Migraine

Migraine symptoms

Headache features

• moderate to severe pain, often throbbing or pulsing
• usually on one side, but can be both sides
• worse with routine activity such as climbing stairs
• lasting 4 to 72 hours in adults (shorter in children)

Accompanying symptoms

• nausea and vomiting
• sensitivity to light (photophobia) and sound
• sensitivity to smells
• dizziness, neck pain and difficulty concentrating

The four phases of a migraine attack

1. Prodrome (hours to days before): yawning, food cravings, mood changes, neck stiffness, frequent urination.
2. Aura (in about 25%, lasting 5 to 60 minutes): visual changes such as shimmering zigzags, flashing lights or blind spots; tingling spreading up an arm or face; difficulty finding words.
3. Headache: the pain phase with nausea and sensitivity.
4. Postdrome: a "migraine hangover" with tiredness, poor concentration and lingering discomfort for up to a day or two.

Not everyone has every phase.

Types of migraine

Migraine vs other headaches

Migraine in children and teenagers

Children often have shorter attacks (2 hours or more), pain on both sides of the forehead, and prominent nausea, vomiting or belly pain. Abdominal migraine and cyclical vomiting can come before typical migraine headaches. Regular sleep, meals, hydration and screen breaks help. Ibuprofen and acetaminophen are first choices, and some triptans are approved for adolescents. Aspirin should not be given to children or teenagers.

Migraine in pregnancy

Many women find attacks improve during pregnancy, particularly migraine without aura, though some worsen in the first trimester. Acetaminophen is generally the first choice for attacks; NSAIDs should be avoided in the third trimester and some preventive medicines, including valproate and topiramate, must be avoided. A new or different headache in pregnancy, especially with high blood pressure, needs urgent assessment for preeclampsia. Discuss any medicine with your prenatal provider.

Causes and triggers

Migraine involves an inherited sensitivity of the brain. During an attack, waves of nerve activity spread across the brain (the basis of aura), and the trigeminal nerve releases inflammatory chemicals including CGRP, which causes pain from blood vessels and membranes around the brain. About 60% of people have a family history.

Common triggers include:

• stress, or the let-down after stress
• changes in sleep: too little, too much, or irregular
• hormonal changes, especially falling estrogen before periods
• skipped meals and dehydration
• alcohol, particularly red wine
• caffeine excess or withdrawal
• bright or flickering lights, loud noise, strong smells
• weather and barometric pressure changes
• certain foods for some people, such as aged cheese or processed meats

Triggers vary widely; a headache diary helps identify yours. Not every exposure causes an attack.

Diagnosis

Migraine is diagnosed from the history and a normal neurological exam. Brain scans are not needed for typical migraine. Imaging is used when there are red flags, an atypical pattern or abnormal findings on examination. A headache diary helps your doctor assess frequency and response to treatment.

Treatment of a migraine attack

Treat early, at the first sign of headache, for best results.

• NSAIDs: ibuprofen, naproxen or aspirin (adults only), or acetaminophen (paracetamol), at the label dose
• Combination medicines with acetaminophen, aspirin and caffeine
• Triptans (sumatriptan, rizatriptan and others) for moderate to severe attacks; not for people with heart disease, stroke or uncontrolled high blood pressure
• Gepants (ubrogepant, rimegepant) and lasmiditan for people who cannot take or do not respond to triptans
• Anti-nausea medicines for nausea, such as metoclopramide or prochlorperazine, which also help pain
• Nasal sprays or injections when vomiting makes tablets ineffective
• Neuromodulation devices as a drug-free option

Rest in a dark, quiet room, apply a cold pack to the forehead or neck, and sip fluids.

Preventing migraine

Preventive treatment is recommended for people with 4 or more headache days a month, or fewer but disabling attacks.

Preventive medicines

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab)
• Gepants for prevention (rimegepant every other day, atogepant daily)
• Beta-blockers such as propranolol or metoprolol
• Anti-seizure medicines such as topiramate or valproate (not in pregnancy)
• Antidepressants such as amitriptyline or venlafaxine
• Candesartan
• OnabotulinumtoxinA (Botox) injections for chronic migraine

Lifestyle

• regular sleep, meals and hydration
• regular aerobic exercise
• stress management, CBT, relaxation and biofeedback
• limiting caffeine and alcohol
• magnesium, riboflavin (vitamin B2) and coenzyme Q10 have some supporting evidence

Migraine and stroke risk

Migraine with aura is associated with a small increase in stroke risk, mainly in women who smoke or take estrogen-containing birth control. Women with migraine with aura are generally advised to avoid combined hormonal contraceptives. Not smoking and controlling blood pressure reduce risk.

Frequently asked questions

What does a migraine feel like?

A migraine is usually a moderate to severe throbbing or pulsing headache, often on one side, that worsens with activity. It often comes with nausea, vomiting and sensitivity to light and sound. Some people see zigzag lines or flashing lights beforehand.

How do I stop a migraine fast?

Take your acute medicine as soon as the headache starts, such as an NSAID or a triptan. Rest in a dark, quiet room, apply a cold pack and drink fluids. An anti-nausea medicine can help both nausea and pain.

What triggers migraines?

Common triggers include stress, irregular sleep, hormonal changes around periods, skipped meals, dehydration, alcohol, caffeine changes, bright lights and strong smells. Triggers vary from person to person, and a diary can help identify yours.

When is a migraine an emergency?

Get emergency care for a sudden, explosive headache, a headache with weakness, confusion, speech problems, fever and stiff neck, or after a head injury, or an aura lasting over an hour. These are not typical of migraine and need urgent assessment.

Can migraines be cured?

There is no cure, but migraine can be well controlled. Many people have far fewer and milder attacks with the right combination of acute treatment, preventive medicine and lifestyle measures. Migraine often improves after menopause.