Migraine Headache FAQs

The difference between headache and migraine often includes intense pain, sensitivity to light, and nausea for migraine headache.

Migraines are disabling headaches that most likely stem from problems with the nerves and blood vessels in the head. Migraine headaches typically last from 4-72 hours. They may occur as often as several times a week to only once a year. People who have migraines are called migraineurs.

Migraine headaches affect a significant percentage of the population. Three times as many women as men have migraines. Most of the migraineurs have family members who have migraines. The following types of migraine headaches have been identified:

• Migraine without aura (common migraine): This type accounts for most migraine headaches. There is no aura before a common migraine.
• Migraine with aura (classic migraine): This type is usually preceded by an aura and is usually much worse than a common migraine. Most often, an aura is a visual disturbance (outlines of lights or jagged light images).
• Status migrainosus: This is the term used to describe a long-lasting migraine that does not go away by itself.

A recent U.S. study found that more Caucasians have migraine headaches than blacks or Asians.

Migraine headaches affect women more than men.

The number of boys and girls who get migraines appears to be similar, but the prevalence of migraine in females begins to climb during the teenage years. By early adulthood, migraines are 3 times as frequent in women as in men.

Symptoms are different for different people and are sometimes different from migraine to migraine. The following 5 phases have been noted:

• Prodrome (a period of warning symptoms): Many symptoms can precede a migraine headache. These include changes in mood (happiness, irritability, sadness) or sensation (funny tastes or smells). Many people experience fatigue and muscle tension before a migraine headache.
• Visual or auditory disturbances (auras): Some people develop scotomas (blind spots), see geometric patterns, experience hemianopsia (vision on only one side), or, less commonly, have auditory (hearing) hallucinations.
• Headache: Although migraine pain usually appears on one side of the head, some migraineurs have them on both sides. The throbbing pain may occur. Many migraineurs feel nauseated and may vomit. Many people become photophobic (sensitive to light) and experience phonophobia (sensitive to sound). This phase may last 4-72 hours.
• Headache termination: Even if untreated, the pain usually goes away with sleep.
• Postdrome: Migraineurs may not feel well for some time after the migraine stops. They might not be able to eat right away. Problems with thinking and tiredness are common.

Yes! A person with any type of intense headache, especially a recurring one, may have a life-threatening underlying condition. A doctor's evaluation is definitely necessary. If the doctor makes a diagnosis of migraine headache, various treatments are available. These treatments can significantly improve a migraineur's quality of life.

A doctor should be called if a person experiences any of the following problems:

• A change in frequency, severity or features of the migraines typically experienced
• A progressively worsening headache that lasts for days
• A headache brought on by what doctors call Valsalva maneuvers (coughing, sneezing, bearing down, straining while on the toilet)
• Large weight loss (unintentional)
• Weakness or paralysis that lasts after a headache stops

A person who has any of the following should go or be taken to a hospital emergency department:

• The worst headache of his or her life, especially if the headache comes on suddenly
• Headache associated with trauma to the head
• Loss of consciousness associated with trauma to the head
• Fever or stiff neck associated with a headache
• Decreased level of consciousness
• Confusion
• Paralysis on one side of the body
• Seizures

Although migraine headaches are excruciating, they are seldom life-threatening. They are harmful to a person's quality of life, however. They sometimes cause depression and/or anxiety disorders, especially if the headaches are uncontrolled by medication or other therapies. Doctors conduct thorough examinations and tests of persons with migraine headaches in order to rule out truly life-threatening possibilities like tumors or bleeding in the brain.

Not all severe headaches are migraines. Headaches can be warnings of more serious conditions. The following signs (what doctors find) or symptoms (what patients report) are reasons for concern:

• Headaches associated with other neurological (relating to the brain, spinal cord, or nerves) signs or symptoms (for example, diplopia [seeing double], loss of sensation, weakness, ataxia [clumsiness])
• Headaches that have an abrupt onset (come on very fast)
• Headaches that do not go away, especially if they last longer than 72 hours
• Headaches that first occur after age 55 years
• Headaches that develop after a head injury or major trauma
• Headaches accompanied by a stiff neck or fever
• Headaches in a person who does not have a clear family history of migraine headaches

No one fully understands the exact cause(s) of migraine headaches. Many experts think that a migraine begins with abnormal brainstem (a part of the brain) activity that leads to spasm (rapid contraction) of blood vessels in the cerebrum (the main part of the brain) and dura (the covering of the brain). The first wave of spasm decreases blood supply, which causes the aura that some people experience. After the first spasm, the same arteries become abnormally relaxed, which increases blood flow and gives rise to migraine headache pain.

Certain chemicals normally found in the brain (namely, dopamine and serotonin) may be involved in causing migraines. These chemicals are called neurotransmitters because they transmit signals within the brain. Neurotransmitters can cause blood vessels to act in unusual ways if they are present in abnormal amounts or if the blood vessels are particularly sensitive to them.

Various triggers are thought to bring about migraine in people who have a natural tendency for having migraine headaches. Different people may have different triggers.

• Certain foods, especially chocolate, cheese, nuts, alcohol, and monosodium glutamate (MSG) can trigger migraines. (MSG is a food enhancer used in many foods, including Chinese food.)
• Missing a meal may bring on a headache.
• Stress and tension are also risk factors. People often have migraines during times of increased emotional or physical stress.
• Birth control pills are a common trigger. Women may have migraines at the end of the pill cycle as the estrogen component of the pill is stopped. This is called an estrogen-withdrawal headache.

Most migraineurs have normal examination findings. The diagnosis of migraine headache is made solely on the symptoms a migraineur describes to the doctor.

Other possible causes of headaches include stroke, tension, meningitis (infection of the brain's coverings), or sinus infections. The following tests and images may be performed or taken if the doctor thinks a person's headaches are being caused by something other than migraines:

• Blood tests
• X-rays films
• CT scans of the head to look for bleeding, stroke, or tumor
• A lumbar puncture (spinal tap) to look for evidence of infection or bleeding

Self-care at home

Most migraineurs can deal with mild-to-moderate migraine attacks at home. The following measures may help relieve migraine headache pain:

• Using a cold compress to the area of pain
• Resting with pillows comfortably supporting the head or neck
• Resting in a dark, quiet place
• Avoiding odors
• Withdrawing from stressful surroundings
• Sleeping
• Drinking a moderate amount of caffeine

Taking certain over-the-counter headache remedies: Note that none of the following (with the exception of acetaminophen, aspirin, and caffeine combinations) has been clearly shown to relieve migraine headache pain.

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Examples of NSAIDs include aspirin, ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve), and ketoprofen (Orudis). These medicines sometimes cause stomach ulcers and bleeding; therefore, anyone with a history of stomach bleeding should not take them. Even people without such history should not take NSAIDs over a long period. The doctor or pharmacist should be asked about possible drug interactions if other medications are also being taken.
• Acetaminophen (Tylenol): Acetaminophen may be safely taken with an NSAID or other pain medicine for an additive effect. Taking acetaminophen by itself is usually safe, even for people with a history of stomach ulcers or bleeding, but it should not be taken if a person has liver problems. Taking large amounts of acetaminophen is associated with liver and kidney damage. Patients should always tell their doctor how much acetaminophen they take each day.
• Combination medications: Some over-the-counter pain relievers have been approved for use with migraine, including Excedrin Migraine, which contains acetaminophen, aspirin, and caffeine.

Medical treatment

Despite advances, migraines can be difficult to treat. About half of migraineurs stop seeking medical care for their headaches because they are dissatisfied with treatment results. This is unfortunate because the right drug or combination of drugs may eventually be found if the migraineur keeps visiting his or her doctor for follow-up visits.

Migraines can be treated with 2 approaches: abortive and preventive.

• Abortive: The goal of abortive therapy is to prevent a migraine attack or to stop it once it starts. The prescribed medications stop a headache during its prodrome stage or once it has begun and may be taken as needed. Some can be administered as a self-injection into the thigh; others, as a wafer that melts on the tongue. These forms of medication are especially useful for people who vomit during a migraine, and they work quickly.

Abortive treatment medications include triptans, which specifically target serotonin. They are all very similar in their action and chemical structure. The triptans are used only to treat headache pain and do not relieve pain from back problems, arthritis, menstruation, or other conditions.

• Sumatriptan (Imitrex)
• Zolmitriptan (Zomig)
• Eletriptan (Relpax)
• Naratriptan (Amerge, Naramig)
• Rizatriptan (Maxalt)
• Frovatriptan (Frova)
• Almotriptan (Axert)

The following drugs are also specific and affect serotonin, but they affect other brain chemicals. Occasionally, one of these drugs works when a triptan does not.

• Ergotamine tartrate (Cafergot)
• Dihydroergotamine (D.H.E. 45 Injection, Migranal Nasal Spray)
• Acetaminophen-isometheptene-dichloralphenazone (Midrin)

The following drugs are mainly used for nausea, but they sometimes have an abortive or preventive effect on headaches:

• Prochlorperazine (Compazine)
• Promethazine (Phenergan)

The next drugs are weak members of the narcotic class. They are not specific for migraine, but they can help relieve almost any kind of pain. Since they are habit-forming, they are less desirable than the specific headache drugs listed above. These drugs should be used primarily as a "backup" for the occasions when a specific drug does not work.

• Butalbital compound (Fioricet, Fiorinal)
• Acetaminophen and codeine (Tylenol With Codeine)

Preventive: This type of treatment is considered if a migraineur has more than 1 migraine per week. The goal is to lessen the frequency and severity of migraine attacks. Medication to prevent a migraine can be taken daily. Preventive treatment medications include the following:

• Medications used to treat high blood pressure -- Beta-blockers (propranolol [Inderal]), calcium channel blockers (verapamil [Covera])
• Antidepressants -- Amitriptyline (Elavil), nortriptyline (Pamelor)
• Antiseizure medications -- Gabapentin (Neurontin), valproic acid (Depakote), topiramate (Topamax)
• Some antihistamines and anti-allergy drugs, including diphenhydramine (Benadryl) and cyproheptadine (Periactin)

A new class of monoclonal antibody drugs was approved by the FDA to prevent migraine headaches. These medications work by targeting calcitonin gene-related peptide (CGRP), which is elevated in the blood during a migraine attack. The new FDA-approved drugs are:

• erenumab-aooe (Aimovig)
• fremanezumab-vfrm (Ajovy)
• galcanezumab-gnlm (Emgality)

Botulinum toxin (Botox) also has been approved by the FDA to treat chronic migraine in adults and is used as a migraine preventive. The health care professional gives Botox injections at specific points in the head and neck muscles, and the effects last up to 3 months.

Migraineurs must see their doctor regularly. Keeping a "pain journal" is often helpful to track how often attacks happen and what drugs were used to treat them. Sometimes it takes several doctor visits before an effective treatment plan is found.

Some migraineurs have been helped by alternative or complementary therapies such as chiropractic, acupuncture, osteopathic manipulation, and herbal remedies, though none of these treatments is supported by reliable scientific evidence.

• Migraineurs must have realistic expectations and should understand that their headaches are a chronic (long-term) condition that will likely be with them for their entire lives.
• The good news is that the prognosis is very good once the headaches are under control.
• Migraineurs should expect to try several times before finding an effective treatment plan.
• Different drugs work for different people, and several may have to be tried before finding the best one for a specific person.
• In many instances, a combination of different medications is needed to provide relief.

• Migraineurs should identify and avoid migraine triggers.
• This may include avoiding certain types of foods and certain emotional situations.
• If missing meals triggers headaches, the migraineur should make every effort to eat on a regular basis.
• In some instances, the use of biofeedback (a technique that helps people learn to have some degree of control over certain "automatic" body functions like heart rate) may help lessen the severity and frequency of attacks.
• Additionally, migraineurs should remember to take any prescribed medications at the dosages and times the doctor specifies.

American Academy of Neurology

American Migraine Foundation

National Institute of Neurological Disorders and Stroke