Migraine

Not every person with migraine will have the same experience. And one individual may not have the same symptoms during every migraine attack, which can make diagnosing and treating migraine more complicated.

According to the Mayo Clinic, migraine symptoms generally include:

• Pain
• Nausea
• Vomiting
• Sensitivity to light and sound

A migraine will typically progress in four phases, and each includes different combinations of symptoms. However, you may not necessarily experience all four stages.

Stage 1: Prodrome

Some people may notice warning signs of a migraine 24 to 48 hours before their attack. Symptoms during this time may include:

• Constipation
• Shifts in mood
• Cravings for specific foods
• Changes in thirst and urination
• Neck pain or stiffness
• Frequent yawning

Brain imaging and neurological research have shown that migraine activity begins much earlier³ than the onset of a migraine headache.

“We know where in the brain an attack actually begins and we know it begins before the pain actually starts,” Dr. Dodick says. “Some patients will have symptoms during the prodromal phase of an attack and they can use these clues to predict an attack.” Depending on how early these symptoms occur, you may be able to use these symptoms as a sign to begin taking your abortive medication if you are prescribed one (we’ll discuss medications later on) or to try to prepare by doing things that make you feel more comfortable.

Stage 2: Aura

About 25% of people with migraine experience an aura,⁴ or sensory, motor, and speech symptoms. Aura can occur either before the onset of pain or during the main attack. Aura symptoms may include:

• Seeing flashes of light
• Having blurred vision
• Vision loss
• Feeling numb or tingly
• Feeling weak on one side of your body
• Having trouble speaking

Generally, each symptom develops slowly and can last between 20 to 60 minutes. Visual aura symptoms typically involve both eyes, according to the Mayo Clinic.

Stage 3: Attack

Stage three is what most people probably think about when they hear the word migraine. This is when you may experience symptoms such as:

• Moderate-to-severe head pain
• Neck pain
• Nausea
• Sensitivity to light and sound
• Vomiting

This phase typically lasts from 4 to 72 hours. Although these symptoms are common during an attack, you may not experience all of them. Or you may have other symptoms in addition to these, according to Dr. Dodick. “Many patients have some other symptoms like cognitive dysfunction, difficulty concentrating, vertigo, or dizziness. They may experience heightened sensitivity to odors or smell,” he says.

Stage 4: Post-drome

After the attack, some people enter a fourth phase that is colloquially referred to as a migraine “hangover” but is known medically as the post-drome phase. During this stage, you may feel exhausted, confused, or just feel unwell for about a day after the attack ends. About 80% of people who have migraine experience this aftereffect, according to the Cleveland Clinic.

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There are several types of migraine, and it’s important to recognize the distinct characteristics of each for a variety of reasons. Some may be triggered by particular events or even be a sign of another health condition.

Migraine is typically categorized as occurring with or without aura, in other words, whether or not you experience the sensory aura symptoms:

• Migraine with aura: These include the aura symptoms as well as common migraine symptoms (nausea, headache, light sensitivity) described above.
• Migraine without aura: These include the common migraine symptoms but do not include the aura symptoms.

You may experience several types of migraine that have different symptoms and may or may not include aura:

• Vestibular migraine: These generally involve sensory symptoms, such as vertigo, unsteadiness, trouble balancing, and sensitivity to motion. You may also have a headache, visual aura symptoms, and nausea, according to Johns Hopkins Medicine.
• Migraine with visual aura: Generally, this term is used to describe when someone experiences vision changes during their migraine, according to the Mayo Clinic. (In the past, you may have heard of this called an ocular migraine.) So, someone who has aura symptoms such as flashing lights, blurred vision, or vision loss would have an ocular migraine. It’s important to note that with an ocular migraine you may only experience visual disturbances and no accompanying head pain.
• Retinal migraine: This is a very rare form of migraine that includes repeated spurts of blurriness, vision problems, and pain in one eye, according to the Mayo Clinic. These symptoms can occur with or without a headache and other migraine symptoms. Retinal migraine can be mistaken for another health condition, for instance, an eye stroke, so it’s important to seek medical care for a proper diagnosis if you experience one. Retinal migraine vision symptoms only affect one eye, which is one way to differentiate this from a general migraine with aura.
• Acephalgic migraine: This is an outdated term that you may have heard used to refer to an aura without headache. Sometimes, these are called a silent migraine because they occur when someone experiences migraine symptoms, such as aura, but without an accompanying headache.
• Menstrual or hormonal migraine: These occur before or during the menstrual cycle and are triggered by the natural drop in estrogen that happens right before you start your period. You can get these about three days before your period starts, according to the Cleveland Clinic. Menstrual migraine attacks include the common migraine symptoms previously discussed.

Additionally, some people may talk about migraine in terms of how frequently they experience episodes:

• Episodic migraines are used to describe migraines that are accompanied by 0 to 14 headache days per month,⁵ meaning that people have headaches for up to 14 days out of the month.
• Chronic migraine is characterized as having 15 or more headache days per month for more than three months, in addition to other migraine symptoms for at least eight days total.

Sometimes people refer to other serious headaches as a migraine even though they are not clinically recognized as such. For example, someone may say they have a stress migraine when they have a really severe headache and are experiencing an unusual amount of stress. Of course, stress can trigger a migraine, but a “stress migraine” isn’t one of the migraine classifications. Or sometimes people mistakenly call their cluster headache (a very painful headache that typically occurs at the same time on various days) a cluster migraine. Of course, these headaches can be debilitating and affect your daily life. So, if you experience these severe headaches, it’s worth talking to your doctor about how you can best manage your pain.

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Unfortunately, the exact causes of migraine haven’t been identified, but researchers believe genetics may explain why some people develop the condition. Up to 80% of people with migraine have a first-degree relative who also experiences the disorder. On a related note, if one parent has migraine, then their kids have a 50% chance of also developing the disorder, according to research from the National Headache Foundation. If both parents have migraine, then their children have a 75% risk of developing the condition.

In addition to genetics, experts believe environmental factors can also contribute to migraine episodes, but this has not been clinically proven and the specifics are unknown. Although stress and smoking don’t cause migraine, they are considered risk factors for migraine attacks, according to the Cleveland Clinic. Migraine is also more likely to affect people with vaginas, particularly people between the ages of 15 and 55. Presumably, this is because of hormone fluctuations common around the menstrual cycle.

Because there’s a lot that still needs to be determined, doctors aren’t able to treat the underlying causes of migraine. Instead, physicians usually recommend that people try to identify the events or situations that trigger a migraine episode and minimize those whenever possible.

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Doctors recommend doing your best to prevent migraine episodes in the first place, which, of course, is not always possible. However, identifying migraine triggers that lead to attacks can help you avoid them. There are numerous migraine triggers and they vary by person. According to the Mayo Clinic, some of the most common migraine triggers include:

• Stress
• Inconsistent sleep schedules
• Dehydration
• Hormonal changes
• Caffeine
• Alcohol
• Weather changes
• Strong scents, such as perfume
• Certain foods, like cured meats and aged cheeses

Due to the personal nature of migraine triggers, it may be helpful to keep a migraine diary that details your symptoms and routine. Over time, looking through your journal can help you detect patterns and identify your migraine triggers. Here are a few things to document in your diary:

• Your meals and beverages
• The times that you eat
• Your exercise routine and schedule
• The weather each day
• Stressful events
• Your menstrual cycle
• The time and severity of your headache
• Details of your pain, for example, where your pain is located
• Any other migraine symptoms
• Any medications you take, when you take them, and how well they work

Although this may seem tedious, it’s important to be consistent with writing in your diary as it can take months to spot any patterns.

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Knowing your unique triggers is a big part of migraine prevention. Once you know what leads to your migraine episodes, you can create a new schedule or routine that minimizes exposure to your specific triggers whenever possible. Some triggers may be outside of your control, such as stressful situations or extreme weather exposure, but others will be easier to address, such as staying hydrated or eating regular meals when you can.

However, migraine triggers can build up, so limiting the number you experience at a given time may help you prevent a migraine or to reduce the severity of an attack, according to the University of Michigan Health. For example, maybe you notice that hot weather, skipping meals, and sleeping less than eight hours are all migraine triggers for you. You can do your best to schedule meals and make sure you get plenty of sleep leading up to particularly hot days. Or maybe you are prone to hormonal migraine attacks and know that eating and drinking certain foods and beverages lead to episodes. You can avoid these foods as best as possible around your menstrual cycle.

This all might sound overwhelming and like a lot of work, but knowing your triggers may help you prevent future migraine attacks. Additionally, keeping a journal can help you better communicate migraine patterns with your physician so they can suggest treatment strategies that might work best for you.

There are also medications, which we will discuss in the treatment section, that your doctor may prescribe to help prevent migraine attacks.

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Some people may self-diagnose and rely on over-the-counter pain medications, but it’s a good idea to get a proper migraine diagnosis to ensure the best treatment and rule out any other serious health conditions. If you think what you’re experiencing is a migraine, Dr. Dodick recommends making an appointment with your primary care physician if you have one. Your doctor may be able to diagnose and treat you, or they may refer you to a neurologist. (You can also look for a neurologist or a headache specialist by searching the provider database on the American Migraine Foundation website.)

There is no single test that can confirm a migraine diagnosis. During your appointment, your physician will discuss your symptoms and ask about your family’s medical history since migraine may be genetic. (You can prepare for your appointment by keeping a symptoms diary as we mentioned, bringing a list of the medications you take, and writing down any questions you may have.) You may also be asked to take several tests to rule out other neurological conditions.

• MRI uses magnetic field and radio waves to show images of your brain and blood vessels, according to the Mayo Clinic. Doctors use these to help rule out tumors, strokes, infections, and other neurological conditions.
• CT scan uses X-rays to show a cross-section your brain, according to the Mayo Clinic. Doctors use these to rule out tumors, brain damage, bleeding, and other conditions that could lead to headaches.

Additionally, the International Headache Society⁶ created diagnostic criteria for both migraine and migraine with aura.

The diagnostic criteria for migraine without aura is characterized by having at least five attacks lasting from 4 to 72 hours. Further, these migraine episodes must meet at least two of the following criteria:

• Pain must be described as moderate or severe
• Is experienced in one location
• Be described as pulsating
• Interfere with your daily routine

And at least one of the following criteria:

• Nausea with or without vomiting
• Sensitivity to light and sound

For a migraine with aura, the diagnostic criteria state that you must have at least two attacks that include one or more aura symptoms, such as changes in vision, speech, or sensations. Additionally, your auras would need to have at least three of these characteristics:

• Having at least one aura symptom that develops gradually for more than five minutes
• Have two or more aura symptoms that occur in succession
• Have aura symptoms that each last between five minutes to an hour
• Have at least one aura symptom that occurs just on one side of your body
• Experience a pins and needles sensation or see flashing lights or sparkles
• Have a headache within 60 minutes of your aura symptoms

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While there is no cure for migraine at this time, there are a variety of migraine treatment options that can include behavioral changes, alternative therapies, over-the-counter medications, and prescription drugs. It is common for people to respond differently to these treatments, so identifying the right combination may require a trial and error approach.

• Behavioral changes: Depending on your situation, making lifestyle changes may help alleviate some of your discomfort. For instance, if you experience light sensitivity then you may choose to ride out the attack in a dark room. Or you may find relief by using an ice pack or cold compress to ease sore muscles or neck pain. Drinking a small amount of caffeine can also help relieve pain as long as you are not sensitive to caffeine as a trigger, according to the Mayo Clinic. (You’ll also want to avoid drinking caffeine too close to your bedtime as it could interfere with your sleep schedule.) Using a method called biofeedback, which involves monitoring how your body reacts to stress and then trying to make changes to manage your stress as best as possible, is also helpful, according to the American Migraine Foundation.
• Complementary therapies: Some doctors recommend using neuromodulation devices that you can wear on your head to stimulate nerves there, according to the Cleveland Clinic. Some of these devices work by preventing your migraine and others work by alleviating your pain during an episode. However, these devices can be expensive and generally aren’t covered by insurance. Acupuncture, which involves inserting thin needles into various points in your skin, may also help with headache pain, per the Mayo Clinic.

Migraine medications may be one part of your treatment plan. Of course, identifying the right medication can take some experimenting. Generally, medications are considered either preventive, meaning they help you avoid a migraine attack, or rescue, meaning they help alleviate your symptoms during an episode. These are the various types of migraine medications available:

• OTC drugs such as ibuprofen, aspirin, or naproxen are generally the first line of defense to manage migraine pain. These are easily accessible, but it’s a good idea to talk to your doctor about the best way to use these if possible. That’s because you can overmedicate, which can actually lead to more headaches when you take them too often, according to the Mayo Clinic. (They recommend not taking OTC pain relievers more than twice a week.) It’s always best to talk to your doctor about your available options, particularly if you have chronic migraine.
• Prescription rescue medications are sometimes called abortive treatments because they minimize or decrease migraine symptoms rather than prevent their occurrence. Triptans are one common class of rescue drugs that block pain pathways in the brain. These come in the form of pills, tablets, injections, suppositories, and nasal sprays.
• Preventive medications are taken as directed by your physician regardless of whether or not you have a migraine to reduce the number of your attacks. There are numerous kinds of preventative medications you can try.
• Calcitonin gene-related peptide (CGPR) antibodies are a fairly new form of preventive medication. They work by latching onto and inhibiting the calcitonin gene-related peptide,⁷ which has been identified as contributing to migraine. They are most commonly administered through a monthly injection.
• Gepants and ditans are two newer classes of drugs that you can take at the onset of an attack to treat your symptoms.
• Blood-pressure medications, antidepressants, and anti-seizure drugs may be used to treat other conditions, but they have also been found to help manage migraine. These commonly include beta-blockers used for lowering blood pressure, such as atenolol, propranolol, and nadolol; antidepressants such as amitriptyline, nortriptyline, doxepin, venlafaxine and duloxetine; and anti-seizure medications such as valproic acid and topiramate.
• Botox⁸ can also be used as a migraine medication. People who experience chronic migraine may choose to get Botox injections. Experts aren’t entirely sure why the treatment works but theorize that Botox may deactivate pain receptors and prevent nerves from sending pain signals to your brain. The results aren’t permanent and people with chronic migraine can get injections roughly every three months. And if you have insurance, Botox may be covered if you meet the guidelines for having chronic migraine. Sometimes, people use Botox in conjunction with migraine medication.
• Anti-nausea medications can be used in addition to other medications to manage nausea and vomiting symptoms, according to the Mayo Clinic. Common anti-nausea medications include chlorpromazine, metoclopramide, or prochlorperazine. Typically, these are taken with pain medications.

Dr. Dodick says that he’s hopeful for even more medications specifically made to treat migraine. He believes there are clear signs that developments in the migraine treatment space are only just beginning. For starters, the CGPR therapies are one very positive development, he says. And researchers have potentially identified another protein and neuropeptide that are associated with migraine attacks, which they hope can be used to target migraine in future medications. While they may not emerge for another 8 to 10 years, that is something to be positive about, he says.

“Historically, we haven’t had a single drug on the market or a single drug available that was specifically designed, manufactured, and made available for migraine prevention [until CGPR therapies],” Dr. Dodick said. “This is a disorder that’s been around forever, and yet you had to wait until 2018 for something specific to prevent this disease. So the fact that we now have a number of new drugs, specifically designed to treat a migraine attack or to prevent migraines, means that we know much more about the biology of the disease.” 

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If you have this debilitating condition, then you may understandably feel overwhelmed when it comes to finding a migraine management plan that works for you. And you may be discouraged if you have tried OTC medications or other commonly prescribed remedies but are still not seeing an improvement in pain or frequency. Although it may not be possible to eradicate migraine altogether, there are options out there to help you manage the condition, which might mean fewer or less severe migraine episodes.

In order to achieve this, Dr. Dodick recommends finding a specialist who can really work with you to fully explore all of the available treatment options, from Botox to the lesser-known alternative therapies. A specialist may know more about the latest migraine research and drug authorization as well as have more experience helping people manage their symptoms through lifestyle habits.

“If your BMW or your Volkswagen breaks down, you need to get your car fixed presumably by a mechanic who works on that type of car,” Dr. Dodick says. “It’s no different here. If you’re having trouble and you're not getting the help you need, and routine things and standard therapies aren’t working, you need to be seen by a specialist.”

And if you find that your migraine episodes are increasing, the severity of your pain is getting worse, or you’re developing new symptoms, it’s worth scheduling an appointment with a medical professional. They’ll be able to determine if a certain medication can help and can rule out any other health conditions that may be playing a role in your symptoms.

Importantly, you should know that it isn’t all on you to stop your migraine pain. As Dr. Dodick explains, it’s nearly impossible to prevent all future attacks purely through lifestyle changes, as migraine episodes can be triggered spontaneously through naturally occurring changes in brain activity.

“There have been studies that have shown the ‘cycling’ brain,⁹ meaning the changing activity that spontaneously occurs in certain areas of the brain. And this ‘cycling’ can drive migraine for someone genetically predisposed—even though they're not doing anything differently,” said Dr. Dodick. In other words, you don’t need to strive for perfection when it comes to migraine management. Your migraine treatment plan will likely include both lifestyle and medical remedies.

Those lifestyle changes may include things like:

• Having a consistent sleep schedule
• Limiting the number of alcoholic drinks you have on the weekdays
• Eating regular meals
• Setting an alarm to drink water
• Practicing yoga to help you lower stress

Taking care of your mental health is another important aspect of your migraine management plan. Dealing with ongoing pain can affect your ability to work, socialize, and care for yourself. Undoubtedly, missing out on activities can sometimes feel like your life is controlled by your condition. Not to mention, dealing with pain on an ongoing basis can affect your mood. One way to find support throughout your migraine journey is by connecting with other people who have the condition too. There are numerous online support groups that can help you feel understood and supported, which you can find by searching online or on social media. The American Migraine Foundation runs a Facebook support group, Move Against Migraine, that posts information about treatments, clinical trials, and other resources. The Chronic Daily Headache and Migraine Support Group on Facebook is another option that’s run by people who live with migraine. There, members offer encouragement, tips for getting through a bad migraine episode, and support.

Although migraine has no cure, learning more about the disease can help you better understand how to get support and develop a migraine management plan. If you or someone you love is dealing with migraine, know that there are many ways to make the condition bearable.

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Sources:

1. StatPearls, Migraine Headache
2. American Journal of Managed Care, Migraine Overview and Summary of Current and Emerging Treatment Options
3. Headache: The Journal of Head and Face Pain, A Phase-by-Phase Review of Migraine Pathophysiology
4. Stat Pearls, Migraine with Aura
5. Current Pain and Headache Reports, Defining the Differences Between Episodic Migraine and Chronic Migraine
6. International Headache Society, ICHD-3
7. The Journal of Headache and Pain, Blocking CGRP in Migraine Patients – A Review of Pros and Cons
8. Food and Drug Administration, BOTOX
9. International Headache Society, Cognitive Performance Along the Migraine Cycle: A Negative Exploratory Study