Headache Pain: Migraine

Overview

A migraine can cause severe throbbing pain or a pulsing sensation, usually on just one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound.

Migraine attacks can cause significant pain for hours to days and can be so severe that the pain is disabling.

Warning symptoms known as aura may occur before or with the headache. These can include flashes of light, blind spots, or tingling on one side of the face or in your arm or leg.

Medications can help prevent some migraines and make them less painful. Talk to your doctor about different migraine treatment options if you can’t find relief. The right medicines, combined with self-help remedies and lifestyle changes, may help.

Symptoms

Migraines often begin in childhood, adolescence or early adulthood. Migraines may progress through four stages: prodrome, aura, headache, and post-drome, though you may not experience all stages.

Prodrome

One or two days before a migraine, you may notice subtle changes that warn of an upcoming migraine, including:

• Constipation
• Mood changes, from depression to euphoria
• Food cravings
• Neck stiffness
• Increased thirst and urination
• Frequent yawning

Aura

An aura may occur before or during migraines. Most people experience migraines without aura.

Auras are symptoms of the nervous system. They are usually visual disturbances, such as flashes of light or wavy, zigzag vision.

Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Your muscles may get weak, or you may feel as though someone is touching you.

Each of these symptoms usually begins gradually, builds up over several minutes and lasts for 20 to 60 minutes. Examples of migraine aura include:

• Visual phenomena, such as seeing various shapes, bright spots or flashes of light
• Vision loss
• Pins and needles sensations in an arm or leg
• Weakness or numbness in the face or one side of the body
• Difficulty speaking
• Hearing noises or music
• Uncontrollable jerking or other movements

Sometimes, a migraine with aura may be associated with limb weakness (hemiplegic migraine).

Attack

A migraine usually lasts from four to 72 hours if untreated. The frequency with which headaches occur varies from person to person. Migraines may be rare or strike several times a month. During a migraine, you may experience:

• Pain on one side or both sides of your head
• Pain that feels throbbing or pulsing
• Sensitivity to light, sounds, and sometimes smells and touch
• Nausea and vomiting
• Blurred vision
• Lightheadedness, sometimes followed by fainting

Post-drome

The final phase, known as post-drome, occurs after a migraine attack. You may feel drained and washed out, while some people feel elated. For about 24 hours, you may also experience:

• Confusion
• Moodiness
• Dizziness
• Weakness
• Sensitivity to light and sound

When to see a doctor

Migraines are often undiagnosed and untreated. If you regularly experience signs and symptoms of migraine attacks, keep a record of your attacks and how you treated them. Then make an appointment with your doctor to discuss your headaches.

Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.

Causes

Though migraine causes aren’t understood, genetics and environmental factors appear to play a role.

Migraines may be caused by changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway.

Imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system — also may be involved. Researchers are still studying the role of serotonin in migraines.

Serotonin levels drop during migraine attacks. This may cause your trigeminal nerve to release substances called neuropeptides, which travel to your brain’s outer covering (meninges). The result is migraine pain. Other neurotransmitters play a role in the pain of migraine, including calcitonin gene-related peptide (CGRP).

Risk factors

Several factors make you more prone to having migraines, including:

• Family history. If you have a family member with migraines, then you have a good chance of developing them too.
• Age. Migraines can begin at any age, though the first often occurs during adolescence. Migraines tend to peak during your 30s, and gradually become less severe and less frequent in the following decades.
• Sex. Women are three times more likely to have migraines. Headaches tend to affect boys more than girls during childhood, but by the time of puberty and beyond, more girls are affected.
• Hormonal changes. If you are a woman who has migraines, you may find that your headaches begin just before or shortly after the onset of menstruation. They may also change during pregnancy or menopause. Migraines generally improve after menopause. Some women report that migraine attacks begin during pregnancy, or their attacks worsen. For many, the attacks improved or didn’t occur during later stages in the pregnancy. Migraines often return during the postpartum period.

Complications

Sometimes your efforts to control your migraine pain cause problems, such as:

• Abdominal problems. Certain pain relievers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others) may cause abdominal pain, bleeding, ulcers and other complications, especially if taken in large doses or for a long period of time.
• Medication-overuse headaches. Taking over-the-counter or prescription headache medications more than 10 days a month for three months or in high doses may trigger serious medication-overuse headaches. Medication-overuse headaches occur when medications stop relieving pain and begin to cause headaches. You then use more pain medication, which continues the cycle.
• Serotonin syndrome. Serotonin syndrome is a rare, potentially life-threatening condition that occurs when your body has too much of the nervous system chemical called serotonin. While the risk is considered extremely low, taking migraine medications called triptans and antidepressants known as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) may increase the risk of serotonin syndrome. These medications naturally raise serotonin levels, and it is possible that combining them could cause levels that are too high. Triptans and SSRIs or SNRIs may be used together, but it’s important to watch out for possible symptoms of serotonin syndrome such as changes in cognition, behavior and muscle control (such as involuntary jerking). Triptans include medications such as sumatriptan (Imitrex) or zolmitriptan (Zomig). Some common SSRIs include sertraline (Zoloft), fluoxetine (Sarafem, Prozac) and paroxetine (Paxil). SNRIs include duloxetine (Cymbalta) and venlafaxine (Effexor XR).

Also, some people experience complications from migraines such as:

• Chronic migraine. If your migraine lasts for 15 or more days a month for more than three months, you have chronic migraine.
• Status migrainosus. People with this complication have severe migraine attacks that last for longer than three days.
• Persistent aura without infarction. Usually, an aura goes away after the migraine attack, but sometimes aura lasts for more than one week afterward. A persistent aura may have similar symptoms to bleeding in the brain (stroke), but without signs of bleeding in the brain, tissue damage or other problems.
• Migrainous infarction. Aura symptoms that last longer than one hour can signal a loss of blood supply to an area of the brain (stroke), and should be evaluated. Doctors can conduct neuroimaging tests to identify bleeding in the brain.

Prevention

Until recently, experts recommended avoiding common migraine triggers. Some triggers can’t be avoided, and avoidance isn’t always effective. But some of these lifestyle changes and coping strategies may help you reduce the number and severity of your migraines:

• Transcutaneous supraorbital nerve stimulation (t-SNS). This device (Cefaly), similar to a headband with attached electrodes, was recently approved by the Food and Drug Administration as a preventive therapy for migraines. In research, those that used the device experienced fewer migraines.
• Learn to cope. Recent research shows that a strategy called learning to cope (LTC) may help prevent migraines. In this practice, you are gradually exposed to headache triggers to help desensitize you to them. LTC may also be combined with cognitive behavioral therapy. More research is needed to better understand the effectiveness of LTC.
• Create a consistent daily schedule. Establish a daily routine with regular sleep patterns and regular meals. In addition, try to control stress.
• Exercise regularly. Regular aerobic exercise reduces tension and can help prevent migraines. If your doctor agrees, choose any aerobic exercise you enjoy, including walking, swimming, and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches. Regular exercise can also help you lose weight or maintain healthy body weight, and obesity is thought to be a factor in migraines.
• Reduce the effects of estrogen. If you are a woman who has migraines and estrogen seems to trigger or make your headaches worse, you may want to avoid or reduce the medications you take that contain estrogen.