Migraines: Causes, Symptoms and Treatments.

A migraine is a severe, painful headache that can be preceded or accompanied by sensory warning signs such as flashes of light, blind spots, tingling in the arms and legs, nausea, vomiting, and increased sensitivity to light and sound.

The excruciating pain that migraines bring can last for hours or even days. Migraine is a common problem affecting 36 million Americans, about 12% of the population.

Fast facts on migraines

Here are some key points about migraines. More detail and supporting information is in the main article.

  • The cause of migraines is still largely unknown.
  • Migraines can be preceded by an aura of sensory disturbances followed by a severe one-sided headache.
  • Approximately 12% of Americans get migraine headaches.
  • Migraine tends to affect people between 15-55 years of age.
  • Some people who suffer from migraines can clearly identify triggers or factors that cause the headaches such as allergies, light and stress.
  • Some people get a warning prodrome, preceding the onset of a migraine headache.
  • Many migraine sufferers can prevent a full-blown attack by recognizing and acting upon the warning signs.
  • Over-the-counter medications can eliminate or reduce pain.
  • Specific medications can help some sufferers.
  • People who suffer from severe attacks can take preventative medicines.

What are migraine headaches?

The exact cause of migraine headaches is unknown; it is thought to be due to abnormal brain activity causing a temporary alteration in the nerve signals, chemicals and blood flow in the brain.

Lady holding head in pain
Migraine headaches can be very debilitating.

Migraine headaches can be very debilitating affecting 1 in 4 households in America. They are more common in women than men, and 3% of people have chronic migraines where they experience symptoms for half the month for six months.1

How common are migraines?

The prevalence of migraine headaches is high, affecting roughly 1 out of every 7 Americans annually, and has remained relatively stable over the last 8 years.

Migraine and headache are leading causes of outpatient and ED visits and remains an important public health problem, particularly among women during their reproductive years.2

The National Headache Foundation states that health care providers have properly diagnosed fewer than half of all migraine sufferers.

Migraine is commonly misdiagnosed as tension-type headache or sinus headache.

What triggers migraine headaches?

Some people who suffer from migraines can clearly identify triggers or factors that cause the headaches, but many cannot. Potential migraine triggers include:

  • Allergies and allergic reactions
  • Bright lights, loud noises, flickering lights, smoky rooms, temperature changes, strong smells and certain odors or perfumes
  • Physical or emotional stress, tension, anxiety, depression, excitement
  • Physical triggers such as tiredness, jet lag, exercise
  • Changes in sleep patterns or irregular sleep
  • Smoking or exposure to smoke
  • Skipping meals or fasting causing low blood sugar
  • Dehydration
  • Alcohol
  • Hormonal triggers such as menstrual cycle fluctuations, birth control pills, menopause
  • Tension headaches
  • Foods containing tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, and some beans), monosodium glutamate (MSG), or nitrates (like bacon, hot dogs and salami)
  • Other foods such as chocolate, nuts, peanut butter, avocado, banana, citrus, onions, dairy products and fermented or pickled foods
  • Medication such as sleeping tablets, the contraceptive pill, hormone replacement therapy.

Recent developments on the possible causes of migraine headaches from MNT news

Is there an association between obesity and migraines?

A higher percentage of obese people have episodic (occasional) migraines compared to individuals with a healthy body weight, researchers at the Johns Hopkins University School of Medicine reported in the journal Neurology.

Scientists find migraine gene mutation

A team of scientists, including Emily A. Bates, PhD, from the University of California, San Francisco (UCSF) and Brigham Young University, who has been plagued by migraines since her teens, have identified a gene mutation that increases a person’s susceptibility to migraines. They published their findings in Science Translational Medicine (May 2013 issue).

Symptoms of migraines

Fortifikation (Migräne)
Migraine with aura – zigzag objects affect vision
Gesichtsfeldausfall (Brandenburger Tor Blaue Stunde) 1
Migraine with aura – vision is lost on one side
Negatives Skotom (Brandenburger Tor Blaue Stunde) 1
Migraine with aura – structures and contrasts are lost
Positives Skotom (Brandenburger Tor Blaue Stunde) 1
Migraine with aura – structures that are not there are perceived

Symptoms of migraine can occur a while before the headache, immediately before the headache, during the headache and after the headache. Although not all migraines are the same, typical symptoms include:

  • Moderate to severe pain, usually confined to one side of the head during an attack, but can occur on either side of the head
  • The pain is usually a severe, throbbing, pulsing pain
  • Increasing pain during physical activity
  • Inability to perform regular activities due to pain
  • Feeling sick and physically being sick
  • Increased sensitivity to light and sound, relieved by lying quietly in a darkened room
  • Some people experience other symptoms such as sweating, temperature changes, tummy ache and diarrhea.

Migraines with aura

Many people experience migraines with auras or warning signs just before or during the head pain, but many do not. Auras are perceptual disturbances such as:

  • Confusing thoughts or experiences
  • The perception of strange lights, sparkling or flashing lights
  • Zigzag lines in the visual field
  • Blind spots or blank patches in the vision
  • Pins and needles in an arm or leg
  • Difficulty speaking
  • Stiffness in the shoulders, neck or limbs
  • Unpleasant smells.

If any migraine sufferer experiences unusual or worrying features that they do not normally have, then they should seek medical help rather than blaming the migraine.

Symptoms such as unusual severe headache, visual disturbance, loss of sensation or power, difficulties with speech are all important features, which, if unusual for the sufferer, should not be ignored.

According to the National Health Service in the UK, about one-third of people who get migraines also have auras.

When migraines with aura affect vision, the patient may see things that are not there, such as transparent strings of objects, not see parts of the object in front of them, or even feel as if part of their field of vision appears, disappears and then comes back again.

It is common for patients to describe the visual disturbance as similar to the sensation one has after being photographed with a very bright camera flash, especially if one walks into a darker room straight away.

For many migraine sufferers, the auras act as a warning, telling them that the headache is soon to come.

The Migraine Trust says that in adults auras usually occur before the headache, but in children they may happen at the same time.

Migraine sufferers also may have premonitions know as a prodrome that can occur several hours or a day or so before the headache. These premonitions may consist of  feelings of elation or intense energy, cravings for sweets, thirst, drowsiness, irritability, or depression.

How is migraine diagnosed?

Migraine can be difficult to diagnose, and there are no specific tests to confirm the diagnosis.

The International Headache Society recommends the “5, 4, 3, 2, 1 criteria” to diagnose migraines without aura.

This stands for:

  • 5 or more attacks
  • 4 hours to 3 days in duration
  • At least 2 of unilateral location, pulsating quality, moderate to severe pain, aggravation by or avoidance of routine physical activity
  • At least 1 additional symptom such as nausea, vomiting, sensitivity to light, sensitivity to sound.

To help diagnose migraines, it can be useful to keep a diary of symptoms noting the time of onset, any triggers, how long the headache lasted, any preceding factors or aura and any other symptoms as well as the headache.

A headache diary is ideally used for a minimum of eight weeks and should record:7

  • The frequency, duration, and severity of headaches
  • Any associated symptoms
  • All prescribed and over-the-counter medications taken to relieve headaches and their effect
  • Possible triggers
  • Relationship of headaches to menstruation.

During the initial diagnosis of migraines, the doctor may suggest some tests to exclude other causes of headache such as electroencephalography (EEG), computed tomography (CT), magnetic resonance imaging (MRI) and spinal tap.

Differential diagnosis of migraine

Headaches are notoriously difficult for doctors to diagnose, and sometimes other causes need to be ruled out:

  • Bleeding within the skull
  • Blood clot within the membrane that covers the brain
  • Stroke
  • Dilated blood vessel in the brain
  • Too much or too little cerebrospinal fluid
  • Inflammation of the membranes of the brain or spinal cord
  • Nasal sinus blockage
  • Postictal headache (after stroke or seizure)
  • Tumors.

Treatments for migraines

There is currently no cure for migraine, so treatment is aimed at preventing a full-blown attack, and alleviating symptoms if they come.

woman stretching legs
Regular physical exercise may help reduce migraine frequency.

Different people respond to different treatments.

Some lifestyle alterations might help reduce migraine frequency, says Mayo Clinic doctor, Robert Sheeler MD. These include:

  • Getting enough sleep
  • Reducing stress
  • Drinking plenty of water
  • Avoiding certain foods
  • Regular physical exercise.

Migraine treatment (abortive therapies) and prevention (prophylactic therapies) focus on avoiding triggers, controlling symptoms and taking medicines.

Medication

Analgesia:

  • Over-the-counter medications such as naproxen, ibuprofen, acetaminophen (paracetamol), and other analgesics like Excedrin (aspirin with caffeine) are often the first abortive therapies to eliminate the headache or substantially reduce pain
  • Painkillers should be taken early rather than allowing the headache to develop.

Anti-emetics:

  • Metoclopramide may also be used to control symptoms such as nausea and vomiting.

Serotonin agonists:

  • Sumatriptan may also be prescribed for severe migraines or for migraines that are not responding to the over-the-counter medications
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Antidepressants such as tricyclics – are prescribed to reduce migraine symptoms although they are not approved in all countries for this purpose.
  • Ergots:

    • Another class of abortive treatments is called ergots, which are usually effective if administered at the first sign of a migraine.

    Other drugs:

    • Combinations of barbiturates, paracetamol or aspirin, and caffeine (Fioricet or Fiorinal)
    • Combinations of acetaminophen, dichloralphenazone and isometheptene (Amidrine, Duradrin, and Midrin).

    In January 2015, The American Headache Society undertook a review of the acute treatment of migraine in adults.

    • Migraine specific medications – triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan [oral, nasal spray, injectable, transcutaneous patch], zolmitriptan [oral and nasal spray]) and dihydroergotamine (nasal spray, inhaler) are effective (Level A)
    • Ergotamine and other forms of dihydroergotamine are probably effective (Level B)
    • Effective nonspecific medications include acetaminophen, nonsteroidal anti-inflammatory drugs (aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal spray), sumatriptan/naproxen, and the combination of acetaminophen/aspirin/caffeine (Level A)
    • Ketoprofen, intravenous and intramuscular ketorolac, flurbiprofen, intravenous magnesium (in migraine with aura), and the combination of isometheptene compounds, codeine/acetaminophen and tramadol/acetaminophen are probably effective (Level B)
    • The antiemetics prochlorperazine, droperidol, chlorpromazine, and metoclopramide are probably effective (Level B)
    • There is inadequate evidence for butalbital and butalbital combinations, phenazone, intravenous tramadol, methadone, butorphanol or meperidine injections, intranasal lidocaine, and corticosteroids, including dexamethasone (Level C)
    • Octreotide is probably not effective (Level B)
    • There is inadequate evidence to refute the efficacy of ketorolac nasal spray, intravenous acetaminophen, chlorpromazine injection, and intravenous granisetron (Level C)
    • Although opioids, such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen, are probably effective, they are not recommended for regular use.

    Prophylactic therapies (prevention)

    Migraine prevention begins with avoiding things that trigger the condition.

    The main goals of prophylactic therapies are to reduce the frequency, painfulness and duration of migraine headaches and to increase the effectiveness of abortive therapies.

    There are several categories of preventive migraine medicine, ranging from diet changes and exercise to prescription drugs. Some of these include:

    woman with acupuncture needles in forehead
    There have now been many controlled trials of acupuncture for migraine, with some large, high-quality ones in recent years.
    • Prescription beta blockers
    • Anticonvulsants (Topiramate)
    • Antidepressants (Tricyclics and SSRIs)
    • Gabapentin
    • Botulinum toxin A (Botox)
    • Herbs and vitamins such as butterbur, cannabis, coenzyme Q10, feverfew, magnesium citrate, riboflavin, B12, melatonin
    • Spinal cord stimulator implantation
    • Hyperbaric oxygen therapy
    • Vision correction
    • Exercise, sleep, sexual activity
    • Visualization and self-hypnosis
    • Chiropractic care or acupuncture.

    Some people find that special diets such as gluten-free can help.

    It is possible for people to get a medication overuse headache (MOH) – or rebound headache – when taking too many medications in an attempt to prevent migraine.

    Surgery

    In the last decade, novel approaches to the treatment of migraines have been developed. Botulinum toxin (Botox) injection and surgical decompression of the extracranial sensory branches of the trigeminal and cervical spinal nerves have been shown to reduce or eliminate migraines in patients who are incompletely treated by traditional medical management.

    Recent developments on migraine headache treatment from MNT news

    Two new migraine prevention drugs show promise in small studies

    two experimental drugs may offer hope for people with migraine. Two small studies of the drugs, which are aimed at preventing headaches rather than stopping them once they have started, show they reduced the frequency of headaches in migraine sufferers. The researchers say larger trials are now needed to confirm the findings.

    Minimally invasive migraine treatment ‘reduced painkiller use in 88% of patients’

    A new intranasal treatment for migraine has been found to lower use of pain-relief medication among 88% of patients in a retrospective analysis.

    Migraine sufferers may find meditation helps

    A small randomized controlled trial of patients in the US suggests migraine sufferers might find relief in a type of meditation designed to reduce stress.

    Scientists discover potential biomarker for migraine in the blood

    A team of researchers believes that it may have discovered a new biomarker for episodic migraine in the blood. The findings of the study, published in Neurology, could have implications for the diagnosis and treatment of episodic migraine if they can be supported by further research.

    When to go to the ER

    According to AHRQ (Agency for Healthcare Research and Quality), part of the US Department of Health and Human Services, if your migraine symptoms become too severe and none of the treatments are working, you may choose to go to the ER (emergency room).

    If you decide to go to the ER do not drive there, get someone else to take you. The signs and symptoms of migraine can sometimes be confused with those of a stroke.

    Go straight to hospital if:

    • Your headache is very severe
    • You have problems with movement, balance, vision or speech, and these symptoms are different or new from those you have experienced before with your migraines
    • You have a fever with your headache
    • You have a stiff neck with your headache
    • “The headache starts suddenly like a thunderclap,” especially if you are at least 50 years of age.