Headache - migraine
Signs and Symptoms
The headache from a migraine, with or without aura, has the following characteristics:
- Throbbing, pounding, or pulsating pain
- Often begins on one side of your head and may spread to both or stay on one side
- Intense pain is often concentrated around the sides of the forehead
- Can last from 4 to 72 hours
These symptoms may happen at the same time or before the headache:
- Nausea and vomiting
- Dizziness, lightheadedness, or vertigo (feeling like the room is spinning)
- Loss of appetite
- Visual disturbances, like seeing flashing lights or zigzag lines, temporary blind spots, or blurred vision
- Parts of your body may feel numb, weak, or tingly
- Light, noise, and movement, especially bending over, worsen head pain. You want to lie down in a dark, quiet room.
Symptoms that may linger even after the headache is gone:
- Feeling mentally dull like your thinking is not clear or sharp
- Neck pain
Researchers are not sure what causes a migraine, but they know it involves changes in the blood flow to the brain. At first, blood vessels narrow or constrict, reducing blood flow and leading to visual disturbances, difficulty speaking, weakness, numbness, or tingling sensation in one area of the body, or other similar symptoms. Later, the blood vessels dilate or enlarge, leading to increased blood flow and a severe headache.
There also seems to be a genetic link to migraine headaches. More than half of people with migraines have an affected family member. Migraine triggers can include the following:
- Alcohol, especially beer and red wine
- Certain foods, such as aged cheeses, chocolate, nuts, peanut butter, some fruits (like avocado, banana, and citrus), foods with monosodium glutamate (MSG), onions, dairy products, meats containing nitrates (bacon, hot dogs, salami, and cured meats) fermented or pickled foods
- Skipping meals
- Fluctuations in hormones, for example during pregnancy, before and during your period, and menopause
- Certain odors, such as perfume or smoke
- Bright lights
- Loud noises
- Stress, physical or emotional. The headache often happens when a person is relaxing after a particularly stressful time.
- Sleeping too little or too much
- Smoking or exposure to tobacco smoke
- Some medications
- Heat, high humidity, and high altitude
- Headache medications. Using headache medications excessively can lead to more frequent and more severe headaches. Called medication overuse headaches, these headaches may complicate every type of headache, including migraine.
- Gender. Women are nearly 3 times more likely to get migraines than men.
- Having other family members with migraine headaches
- Being under age 40; migraines tend to get better as you age
- Taking birth control pills, if your migraines are affected by changes in estrogen levels
- Exposure and sensitivity to any of the potential triggers listed above
Your doctor will take a detailed medical history so he or she can determine whether you have a migraine or another kind of headache, such as a tension or sinus headache. Your doctor will ask questions about when your headaches occur, how long they last, how often they come on, the location of the pain, and any symptoms that accompany or precede the headaches. Sometimes it helps to keep a diary about your headaches before seeing the doctor, so you'll have an accurate recording of how often they happen. (See Lifestyle section for what information to include in a diary.)
Tests your doctor may order, depending on your symptoms and exam, include:
- Computerized tomography (CT) scan, to look for other problems that could be causing your headache
- Magnetic resonance imaging (MRI), to look for brain abnormalities, and to look closely at the blood vessels in the brain
- Lumbar puncture (spinal tap), if your doctor suspects meningitis or other conditions
Call 911 or go to the emergency room if you have the following symptoms:
- You have unusual symptoms you have not experienced before, such as speech problems, change in vision, loss of balance, or difficulty moving a limb
- Your headache pattern or intensity is different
- You are experiencing "the worst headache of your life"
- Your headache gets worse when you are lying down
These may indicate a stroke, a bleed in the brain, or other serious condition.
Treatment for migraines is aimed at preventing them from happening and reducing pain once an attack starts.
You can control your migraines with a combination of medications, lifestyle changes, and complementary therapies. Biofeedback (see also: Mind-body medicine) may help control the initial contraction of blood vessels. Relaxation techniques may reduce both the frequency and intensity of attacks.
Keeping a migraine diary, particularly when you first begin to have migraines, can help identify the triggers for your headaches so you can avoid them. When a migraine happens, write down the date and time it started. Note what you ate for the preceding 24 hours, how long you slept the night before, what you were doing just before the headache, any unusual stress in your life, how long the headache lasted, and what you did to make it stop.
Other lifestyle measures that may reduce the number of migraines include:
- Avoiding cigarettes, caffeine, and alcohol
- Exercising regularly
- Getting enough sleep each night
- Relaxing and reducing stress in your life (see Mind-Body Medicine section)
- Eating regular meals
Once a headache or migraine symptoms begin, it helps to:
- Rest in a quiet, darkened room
- Drink fluids to avoid dehydration, especially if you have vomited
Medications for migraines can be classified in two major categories: those designed to prevent attacks, and those designed to relieve pain.
Drugs for Prevention
Your doctor may prescribe medications to prevent migraines if you have 2 or more migraines per month, use pain relievers more than twice a week, or if your symptoms are especially debilitating. Depending on your condition and medication, your doctor may recommend taking the medication daily or when a known trigger is about to happen.
Beta-blockers. Also used to treat heart disease; researchers are not sure why they work for migraines, although they may help keep blood vessels in the brain from constricting and dilating. Beta-blockers include:
- Atenolol (Tenormin)
- Metoprolol (Lopressor, Toprol-XL)
- Propranolol (Inderal, Inderal LA)
Calcium-channel blockers. Another heart disease drug that can help prevent migraines, including:
- Verapamil (Calan, Isoptin)
- Diltiazem (Cardizem, Dilacor)
Antidepressants. Tricyclic antidepressants are helpful in preventing all kinds of headaches, including migraines. Tricyclic antidepressants include:
- Amitriptyline (Elavil)
- Nortriptyline (Pamelor)
- Doxepin (Sinequan)
- Imipramine (Tofranil)
Anticonvulsants. Some antiseizure drugs help prevent migraines, although researchers are not sure why:
- Divalproex sodium (Depakote)
- Gabapentin (Neurontin)
- Topiramate (Topamax)
Botox. Botox, a medication made from a purified form of botulinum toxin, has been approved to treat migraines. Researchers are not sure why it helps some people. To treat migraines, Botox is given as a series of injections in the forehead, temples, back of the neck, and shoulders. Injections are given about every 3 months.
Drugs for Treatment
To work, these medications should be taken as soon as you feel a migraine coming on.
Triptans. These medications are often the first ones prescribed to relieve pain, nausea, and sensitivity to light and sound. They work by constricting the blood vessels in the brain. Triptans include:
- Almotriptan (Axert)
- Eletriptan (Relpax)
- Frovatriptan (Frova)
- Naratriptan (Amerge)
- Rizatriptan (Maxalt)
- Sumatriptan (Imitrex)
- Zolmitriptan (Zomig)
Ergots. Ergots also work by constricting blood vessels, but tend to have more side effects than triptans. Ergots include:
- Dihydroergotamine (Migranal)
- Ergotamine (Ergomar, Cafergot)
Isometheptene, dichloralphenazone, and acetaminophen (Midrin). Midrin combines a pain reliever (acetaminophen) and sedative (dichloralphenazone) with a medication that constricts blood vessels (isometheptene) to prevent migraines.
Other medications used to treat the headache pain or associated symptoms:
- Antinausea drugs
- Acetaminophen, aspirin, and caffeine (Excedrin Migraine) is an FDA-approved, over-the-counter treatment for migraine.
- Ibuprofen (Advil Migraine, Motrin Migraine) is also an FDA-approved, over-the-counter migraine medication.
- Narcotics, such as codeine, are sometimes used for people who can't take triptans or ergots, however, they can cause dependency and rebound headaches.
Nutrition and Dietary Supplements
The following foods may trigger migraine headaches:
- Monosodium glutamate (MSG), a flavor enhancer found often in food from Chinese restaurants
- Foods containing the amino acid tyramine, found in red wine, aged cheese, smoked fish, chicken livers, figs, and some beans
- Peanut butter
- Some fruits, like avocado, banana, and citrus
- Dairy products
- Meats containing nitrates, such as bacon, hot dogs, salami, cured meats
- Fermented or pickled foods
If you think that any of these foods cause your migraines, try eliminating all the items on this list from your diet and then reintroducing them one at a time. Pay close attention to when the number of headaches increases after eating certain foods. Then you know which trigger foods to avoid. You may also want to consider food allergy testing to determine your specific sensitivities or triggers.
- 5-hydroxytryptophan (5-HTP). Your body makes the amino acid 5-HTP and converts it into serotonin, an important brain chemical. Researchers think abnormal serotonin function in blood vessels may be related to migraines, and some of the drugs used to treat migraines work by affecting serotonin. Several studies indicate that 5-HTP may be as effective as some prescription migraine medications at reducing the intensity and frequency of attacks. But not all studies agree. One study found that 5-HTP was less effective than the beta-blocker Inderal. More studies are needed to be sure that 5-HTP is helpful in treating migraines. If you have a history of psychiatric illness, take an antidepressant, or supplements such as St. John's wort or SAMe, you should not take 5-HTP except under your doctor's supervision. If you are pregnant or breastfeeding, do not take 5-HTP without first asking your doctor.
- Magnesium. People with migraines often have lower levels of magnesium than people who do not have migraines, and several studies suggest that magnesium may reduce the frequency of migraine attacks in people with low levels of magnesium. In one study, people who took magnesium reduce the frequency of attacks by 41.6%, compared to 15.8% in those who took placebo. Some studies also suggest that magnesium may help women whose migraines are triggered by their periods. Side effects from magnesium can include lower blood pressure and diarrhea. Magnesium can interact with medications, including heart medications, diuretics or water pills, some antibiotics, and muscle relaxers.
- Vitamin B2 (riboflavin). A few studies indicate that riboflavin may reduce the frequency and duration of migraines. In one study, people who took riboflavin had more than a 50% decrease in the number of attacks. Not all studies have found riboflavin to be effective, however. More research is needed. Riboflavin can interact with some medications, including tricyclic antidepressants, medications called anticholinergic drugs that are used to treat a variety of conditions, the antiseizure drug phenobarbital, and probenecid, used to treat gout.
Preliminary research indicates that these supplements may also help prevent migraines, although more research is needed to say for sure:
- Coenzyme Q10 (CoQ10). CoQ10 can interact with several medications including blood thinners, such as warfarin (Coumadin), some cancer medications, and medications for high blood pressure.
- Melatonin. Melatonin can interact with a number of medications, so ask your doctor before taking it.
The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care practitioner.
- Butterbur (Petasites hybridus). A few studies suggest that butterbur may help reduce both the frequency and duration of migraine attacks when taken on a regular basis for up to 4 months. More research is needed to see whether butterbur is effective at preventing migraines. The studies used a standardized extract that lowered the amount of substances in the herb that might potentially harm the liver. If you want to try butterbur for your migraines, ask your doctor about a safe extract and dose. Women who are pregnant or breastfeeding should not take butterbur. People who are allergic to ragweed may find that they are sensitive to butterbur as well. Butterbur can potentially interact with certain medications. Speak to your doctor about the medications you are taking and if they are compatible with butterbur.
- Feverfew (Tanacetum parthenium). Feverfew has been used traditionally to treat headaches, and several well-designed studies have found that it may help prevent and treat migraines. In one study of people with migraines, those who took feverfew capsules every day for 4 months saw a substantial drop in the number of attacks, as well as far fewer symptoms, such as nausea and vomiting, compared to those who received placebo. Some studies have mixed results, however. Feverfew can increase the risk of bleeding, and should not be taken with blood thinners, such as warfarin (Coumadin) or clopidogrel (Plavix). Feverfew can potentially interact with a number of medications. Speak with your physician. Women who are pregnant or breastfeeding should not take feverfew. If you are allergic to ragweed, you may also be allergic to feverfew. There is not much research about the safety of long-term use of feverfew so work with a knowledgeable prescriber.
Although there are no scientific studies showing these herbs work, they are sometimes suggested to treat migraines and other types of headaches. People who take blood-thinning medications, or who have bleeding disorders, should not take these herbs and check with your doctor regarding any medications that you may be taking:
- Dong quai (Angelica sinensis). Ask your doctor before taking dong quai, as it may interact with some medications or cause problems for people with some cancers.
- Ginger (Zingiber officinale)
- Ginkgo biloba
- Willow bark(Salix spp.). People who are sensitive to aspirin should not take willow bark.
Acupuncture has been studied as a treatment for migraine headache for more than 20 years. While not all studies have shown it helps, researchers agree that acupuncture appears safe, and may work for some people. A study published in 2003 suggest that getting an acupuncture treatment when migraine symptoms first start works as well as taking the drug Imitrex. As symptoms continue, however, the medication works better than acupuncture.
In addition to needling treatment, acupuncturists may recommend lifestyle changes, such as suggestions for specific breathing techniques, qi gong exercise, and dietary changes.
Several clinical trials indicate that spinal manipulation therapy may help treat migraine headaches. In one study of people with migraines, 22% of those who received chiropractic manipulation reported more than a 90% reduction of attacks. Also, 49% reported a significant reduction of the intensity of each migraine.
In another study, people with migraine headaches were randomly assigned to receive spinal manipulation, a daily medication (Elavil), or a combination of both. Spinal manipulation worked as well as Elavil in reducing migraines and had fewer side effects. Combining therapies didn't work any better.
In addition, researchers reviewed 9 studies that tested chiropractic for tension or migraine headaches and found that it worked as well as medications in preventing these headaches. More research is needed to say for sure whether chiropractic care can prevent migraines.
Massage and Physical Therapy
Reflexology is a technique that places pressure on specific "reflex points" on the hands and feet that are believed to correspond to areas throughout the body. Preliminary studies suggest it may relieve pain and allow people with migraines to take less pain medication. More research is needed. Practitioners believe reflexology helps you become more aware of your own body signals, which might help you sense an oncoming migraine, before pain starts. They also believe reflexology helps improve general well-being and energy level.
One of the most common reasons people seek homeopathic care is to treat chronic headaches. However, only 1 out of 4 studies included in a scientific review found that individually prescribed homeopathic remedies significantly reduced the frequency, severity, and duration of migraines. Some of these effective remedies are listed below.
Professional homeopaths may also recommend treatments based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account the individual's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.
The following are some of the remedies found to be effective:
- Belladonna. For throbbing headaches that come on suddenly; these types of headaches tend to worsen with motion and light, but are partially relieved by pressure, standing, sitting, or leaning backwards.
- Bryonia. For headaches with a steady, sharp pain in the forehead that may radiate to the back of the head; these types of headaches worsen with movement and light touch, but improve with firm pressure; this remedy is most appropriate for individuals who are irritable and may also experience nausea, vomiting, and constipation.
- Gelsemium. For pain that extends around the head and feels like a tight band of constriction; pain usually originates in the back of the head and may be relieved following urination; this remedy is most appropriate for individuals who feel extremely weak and have difficulty keeping their eyes open.
- Ignatia. For pain that may be described as a feeling of something being driven into the skull; these types of headaches tend to be triggered by emotion, including grief or anxiety, and the treatment is appropriate for both children and adults.
- Iris versicolor. For periodic migraines that begin with blurred vision, especially after eating sweets; pain usually occurs on one side of the head and may be partially relieved by gentle movement and/or fresh air.
- Kali bichromicum. For aching and pressing pains on the forehead (particularly between and behind the eyes); may be accompanied by sinus congestion or nausea and vomiting; this remedy is most appropriate for individuals who prefer to lie down in a dark room and who experience relief from warmth and eating.
- Lachesis. For migraines on the left side of the head that are typically worse in the mornings and before menstruation; this type of headache is aggravated by warmth and sunlight and relieved by open air and firm pressure.
- Natrum muriaticum. One of the most common remedies used for migraine headaches, particularly those that are described as "hammers beating the head;" pain is relieved when the individual is lying down, alone, in a quiet dark room; these migraines may be associated with either menstruation or a grieving experience and are worse in the middle of the day; this remedy is most appropriate for children who look pale and feel nauseated, nervous, and emotional.
- Nux vomica. For headaches that are described as a "nail being driving into the head;" often accompanied by nausea and/or dizziness; this remedy is most appropriate for individuals who are constipated and irritable.
- Sanguinaria. For right-sided headaches that begin in the neck and move upwards, recur in a predictable pattern (such as every seven days), and are accompanied by nausea and vomiting; pain is aggravated by motion, light or sun exposure, odors, and noise; this remedy is appropriate for children who may have a craving for spicy or acidic foods, despite having a general aversion to eating due to the headache.
- Sepia. For migraines that are accompanied by nausea and are relieved when the individual is lying down; light and movement tend to worsen symptoms; this remedy is most appropriate for individuals who are moody and do not like being alone, but worry about being with others.
Homeopaths may also prescribe the following remedies based on their knowledge and clinical experience:
- Pulsatilla. For headaches triggered by eating rich, fatty foods, particularly ice cream; pain tends to move but may be concentrated in the forehead or on one side of the head; may be accompanied by digestive problems or occur around the time of menstruation; children for whom this remedy is appropriate often develop these symptoms while at school.
- Spigelia. For migraines described as a stinging, burning, or throbbing pain, often on the left side of the head; symptoms tend to worsen with exposure to cold weather and with motion, but are temporarily relieved by cold compresses and when the individual is lying on the right side with the head propped up.
Reducing and learning to cope with stress may help reduce the number and intensity of your headaches. Techniques that can help include:
- Joining a support group
- Relaxation techniques, such as progressive muscle relaxation (alternately contracting and releasing muscles throughout your body), meditation, and guided imagery
Many of the medications, herbs, and supplements used to prevent or treat migraines should not be used during pregnancy. Talk to your doctor before using any medication, over-the-counter or prescription, or any complementary therapy before or during your pregnancy. Some doctors may recommend treating mild-to-moderate attacks during pregnancy with acetaminophen (Tylenol).
Warnings and Precautions
Use medications only as directed. Using some medications on a regular basis can cause rebound headaches.
Call your doctor if you experience a new headache, a change in quality of a previous headache or headache pattern, or if a medication that usually takes away the pain no longer works.
Prognosis and Complications
Migraine headaches generally do not pose a threat to your overall health, although they can be chronic, recurrent, frustrating, and interfere with your daily life. Stroke is an extremely rare complication from severe migraines. Other studies show that migraine headaches are associated with heart disease. People who have migraines are up to 4 times more likely to suffer from depression. Migraine patients also have an increased rate of anxiety and panic disorders.
Adolescent migraine is associated with inflammatory conditions, such as asthma and seasonal allergies, as well as with epilepsy, persistent nightmares, and motion sickness. Many people find that migraines go into remission, meaning they stop for a long time and happen only very infrequently, or even disappear altogether, especially as you get older. For women, this may be related to lower levels of estrogen after menopause.
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