What is a migraine?
Migraine is a primary headache disorder characterized by throbbing and pulsating headache pain that is often accompanied by other symptoms. Primary headaches are those that occur on their own rather than because of another medical condition.
Migraines are caused by oversensitivity of the nerves on the outside of the brain, predominantly the trigeminal and occipital nerves. In migraine sufferers, these nerves have higher concentrations of neurotransmitters that carry pain signals. Migraines occur when there are bursts of activity in these nerve cells followed by a period of inactivity called cortical spreading depression, which starts within the brain cells and then spreads to nearby blood vessels.
Untreated migraine attacks can last for hours, days, or months. For some people, migraines may progress through four stages:
Prodrome may occur one or two days before you have a migraine attack. You may notice the following symptoms:
- Food cravings
- Unexplained mood changes, such as depression or euphoria
- Uncontrollable yawning
- Increased thirst and urination
- Neck stiffness
You may experience warning signs called aura as migraine pain begins or less than 60 minutes before headache onset, although it is more common to have migraine headaches without aura. These warning signs may include:
- Visual disturbances, such as flashes of light or temporary vision loss
- Increased sensitivity to light and sounds
- Difficulty speaking
- Abnormal sensation, numbness, or muscle weakness on one side of the body
- Tingling sensation in your hands or face
- Loss of appetite
During the headache phase (also called a migraine attack), you may have the following symptoms:
- Pulsating, throbbing pain that is usually on one side of the head, starting gradually and building in intensity
- Sensitivity to light, sounds, smell, or touch
- Nausea and vomiting
- Blurred vision
- Lightheadedness, sometimes followed by fainting
- Mood changes
In the postdrome phase that follows a migraine headache, you may experience the following for up to 24 hours:
- Moodiness or euphoria
- Sensitivity to light and sound
Many medical conditions can cause headaches and other symptoms. Contact a medical professional if you are experiencing symptoms.
Abortive treatments is a term used to describe medicines that are given after a migraine has already started. The goal of abortive treatments is to abort—or stop—migraine pain that has already begun.
Triptans and DHE
Triptans are a class of medications commonly used to provide fast relief for migraine headaches. They work by activating the receptors for the neurotransmitter serotonin in the brain, reducing blood vessel dilation and release of the neurotransmitters that cause pain and other symptoms of migraine. Triptan medications are available as oral tablets, orally dissolving tablets, nasal sprays and subcutaneous injection.
Another option is dihydroergotamine (DHE), which binds to serotonin and dopamine receptors on nerve cells and decreases the transmission of pain messages along nerve fibers. Ergot derivative drugs may also be given as an injection (intramuscular or IV) or a nasal spray.
Regardless of the treatment that is chosen, it should be used at the onset of the headache. The longer you wait to treat a headache, the less likely it is to respond to medication.
Try to avoid using over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen more than 15 days per month. These medications can be very effective in treating migraine but also can cause more headaches if taken too often. Medications that contain caffeine (for example, Excedrin and Fioricet) can cause you to have more headaches and should be used infrequently. Preventative medication should be used if headaches occur frequently.
Small Molecule CGRP Antagonists
Medications that work by blocking the activity of calcitonin gene-related peptide (CGRP) have been approved for the acute treatment of migraine pain. CGRP is a protein that is elevated during a migraine attack and can causes dilation of blood vessels and migraine pain.
The two medications in this class available for acute migraine treatment are called ubrogepant (Ubrelvy) and rimegepant (Nurtec).
Ubrelvy is available in two doses, 50mg and 100mg oral tablets. The dose can be repeated after two hours if the initial dose was ineffective. It is generally well-tolerated, but could cause nausea, sleepiness, or dry mouth.
Nurtec is available in one dose, a 75mg oral disintegrating tablet. Patients are limited to one dose per 24-hour period. Like Ubrelvy, Nurtec tends to be well-tolerated, but could cause nausea.
Another acute migraine medication is called lasmiditan (Reyvow). Like triptans and DHE, it works by activating serotonin receptors in the brain.
Unlike triptans or DHE, Reyvow does not cause constriction of blood vessels. For this reason, it is considered to be safe for patients who have coronary artery disease, hypertension, history of stroke, and history of heart attack.
The goal of preventative treatments for migraines is to stop the pain from happening in the first place, or to reduce the number and severity of migraine headaches.
The following lifestyle changes may help prevent migraine attacks:
- Maintaining good sleep habits
- Eating a healthy diet with regularly scheduled meals
- Staying hydrated
- Avoiding suspected triggers
- Regular exercise
Documenting the following in a “headache diary” can help you identify your triggers:
- Day and time the pain began
- What you ate and drank in the previous 24 hours
- How much you slept
- Stress or other emotions you were experiencing before the pain began
- What you were doing when the pain began
The following medications may also help prevent migraine attacks:
Botox for Migraine Prevention
Botox is a drug that is often used to temporarily smooth facial wrinkles, but it can also be an effective treatment for chronic migraine. It is thought to work by preventing the release of the neurotransmitters that cause migraine. The treatment consists of 31 injections in the head and neck every 12 weeks. Each treatment takes about 5-10 minutes and the injections have been described as feeling like tiny pinpricks.
Nerve blocks involve injecting a local anesthetic into the area of certain nerves associated with headache pain.
- Occipital nerve block focuses on the area around the occipital nerves, which are located in the back of the head.
- Trigeminal nerve block focuses on the area around the trigeminal nerve, which carries sensation from the face to the brain.
- Sphenopalatine ganglion block focuses on the sphenopalatine ganglion, a group of trigeminal nerve cells located behind the nose.
- Blood pressure medications may help reduce the frequency and severity of migraines. These include:
- The beta blockers propranolol (Inderal), metoprolol tartrate (Lopressor, Toprol)
- The calcium channel blockers verapamil (Verelan, Calan, Covera, Isoptin), diltiazem (Cardizem, Dilt-cd, Tiazac, Dilacor)
- Antidepressants may be effective in preventing migraines, even in people without depression. These include:
- The tricyclic antidepressants amitriptyline (Elavil) and nortriptyline (Pamelor)
- The selective serotonin reuptake inhibitors (SSRI) fluoxetine (Prozac), paroxetine (Paxil, Pexeva, Brisdelle),
- The serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor)
- Antiseizure medications may reduce the frequency of migraines. These include:
- Topiramate (Topamax)
- Valproate (Depakote)
- CGRP monoclonal antibodies are medications that are administered either as once monthly injections at home or by oral tablet every other day. These include:
- Erenumab (Aimovig)
- Fremanezumab (Ajovy)
- Galcanezumab (Emgality)
- Rimegepant (Nurtec)
How common are migraines?
About 12 percent of the United States population experiences migraines.
Who gets migraines?
Migraines are three times more common in women than in men, and attacks usually begin sometime between childhood and early adulthood.
Migraine sufferers typically have other family members with migraines. Although migraines seem to be genetic, few specific genes have been identified.
Migraines occur more frequently in people with other medical conditions, such as depression, anxiety, bipolar disorder, sleep disorders, and epilepsy.
Migraine triggers vary from person to person, but common triggers include:
- Sudden weather changes
- Too much or too little sleep
- Strong odors or fumes
- Stress or other emotions
- Sudden or loud noises
- Skipping meals
- Tobacco use
- Head and neck trauma
- Certain medications, as well as medication overuse or missed preventive medication doses
- Hormonal changes and menstrual cycle
- Bright or flashing lights
- Certain foods, food additives, and drinks, such as processed meats, cheese, dark chocolate, aspartame, MSG, and red wine
How are migraines diagnosed?
Your doctor may use the following to diagnose migraines:
- Personal and family medical history
- Physical and neurological examinations
- Imaging tests to rule out other headache causes if necessary