Migraine Headache

The headache of migraine is usually throbbing and one sided, though it can affect both sides. It is often associated with nausea, vomiting, and light and sound sensitivity.

A migraine headache is a neurologic disorder that allows outside triggers to begin a cascade of events within the brain that result in pain and other associated symptoms.

4 stages of a migraine headache

The four components to a migraine include premonitory symptoms, aura, headache, and postdrome. Not all four need be present with each episode, and patients differ in how they experience a migraine attack and the different components. The timing and frequency also varies from patient to patient.

1. Premonitory, or prodrome, symptoms may precede the migraine by 1-2 days and are non-specific. They may include fatigue, mood changes, yawning, and difficulty concentrating.
2. Aura describes sensory disturbances that occur just before or during the onset of headache, and last no more than an hour. There may be changes in vision, smell, taste and speech, among others. Sometimes patients can experience the aura without the headache.
3. The headache of migraine is usually throbbing and one sided, though it can affect both sides. It is often associated with nausea, vomiting, and light and sound sensitivity. Most patients cannot function and try to find a quiet, dark place to lie down. The pain can last from four hours to many days.
4. Postdrome symptoms after the headache resolves may last up to a day and can include light and sound sensitivity, and food cravings. Some patients develop headache with head movement during this timeframe.

What is migraine with aura?

In some patients, migraines may be preceded by abnormal sensory symptoms, or an aura, prior to the onset of their headache. They can present with vision changes ranging from flashing lights, zigzag lines or a blind spot in one eye, unusual smell or taste sensations, difficulty with speech and numbness or weakness involving one side of the body. The migraine aura usually begins 15-20 minutes before the headache and lasts up to an hour, and resolves as the head pain begins, but may last throughout the headache.

The aura can be frightening for the patient and family since it may mimic the signs and symptoms of a stroke or transient ischemic attack (TIA). In patients used to the aura it can also raise anxiety, knowing a migraine is about to begin.

What is an episodic migraine?

According to the International Headache Society's International Classification of Headache Disorders, the definition of episodic migraine is based on the frequency of headache days. A patient has episodic migraine if they experience fewer than 15 headache days per month.

Chronic migraine is defined as having headaches on 15 or more days per month for at least 3 months, with at least 8 of those headache days meeting the criteria for migraine.

There are specific criteria for a headache to be diagnosed as a migraine that have to be met for  the headache to be counted as a “migraine day.”

Migraine is a specific medical diagnosis and is more than a just a bad headache, though many people use the terms interchangeably.

Migraines are just one type of headache. Examples of other types of headaches include the following:

• Tension headache, or muscle contraction headache, is a common type of headache due to muscles tightening or contracting in the neck, scalp, or shoulders. They often feel like a dull, squeezing band of pressure around the head and the upper part of the neck.
• Cluster headaches are often excruciatingly painful headaches that strike in cyclical patterns or "clusters." They can happen once a day, usually at the same time, or multiple times a day. They may cause intense, stabbing pain typically around one eye, associated with redness, tearing, and nasal congestion on that side. 
• Sinus headaches are a deep, constant ache or pressure felt in the forehead, cheeks, or around the nose, caused by inflamed sinuses, usually from a cold or allergies, and are often accompanied by a stuffy or congested nose.
• Other types of common headache may be due to other health or environmental issues and may be due to alcohol, dehydration, altitude, and sleep apnea.

Women get migraines three times as frequently as men. This may be explained by hormonal changes, especially those related to menstruation, which can trigger or worsen migraines in many women. Women may experience symptoms of nausea, vomiting, and light sensitivity more frequently, and their symptoms may last longer.

Migraines in women are more often triggered by hormonal changes, while migraines in men are more often associated with physical exertion.

Cluster headaches are more common in men.

The International Headache Society lists examples of headache types including the following:

Migraine without aura or common migraine: This is the most frequent type, characterized by a severe, throbbing, one sided headache, with associated by nausea, vomiting, and light and sound sensitivity, but without aura (pre-headache neurological symptoms).

Migraine with aura or classic migraine: This headache begins with an aura, which are reversible neurological symptoms.

Chronic migraine: A migraine headache occurs at least 15 days or more per month for at least 3 months, with at least 8 of those days having migraine features. Episodic migraines occur less frequently.

Migraine with brainstem aura: This rare migraine type has an aura whose symptoms begin in the brainstem, and may include vertigo, double vision, slurred speech, ringing in the ears, hearing loss, or problems with coordination.

Hemiplegic migraine: Another rare form of migraine that has an aura that presents with paralysis or weakness on one side of the body. It may be genetic (inherited).

Retinal migraine: A rare type where the aura involves temporary vision loss in one eye. There may be flashing lights or blind spots in that eye.

Menstrual migraine: Migraine attacks that are timed to a woman's menstrual cycle due to hormonal changes. They may occur just before, during, or after menstruation.

Typical aura without headache or a silent migraine: The patient develops a typical aura but a headache does not follow.

Abdominal migraine: Usually diagnosed children, this is a migraine variant where there are recurrent episodes of severe abdominal pain, with nausea and vomiting, but without a headache.

Vestibular migraines may or may not be a variation of a migraine headache. They are also known as migraine-associated vertigo (MAV), migraine-related vestibulopathy, and migrainous vertigo. They cause vertigo and loss of balance that can last for minutes to days and may be associated with nausea and vomiting. A headache need not be present. The patient has to have had previous migraines for the diagnosis to be made. The presence of an aura, and its relationship to hormonal changes and other triggers, suggests that the cause of the vertigo is the same as the cause of migraine headaches.

Researchers are continuing to learn about the cause of migraine headache. The pathway to develop a migraine headache is thought to be as follows:

• The patient who develops migraines is already sensitized, perhaps by genetic predisposition, since migraines often run in families.
• A trigger like stress, lack of sleep, or hormonal changes to serotonin levels in the brain causes development of cortical spreading depression (CSD), or an electrical slow wave that may temporarily shut down brain cells.
• This is brain silencing or an aura, that in some patients leads to sensory changes such as visual changes.
• CSD causes inflammation and irritation of the trigeminovascular system. The trigeminal nerve carries pain signals, and the blood vessels are located in the protective layers that line the brain.
• The inflamed trigeminal nerve releases the chemical CGRP (calcitonin gene-related peptide), which causes blood vessels to swell and to leak, resulting in the throbbing headache associated with symptoms of nausea, vomiting, and light sensitivity.
• The swollen vessels may continue to irritate the nerve, causing a vicious cycle, releasing more CGRP, more swelling and pain, and causing a headache that persists.

The most common symptoms of migraine are:

• Severe, often "pounding," pain, usually on one side of the head
• Nausea and/or vomiting
• Sensitivity to light
• Sensitivity to sound
• Eye pain

Other migraine headache symptoms and signs:

• Many people describe their headache as a one-sided, pounding type of pain, with nausea and sensitivity to light, sound, or smells (known as photophobia, phonophobia, and osmophobia). In some cases, the discomfort may be bilateral (both sides of the head). The pain of a migraine is often graded as moderate to severe in intensity. Physical activity or exertion (walking upstairs, rushing to catch a bus or train) will worsen the symptoms.
• Up to one-third of people with migraines have an aura, or a specific non-permanent neurologic symptom, before their headache begins. Frequently, the aura is a visual disturbance described as temporary blindness that obscures part of the visual field. Some describe flashing lights in one or both eyes, sometimes surrounding a blind spot. Other symptoms, including numbness or weakness along one side, or speech disturbances, occur rarely.
• Some people describe visual symptoms of loss of vision, which lasts for less than an hour, and may or may not be associated with head pain once the vision returns, as an ocular migraine. This is also known as retinal migraine and may be associated with symptoms similar to those described as an aura, such as blind spots, complete loss of vision in one eye, or flashing lights. Patients who experience these symptoms regularly need evaluation to exclude a primary retinal problem.
• Eye pain, which is different from sensitivity to light, is not a common component of migraine. If eye pain is persistent, or if eye pain is present and accompanied by blurred vision or loss of vision, then seek prompt evaluation.

The top migraine triggers include the following:

• Stress increases some brain chemicals that can irritate nerves
• Hormonal changes in women
• Not eating
• Weather changes
• Sleep disturbances can affect serotonin levels in the brain
• Bright or flickering lights may overstimulate the brain causing CSD
• Alcohol
• Food

What foods can trigger migraines?

Certain foods and their chemical additives may trigger migraine episodes in more than 25% of patients. A few examples include:

• Red wines (tyramine, sulfites, histamina)
• Aged cheeses (tyramine)
• Cured and processed meats (nitrites)
• Pickled, fermented foods like olives, sauerkraut, or kimchi (tyramine)
• Fermented soy products (tyramine)
• Food additives like monosodium glutamate (MSG) and artificial sweeteners
• Dried fruits (sulfites)

In patients with migraines, keeping a headache diary that includes what foods and drinks have been consumed before the episode may be helpful in determining your headache triggers.

The goal of treatment is to minimize the amount of time that migraine symptoms persist. The time to relief depends upon the type of medication and how it is taken.

Without treatment, most migraine headaches will resolve within 72 hours. However, there are some patients whose headache will persist even longer. This is called status migranosis.

Status migranosis is an uncommon condition affecting less than 30 migraine patients per 100,000, who are mostly women (about 90%). Half the people who have status migranosis will have symptoms that persist for at least 5 days.

Patients who self-administer triptans by injection may get relief within 10-15 minutes. Nasal triptans may take 15-60 minutes to work, and if taken by mouth, 30-60 minutes. Newer calcitonin gene-related peptide (CGRP) medications may take 2 hours to achieve relief. Over the counter medications may also help but may take longer to act.

Migraine headache is a clinical diagnosis made by the healthcare provider.

Detailed questions will be asked about the headache including when the symptoms began and whether an aura was present. Questions about the pain may include its location (is it one sided), the quality (does it throb), and whether any other associated symptoms are present like nausea, vomiting, and light or sound intolerance.

A physical examination, including a neurologic exam, is performed looking for abnormal findings, for example muscle weakness, changes in sensation, balance issues, or abnormal reflexes. Most people who have migraine headaches have normal physical examinations and the purpose of examining the patient is to look for other potential causes of the headache.

The provider will then decide whether the patient’s symptoms match a pattern consistent with migraine features. 

Unless there is concern about another potential cause for the headache, further tests, like CT or MRI scans, are not needed.

The diagnostic criteria for migraine headache without aura require the patient to have had at least five headache episodes that meet the following criteria:

• Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
• Headache with at least two of the following:
  • Unilateral (one sided) location
  • Pulsating (throbbing) quality
  • Moderate or severe pain intensity
  • Made worse by routine physical activity like walking or climbing stairs, or causes the patient to avoid that activity
• During the headache, at least one of the following symptoms needs to be present:
  • Nausea and/or vomiting
  • Extreme sensitivity to light (photophobia) or sound (phonophobia)
• The headache cannot be attributed to another disorder.

Headache treatment needs to be individualized for each patient. The ideal goal is to prevent migraines from occurring, or at least minimize how often they occur. Should a headache happen, the goal then is to minimize the duration and severity.

Other goals include improving quality of life, increasing sleep quality, and preventing episodic migraines from transforming into chronic migraines.

Patient education is important, especially in prevention. It may take weeks to determine if a preventative treatment regimen, whether it is with medications or other interventions is successful. A sustained effort both by the provider and patient are needed while this process continues.

Left untreated, the symptoms of a migraine including headache, nausea, vomiting and light sensitivity may last many hours or days. This prolonged discomfort may disrupt activities of daily living and prevent normal function at work, school, or home until the episode resolves on its own. Over time, untreated or poorly managed migraines may increase anxiety and depression because of the constant stress and anticipation of when the next headache will strike.

Medications used to prevent migraine headaches

• Antihypertensives (high blood pressure): beta blockers, calcium channel blockers, ACE inhibitors
• Anticonvulsants (antiseizure): topiramate, valproic acid, gabapentin
• Antidepressants: amitriptyline and venlafaxine
• CGRP antagonists

Medications available for acute migraine headache treatment

There are a variety of classes of medications that can be used to treat migraine headaches. Many can be successfully administered by the patient at home. If the patient fails home treatments, or develops nausea and vomiting, intravenous medications and rehydration may be considered, but this may require a visit to a healthcare facility.

All medications may interact with other drugs and may also be contraindicated in patients with certain medical conditions. The healthcare provider, along with the patient, will need to decide which medication may be best suited for their situation to provide the best and safest outcome.

• Over the counter pain medications include acetaminophen (Tylenol, Panadol), ibuprofen (Advil, Motrin), and naproxen (Aleve).
• Triptans are medications that target serotonin receptors in the brain and help prevent the serotonin effects that cause the symptoms of migraine. There are a variety of these medications available and they may be taken as a pill by mouth, as a nasal spray, or as an injection under the skin. They may be taken at home and often work best when administered when the first signs or symptoms of a migraine present. Examples include sumatriptan (Imitrex), zolmitriptan (Zomig), and rizatriptan (Maxalt).
• Triptans used in combination with nonsteroidal anti-inflammatory medications (NSAIDs) may be more effective.
• CGRP antagonists may be used to block the activation of the trigeminovascular system in the brain that is responsible for the pain of migraine. Examples include ubrogepant (Ulbrevy), rimegepant (Nurtec) and zavegepant (Zavzpret).
• Lasmiditan (Reyvow) is a selective serotonin inhibitor that may be used to treat acute migraine episodes.
• Antiemetic medications may be used to control nausea and vomiting associated with the migraine.
• Dihydroergotamine (DHE45) is available intravenously or by nasal spray. It cannot be used if triptans have been used in the previous 24 hours.
• Botulism toxin injections are recommended for chronic migraine treatment, but not for episodic migraines.
• Hormonal therapy may be used in women who have menstrual migraines.

• Alternative medications that may be helpful with migraine management include coenzyme Q10 or riboflavin
• Acupuncture
• Neuromodulator devices including transcutaneous supraorbital nerve stimulation and transcranial magnetic stimulation

Patients need to be actively involved in their treatment plans.

Headache diaries are useful in keeping track of headache symptoms for their onset and duration, as well as the circumstances. This may include sleep patterns, activity, diet, alcohol use, or menstrual cycle. Identifying triggers is an important first step in prevention.

Lifestyle modifications can lessen the impact of migraines on the patient and their family. These may include:

• Diet
  • Maintain a regular meal schedule
  • Avoid foods that may provoke a migraine
• Maintain a regular sleep schedule
  • Sleep hygiene
• Regular exercise
• Relaxation and mediation strategies

The prognosis for migraine patients is positive. People live healthy and productive lives. Migraines do not cause brain damage or affect life expectancy. Migraines cannot be cured; it is a life-long illness that needs to be managed and controlled to decrease the frequency and intensity of the headaches. This may be achieved through effective trigger avoidance, lifestyle management, and medications. For some patients, especially those who develop migraines in childhood, the frequency may decrease significantly in adulthood.

Migraines can be managed and the goal is to minimize the frequency and intensity of these headaches.

Avoiding or limiting exposure to headache triggers is an important first step. Enhancing lifestyle habits including working on sleep hygiene and developing a regular sleep schedule, eating regular meals, and staying well hydrated. Minimizing stress and maintaining an exercise program may also help.

If needed, medications may help with headache prevention, as can other treatment modalities such as biofeedback and nerve stimulation.