30s and then gradually become less frequent.
• Sex. Women are three times more likely than men to have migraines.
• Hormonal changes. Migraines might begin just before or shortly after your first menstrual period. They also might change during pregnancy or menopause. Migraines generally improve after menopause.

A complication for some people with migraines is medication overuse headaches. Taking painkillers too often can trigger these headaches. Medication overuse headaches may occur if you take aspirin or ibuprofen (Advil, Motrin IB, others) for more than 14 days a month. Or they can occur if you take medicines known as triptans for more than nine days a month. The risk seems to be highest with medicines that combine aspirin, acetaminophen and caffeine.

Medication overuse headaches can lead to a painful cycle. If medicines stop relieving pain and begin to cause headaches, you might then try taking more pain medicine to find relief.

Migraines can be diagnosed by a specialist trained in treating headaches, known as a neurologist. The diagnosis is based on your medical history, symptoms, and a physical and neurological exam.

If your condition is complex or suddenly becomes serious, tests to rule out other causes of your pain might include:

• An MRI scan. A magnetic resonance imaging scan, also known as an MRI scan, uses a powerful magnetic field and radio waves to produce detailed images of the brain and blood vessels. MRI scans help diagnose tumors, strokes, bleeding in the brain, infections, and other brain and nervous system conditions.
• A CT scan. A computerized tomography scan, also called a CT scan, uses a series of X-rays to create detailed cross-sectional images of the brain. This helps diagnose tumors, infections, brain damage, bleeding in the brain and other medical conditions that can cause headaches.

Migraine treatment is aimed at stopping symptoms and preventing future attacks.

Medicines

Many medicines have been designed to treat migraines. They fall into two broad categories:

• Pain-relieving medicines. Also known as acute or abortive treatments, these medicines are taken during migraine attacks and are designed to stop symptoms.
• Preventive medicines. These medicines are taken regularly, often daily, to reduce migraine symptoms.

Your treatment choices depend on how often you have headaches and how painful they are. Your treatment also depends on whether you have nausea and vomiting, whether your headaches are disabling, and whether you have other medical conditions.

Pain-relieving medicines

Medicines used to relieve migraine pain work best when taken as soon as symptoms begin. These medicines include:

• Pain relievers. Pain relievers that you can get with or without a prescription include aspirin and ibuprofen (Advil, Motrin IB, others). Medicines that combine caffeine, aspirin and acetaminophen (Excedrin Migraine) may be helpful, but usually only against mild migraine pain. But be sure to talk with your healthcare professional about how often it’s safe to take these medicines. When taken too long, they can cause medication overuse headaches and possibly ulcers and bleeding in the gastrointestinal tract.
• Triptans. These prescription medicines can relieve many symptoms of migraine by blocking pain pathways in the brain. Triptans are taken as pills, shots, nasal sprays, nasal powders and disintegrating tablets. They include sumatriptan (Imitrex, Tosymra, others), rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan, almotriptan, eletriptan (Relpax) and frovatriptan (Frova). They might not be safe to take if you’re at risk of a stroke or heart attack.
• Dihydroergotamine (Migranal, Trudhesa). Available as a nasal spray, this medicine is most effective when taken shortly after the start of symptoms for migraines that tend to last longer than 24 hours. Side effects can include worsening of migraine-related vomiting and nausea. People with coronary artery disease, high blood pressure, or kidney or liver disease should avoid dihydroergotamine.
• Lasmiditan (Reyvow). This is an oral medicine approved for the treatment of migraines with or without aura. In studies, lasmiditan significantly improved headache pain. Lasmiditan can make you sleepy and cause dizziness, so don’t drive or operate machinery for at least eight hours after taking it.
• Oral calcitonin gene-related peptides antagonists, also known as gepants. Ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) are oral gepants approved for the treatment of migraines in adults. In clinical trials, medicines from this class were more effective than placebo at relieving pain two hours after taking them. They also were effective at treating migraine symptoms such as nausea and sensitivity to light and sound. Common side effects include dry mouth, nausea and too much sleepiness. Ubrogepant and rimegepant should not be taken with strong CYP3A4 inhibitor medicines such as some medicines used to treat cancer.
• Intranasal zavegepant (Zavzpret). This nasal spray is a gepant that can relieve migraine pain within two hours and for up to 48 hours. It also can improve other symptoms, such as nausea and sensitivity to light and sound. Side effects of zavegepant include a change in your sense of taste, nasal discomfort and throat irritation.
• Antinausea medicines. These are usually taken with pain medicines and can help if you have nausea and vomiting with your migraines. Medicines include chlorpromazine, metoclopramide (Gimoti, Reglan) and prochlorperazine (Compro).
• Opioid and barbiturate medicines. Opioids or barbiturates may help if you can’t take other migraine medicines. However, they’re usually avoided due to better and more effective options. Because they can be highly addictive, these medicines are used only if no other treatments are effective.

Some migraine medicines are not safe to take during pregnancy. If you’re pregnant or trying to get pregnant, don’t use any of these medicines without first talking with your healthcare professional.

Preventive medicines

Medicines can help prevent frequent migraines. Your healthcare professional might recommend these medicines if you have long-lasting, very bad headaches that happen often and don’t respond well to treatment.

Preventive medicine can reduce how often you get a migraine, how painful the attacks are and how long they last. Options include:

• Blood pressure-lowering medicines. These include beta blockers such as propranolol (Inderal LA, InnoPran XL) and metoprolol (Lopressor, Toprol-XL). Calcium channel blockers such as verapamil (Verelan) can be helpful in preventing migraines with aura.
• Antidepressants. Tricyclic antidepressants, such as amitriptyline and nortriptyline, are the most commonly used medicines to prevent migraine. These medicines have side effects that include dry mouth and sleepiness, and they may interact with other medicines. For these reasons, another antidepressant with fewer side effects or interactions, such as venlafaxine (Effexor XR), might be prescribed instead.
• Antiseizure medicines. Valproate and topiramate (Topamax, Qudexy XR, others) might help if you have less frequent migraines. These medicines can cause side effects such as dizziness, weight changes, nausea and others. They’re also not recommended in people who are pregnant or who are trying to get pregnant.
• Botox injections. Shots of onabotulinumtoxinA (Botox) about every 12 weeks help prevent migraines in some adults.
• Calcitonin gene-related peptide, also called CGRP, monoclonal antibodies. These medicines help prevent migraines by blocking the chemical messenger CGRP. Medicines include erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), galcanezumab-gnlm (Emgality) and eptinezumab-jjmr (Vyepti). They’re given monthly or once every three months by injection. The most common side effect is a reaction at the injection site.
• Atogepant (Qulipta). This medicine is a gepant that helps prevent migraines. It’s a tablet taken by mouth daily. Potential side effects of the medicine include nausea, constipation and fatigue.
• Rimegepant (Nurtec ODT). This medicine is unique in that it’s a gepant that helps prevent migraines in addition to treating migraines after they begin.

Ask your healthcare professional if these medicines are right for you. Some are not safe to take during pregnancy. If you’re pregnant or trying to get pregnant, don’t use any of these medicines without first talking with your healthcare professional.

Neuromodulation therapy

Devices that stimulate nerves, known as neuromodulation devices, can reduce the number of migraines you have or make them less painful. The devices are noninvasive and work by stimulating a peripheral or cranial nerve to change the brain’s response to pain. Therapies include transcutaneous supraorbital nerve stimulation, external vagal nerve stimulation and distal transcutaneous electrical stimulation. Combined occipital and trigeminal neurostimulation is another option.

Another therapy called single-pulse transcranial magnetic stimulation treats the brain to relieve migraine pain. For this therapy, you place the device on the back of your head.

When symptoms of migraine start, try heading to a quiet, darkened room. Close your eyes and rest or take a nap. Place a cool cloth or ice pack wrapped in a towel or cloth on your forehead and drink lots of water.

To help soothe migraine pain, you also might want to:

• Try relaxation techniques. Breathing exercises and other forms of relaxation training teach you ways to deal with stressful situations, which might help reduce the number of migraines you have.
• Develop a sleeping and eating routine. Don’t sleep too much or too little. Set and follow a consistent sleep and wake schedule daily. Try to eat meals at the same time every day.
• Drink plenty of fluids. Staying hydrated, particularly with water, might help.
• Keep a headache diary. Recording your symptoms in a headache diary can help you learn more about what triggers your migraines and what treatment is most effective. It also can help your healthcare professional diagnose your condition and track your progress between visits.

• Exercice régulier. Regular aerobic exercise reduces tension and can help prevent a migraine. If your healthcare professional agrees, choose aerobic activities you enjoy, such as walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches.

  Regular exercise also can help you lose weight or maintain a healthy body weight. Obesity is thought to be a factor in migraines.

Nontraditional therapies might help with chronic migraine pain.

• Acupuncture. Clinical trials have found that acupuncture may be helpful for headache pain. In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin at defined points.
• Biofeedback. Biofeedback appears to be effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses related to stress, such as muscle tension.
• Cognitive behavioral therapy. Cognitive behavioral therapy may benefit some people with migraines. This type of psychotherapy teaches you how behaviors and thoughts affect how you perceive pain.
• Meditation and yoga. Meditation may relieve stress, which is a known trigger of migraines. Done on a regular basis, yoga may reduce the number of migraines you have or how long they last.

• Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur might prevent migraines or reduce their severity, though study results are mixed. Butterbur isn’t recommended because of safety concerns.

  A high dose of riboflavin, also called vitamin B-2, may reduce the number of migraines you have and how painful they are. Coenzyme Q10 supplements might decrease the frequency of migraines, but larger studies are needed.

  Magnesium supplements have been used to treat migraines, but with mixed results.

Ask your healthcare professional if these treatments are right for you. If you’re pregnant, talk with your healthcare professional before trying any of these treatments.

You’ll probably first see your primary healthcare professional, who might then refer you to a doctor trained in evaluating and treating headaches, called a neurologist.

What you can do

• Keep track of your symptoms. Keep a headache diary by writing a description of each incident of visual disturbances or unusual sensations. Include when your headaches occurred, how long they lasted and what triggered them. This information can help diagnose your condition.
• Write down key personal information, including major stresses or recent life changes.
• Make a list of all medicines, vitamins and supplements you take, including doses. It’s particularly important to list all medicines you’ve used to treat your headaches.
• Write down questions to ask your healthcare professional.

Take a family member or friend along, if possible, to help you remember the information you receive.

For migraines, questions to ask your healthcare professional include:

• What is likely triggering my migraines?
• Are there other possible causes for my migraine symptoms?
• What tests do I need?
• Are my migraines likely short-term or long lasting?
• What is the best course of action?
• What are the alternatives to the primary approach that you’re suggesting?
• What changes to my lifestyle or diet do you suggest I make?
• I have other health conditions. How can I best manage them together?
• Are there printed materials you can give me? What websites do you recommend?

Don’t hesitate to ask other questions.

What to expect from your doctor

Your healthcare professional is likely to ask you a number of questions, including:

• How often do your headaches occur?
• How bad are your symptoms?
• What, if anything, seems to make your symptoms better?
• What, if anything, appears to worsen your symptoms?
• Does anyone else in your family have migraines?