Migraine

Definition

Migraine is a type of recurring headache that involves blood vessels, nerves, and brain chemicals. Sensations such as visual changes, called auras, may precede a migraine.

The International Headache Society developed a system that classifies migraines as one of two types: migraine occurring with an aura (formerly called "classic") and migraine occurring without an aura (formerly called "common"). Patients may experience a migraine several times a week or once every couple of years. Migraines may be so severe that they interfere with a patient's ability to work and carry on normal activities.

Migraine

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Causes

The precise cause of migraines is unknown. Among the suspected causes are:

  • Environmental triggers
  • Genetic predisposition
  • Dietary triggers
  • Physiologic (menstruation, puberty)

An internal or external trigger sets the process in motion. It is possible that the nervous system reacts to the trigger by conducting electrical activity that spreads across the brain. This electrical activity leads to the release of brain chemicals that make blood vessels swell and become leaky. Scientists think that it is this inflammatory process that causes the pain and other symptoms of a migraine headache.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

About 11% of the population is reported to experience a migraine over the course of a given year. The risk of having a migraine diagnosis over a lifetime increases to nearly 20%.

Risk factors for migraines include:

  • Sex: adult females, but about equal gender risk in pre-adolescents
  • Family members with migraines
  • Youth (50% of cases occur before adulthood, 90% occur before age 40)
  • Medications including:
    • Birth control pills
    • Hormone replacement therapy
    • Drugs to dilate blood vessels
  • Menstruation
  • Fatigue
  • Lack of sleep or changing sleep patterns
  • Stress or relief from stress
  • Skipping meals
  • Alcohol, especially red wine
  • Altitude or weather changes
  • Time zone changes
  • Exertion that is sustained or excessive
  • Glaring or flashing light
  • Perfumes or other odors
  • Eating foods known to trigger migraines
  • Epilepsy
  • Small hole in the heart that is leftover from development in the womb (called patent foramen ovale)

Symptoms

Migraines occur in phases that may include:

A Warning

A warning may precede a migraine. In the hours or days before the headache, symptoms may include:

  • A change in mood
  • A change in behavior
  • A change in the level of activity
  • Fatigue
  • Bloating
  • Tense muscles
  • Yawning
  • Food craving or decreased appetite
  • Nausea, vomiting, diarrhea
  • Sensitivity to sound or light

An Aura

Some migraines are preceded by an aura. The most common aura is visual. The aura lasts about 15-30 minutes and may produce the following sensations:

  • Flashing lights, spots, or zig zag lines
  • Temporary, partial loss of vision
  • Speech difficulties
  • Weakness in an arm or leg
  • Numbness or tingling in the face and hands
  • Restlessness
  • Confusion
  • Dizziness, lightheadedness
  • Speech disturbances
  • Cognitive dysfunction

Very rarely, an aura can occur by itself, with no subsequent headache. In these cases, it is important to seek medical attention to make sure the symptoms are not due to a more serious cause such as stroke or seizure.

The Migraine Headache

Migraine pain starts within an hour of the aura ending. Symptoms include:

  • A headache, usually on one side but may involve both sides. Typically, the headache feels:
    • Intense
    • Throbbing or pulsating
    • More severe with movement
  • Nausea or vomiting
  • Diarrhea
  • Sensitivity to light or sound
  • Sore or achy muscles
  • Lightheadedness or dizziness

A Post-Headache Period

Migraines usually last from 4 to 72 hours. They often go away with sleep. After the headache, you may experience:

  • Food intolerances or cravings
  • Trouble concentrating
  • Fatigue
  • Sore muscles
  • Irritability
  • Restlessness
  • Mood changes

Diagnosis

The doctor will ask about your symptoms and medical history, and perform a physical exam. You may also be given a neurological exam. In some situations, a CT scan or magnetic resonance imaging (MRI) scan may be performed to rule out other conditions. The doctor may order blood tests or other tests before starting treatment.

Treatment

Migraine therapy aims to:

  • Prevent headaches
  • Reduce headache severity and frequency
  • Restore your ability to function
  • Improve quality of life

Treatment options include:

Medications

Pain medications are often required to ease or stop the pain. Over-the-counter pain pills may ease mild symptoms.

Warning: Continuous use of some over-the-counter medications may cause what is called a "rebound headache" when you stop taking the medication.

Some prescription medications act directly to stop the cause of the migraine headache. These include drugs that:

  • Quiet nerve pathways
  • Reduce inflammation
  • Stimulate receptors for serotonin, a brain hormone

These drugs can be taken by mouth (swallowed), but they may act more quickly in forms that dissolve in the mouth, are inhaled through the nose, or injected. Your doctor can help you choose the medication and route of administration most effective for you. Abortive medications include ergots, triptans, steroids, and nonsteroidal anti-inflammatory drugs (NSAIDS).

Other drugs can help prevent migraines for people suffering from frequent migraines. Preventive drugs are taken every day, even if you do not have a headache. Classes of preventative medications include beta-blockers, calcium channel blockers, tricyclics, and anticonvulsants.

Self-care During the Migraine

  • Apply cold compresses to painful areas of your head
  • Lie in a dark, quiet room
  • Massage your scalp and temples
  • Try to fall asleep

Lifestyle Changes

  • Keep a diary to help identify what triggers migraines and what helps relieve them.
  • Learn stress management and relaxation techniques.
  • Consider talking with a counselor to learn new coping skills and relaxation techniques.
  • Exercise regularly.
  • If you are a smoker, quit. Smoking may worsen a migraine, and it probably also increases the rare chance of stroke occurring during a migraine attack. This is especially true if you are a women taking birth control pills or other hormone replacement therapy.
  • Avoid foods that trigger migraines.
  • If low blood sugar precedes your migraines, eat small meals more often.
  • Do not change your regular sleep pattern during the weekend or during vacation.

Prevention

Methods for preventing migraine include avoiding those things that trigger the headache and establishing other healthy habits. Suggestions include:

  • Maintain regular sleep patterns.
  • Learn stress management techniques.
  • Do not skip meals.
  • Avoid red wine and other alcohol.
  • Exercise regularly.
  • Avoid foods known to trigger migraines. These may include:
    • Yogurt
    • Nuts and peanut butter
    • Beans (eg, lima, navy, pinto, and others)
    • Aged or cured meats
    • Aged cheese
    • Processed or canned meat
    • Caffeine (intake or withdrawal)
    • Canned soup
    • Chocolate
    • Buttermilk or sour cream
    • Meat tenderizer
    • Brewer's yeast
    • Avocados
    • Onions
    • Pickles
    • Red plums
    • Sauerkraut
    • Snow peas
    • Soy sauce
    • Anything with MSG (monosodium glutamate), tyramine, or nitrates
    • Food triggers are often very dependent on the individual. Using a food diet can help you identify migraine triggers that are specific to your migraine disorder.

RESOURCES:

American Council for Headache Education
http://www.achenet.org

American Headache Society
http://ahsnet.org

The National Migraine Association
http://www.migraines.org

CANADIAN RESOURCES:

The College of Family Physicians of Canada
http://www.cfpc.ca

The Migraine Clinic
http://www.migraineclinic.ca/

References:

American Academy of Family Physicians website. Available at: http://www.aafp.org/online/en/home.html .

American Academy of Neurology website. Available at: http://www.aan.com/professionals/index.cfm?a=0&fc=1# .

Cephalalgia: An International Journal of Headache . 2004; 24(suppl 1). Available at: http://216.25.100.131/ihscommon/guidelines/pdfs/ihc_II_main_no_print.pdf . Accessed November 15, 2004.

Gladstone JP. Migraine In: Gilman S, ed. MedLink Neurology. San Diego, CA: MedLink Corporation. Available at: http://www.medlink.com . Accessed February 23, 2008.

Griffith's 5-Minute Clinical Consult . Lippincott Williams & Wilkins; 1999.

The International Headache Society. International Classification of Headache Disorders . 2nd ed. 2003.

National Institute of Neurological Disorders and Stroke website. Available at: http://www.ninds.nih.gov/ .

Silberstein SD, Lipton RB. Headache in Clinical Practice . London, England: Martin Dunitz Ltd; 2002.

Textbook of Clinical Neurology . WB Saunders Co; 1999.

The Vestibular Disorders Association website. Available at: http://www.vestibular.org/migraine.html . Accessed November 15, 2004.



Last reviewed February 2008 by J. Thomas Megerian, MD, PhD, FAAP

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

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