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Migraine

Definition

A migraine is a common type of headache that may occur with symptoms such as nausea, vomiting, or sensitivity to light. In many people, a throbbing pain is felt only on one side of the head.

Some people who get migraines have warning symptoms, called an aura, before the actual headache begins. An aura is a group of symptoms, including vision disturbances, that are a warning sign that a bad headache is coming.

Alternative Names

Headache - migraine

Causes, incidence, and risk factors

Migraine attacks may be triggered by:

• Alcohol
• Allergic reactions
• Bright lights
• Certain odors or perfumes
• Changes in hormone levels (which can occur during a woman's menstrual cycle or with the use of birth control pills)
• Changes in sleep patterns
• Exercise
• Loud noises
• Missed meals
• Physical or emotional stress
• Smoking or exposure to smoke

Certain foods and preservatives in foods may trigger migraines in some people. Food-related triggers may include:

• Any processed, fermented, pickled, or marinated foods
• Baked goods
• Chocolate
• Dairy products
• Foods containing monosodium glutamate (MSG)
• Foods containing tyramine, which includes red wine, aged cheese, smoked fish, chicken livers, figs, and certain beans
• Fruits (avocado, banana, citrus fruit)
• Meats containing nitrates (bacon, hot dogs, salami, cured meats)
• Nuts
• Onions
• Peanut butter

This list may not include all triggers.

Symptoms

Vision disturbances, or aura, are considered a "warning sign" that a migraine is coming. The aura occurs in both eyes and may involve any or all of the following:

• A temporary blind spot
• Blurred vision
• Eye pain
• Seeing stars or zigzag lines
• Tunnel vision

Not every person with migraines has an aura. Those who do usually develop one about 10 - 15 minutes before the headache. However, it may occur just a few minutes to 24 hours beforehand. A headache may not always follow an aura.

Migraine headaches can be dull or severe. The pain may be felt behind the eye or in the back of the head and neck. For many patients, the headaches start on the same side each time. The headaches usually:

• Feel throbbing, pounding, or pulsating
• Are worse on one side of the head
• Start as a dull ache and get worse within minutes to hours
• Last 6 to 48 hours

Other symptoms that may occur with the headache include:

• Chills
• Increased urination
• Fatigue
• Loss of appetite
• Nausea and vomiting
• Numbness, tingling, or weakness
• Problems concentrating, trouble finding words
• Sensitivity to light or sound
• Sweating

Symptoms may linger even after the migraine has gone away. Patients with migraine sometimes call this a migraine "hangover." Symptoms can include:

Signs and tests

Your doctor can diagnose this type of headache by asking questions about your symptoms and family history of migraines. A complete physical exam will be done to determine if your headaches are due to muscle tension, sinus problems, or a serious brain disorder.

There is no specific test to prove that your headache is actually a migraine. However, your doctor may order a brain MRI or CT scan if you have never had one before or if you have unusual symptoms with your migraine, including weakness, memory problems, or loss of alertness.

An EEG may be needed to rule out seizures. A lumbar puncture (spinal tap) might be done.

Treatment

There is no specific cure for migraine headaches. The goal is to prevent symptoms by avoiding or changing your triggers.

A good way to identify triggers is to keep a headache diary. Write down:

• When your headaches occur
• How severe they are
• What you've eaten
• How much sleep you had
• Other symptoms
• Other possible factors (women should note where they are in their menstrual cycle)

For example, the diary may reveal that your headaches tend to occur more often on days when you wake up earlier than usual. Changing your sleep schedule may result in fewer migraine attacks.

When you do get migraine symptoms, try to treat them right away. The headache may be less severe. When migraine symptoms begin:

• Drink water to avoid dehydration, especially if you have vomited
• Rest in a quiet, darkened room
• Place a cool cloth on your head

Many different medications are available for people with migraines. Medicines are used to:

• Reduce the number of attacks
• Stop the migraine once early symptoms occur
• Treat the pain and other symptoms

REDUCING ATTACKS

If you have frequent migraines, your doctor may prescribe medicine to reduce the number of attacks. Such medicine needs to be taken every day in order to be effective. Such medications may include:

• Antidepressants such as amitriptyline
• Blood pressure medicines such as beta blockers (propanolol) or calcium channel blockers (verapamil)
• Seizure medication such as valproic acid, gabapentin, and topiramate
• Serotonin reuptake inhibitors (SSRIs) such as venlafaxine
• Selective norepinephrine uptake inhibitor (SNRIs) such as duloxetine

Botulinum toxin (Botox) injections may also help reduce migraine attacks.

STOPPING AN ATTACK

Other medicines are taken at the first sign of a migraine attack. Over-the-counter pain medications such as acetaminophen, ibuprofen, or aspirin are often helpful, especially when your migraine is mild. If these don't help, ask your doctor about prescription medications. (Be aware, however, that overuse or misuse of such pain medications may result in rebound headaches.Chronic rebound headaches typically occur in people who take pain medications more than 3 days a week on an ongoing basis.)

Your doctor can select from several different types of medications, including:

• Triptans -- the most frequently prescribed medicines for stopping migraine attacks -- such as almotriptan (Axert), frovatriptan (Frova), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig)
• Ergots such as dihydroergotamine or ergotamine with caffeine (Cafergot)
• Isometheptene (Midrin)

These medications come in different forms. Patients who have nausea and vomiting with their migraines may be prescribed a nasal spray, suppository, or injection instead of pills.

Some migraine medicines narrow your blood vessels and should not be used if you are at risk for heart attacks or have heart disease, unless otherwise instructed by your health care provider. Ergots should not be taken if you are pregnant or planning to become pregnant, because they can cause serious side effects to an unborn baby.

TREATING SYMPTOMS

Other medications are primarily given to treat the symptoms of migraine. Used alone or in combinations, these drugs can reduce your pain, nausea, or emotional distress. Medications in this group include:

• Nausea medicines such as prochlorperazine
• Over-the-counter pain relievers such as acetaminophen (Tylenol)
• Sedatives such as butalbital
• Narcotic pain relievers such as meperidine
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen

If you wish to consider an alternative, feverfew is a popular herb for migraines. Several studies, but not all, support using feverfew for treating migraines. If you are interested in trying feverfew, make sure your doctor approves. Also, know that herbal remedies sold in drugstores and health food stores are not regulated. Work with a trained herbalist when selecting herbs.

Support Groups

American Council for Headache Education - www.achenet.org

The National Migraine Association - www.migraines.org

National Headache Foundation - www.headaches.org

Expectations (prognosis)

Every person responds differently to treatment. Some people have rare headaches that require little to no treatment. Others require the use of several medications or even occasional hospitalization.

Complications

Migraine headache is a risk factor for stroke in both men and women.

Migraine headaches generally represent no significant threat to your overall health. However, they can be a long-term (chronic) problem and may interfere with your day-to-day life.

Calling your health care provider

Call 911 if:

• You are experiencing "the worst headache of your life"
• You have speech, vision, or movement problems or loss of balance, especially if you have not had these symptoms with a migraine before
• Your headaches are more severe when lying down
• The headache starts very suddenly

• Your headache patterns or pain change
• Treatments that once worked are no longer helpful
• You have side effects from medication, including irregular heartbeat, pale or blue skin, extreme sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain, cramps, dry mouth, or extreme thirst
• You are pregnant or could become pregnant -- some medications should not be taken when pregnant

See the general article on headaches for more information on emergency symptoms

Prevention

Understanding your headache triggers can help you avoid foods and situations that cause your migraines. Keep a headache diary to help identify the source or trigger of your symptoms. Then modify your environment or habits to avoid future headaches.

Other tips for preventing migraines include:

• Avoid smoking
• Avoid alcohol
• Avoid artificial sweeteners and other known food-related triggers
• Get regular exercise
• Get plenty of sleep each night
• Learn to relax and reduce stress -- some patients have found that biofeedback and self-hypnosis helps reduce the number of migraine attacks

References

Wilson JF. In the clinic: migraine. Ann Intern Med. 2007;147(9):ITC11-1-ITC11-16.

Ebell MH. Diagnosis of migraine headache. Am Fam Physician. 2006;74(12):2087-2088.

Detsky ME, McDonald DR, et al. Does this patient with headache have a migraine or need neuroimaging? JAMA. 2006;296(10):1274-1283.

Loder E. Triptan therapy in migraine. N Engl J Med. 2010 Jul 1;363(1): 63-70.

Silberstein SD, Young WB. Headache and facial pain. In: Goetz CG. Textbook of Clinical Neurology. 3rd ed. St. Louis, Mo: WB Saunders; 2007:chap. 53.