Migraines

*The information on this website is not intended to diagnose, treat, cure or prevent any disease.

WHAT ARE MIGRAINES?

Migraines are headaches which are recurrent in nature and result in moderate to severe pain in the person suffering from them. Unlike other types of headaches, migraines also last a long time, from several hours up to two days in duration. They can have a severe impact on an individuals’ life, interfering with work, social activity, and healthy living. In many sufferers, it may become difficult to speak, and light and sound can seem overwhelming and painful.

For most people, migraines begin sometime during childhood or puberty, worsening into adulthood. They are an extremely common condition, estimated to affect around 15% of all people. There are four recognized phases to migraines, although suffers may not experience every single phase. The four phases of a migraine are:

Prodromal Phase
Aura
Pain Phase
Postdromal phase

Each phase can have its own distinct symptoms, and each sufferer may experience a different combination of these phases. The symptoms of each phase are described in the “Common Symptoms” section below. Each sufferer may experience a different combination of symptoms, and these can vary between attacks.

Migraine experiences can vary so widely that there is a medical classification system created by the International Headache Society with six different groups that migraine diagnoses can fall under (as well as subgroups). The classes are:

Migraines without auras
Migraines with auras
Chronic migraines
1. These are migraines that can occur for more than 15 days out of a month for 3 months or more.
Complications of migraine
1. This can include a migraine attack lasting for more than 72 hours
Probable migraine
Episodic syndromes that may be associated with migraines
1. Abdominal migraines
2. Cyclical vomiting syndrome

Migraines are a leading cause of medical disability, resulting in missed work, decreased productivity, and decreased social-life and personal well-being. Although migraines are poorly understood, there are treatment options which can help individuals overcome attacks more quickly. Additionally, for some people there are triggers which they may be able to avoid to reduce the change of suffering an attack.

COMMON SYMPTOMS

Migraines have four possible phases, but each person may not experience each individual phase. Each phase with possible symptoms is presented below:

Prodromal Phase (2-72 hours before migraine)

Mood changes
- Depression
- Irritability
- Elation
Unusual food cravings
Exhaustion or fatigue
Muscle/neck stiffness

Aura (minutes to 1 hour before migraine)

Perceptual disturbances such as
- Blurry vision
- Blind spots
- Flashing or shimmering lights
- Visualization of geometric shapes/patterns
- Colored spots
Vertigo
Tingling
Feelings of fear or confusion
Difficulty/changes in speaking patterns
Auditory disturbances

Pain Phase

Moderate to severe pain
- Often starting above the eyes
- Often affecting only one side of the head
Extreme sensitivity to light and sound
Nausea
Vomiting
Fainting

Postdromal Phase (begins following attack, can last for hours to days)

Fatigue
- Some people have feelings of being re-energized
Dizziness
Sensitivity to light/sound
Difficult concentrating
Depression

DIAGNOSIS

The diagnosis of migraines can sometimes be challenging due to the variety of ways in which they can appear, however advanced diagnostics are not usually needed. Many people, especially those with infrequent migraines, likely never receive a formal diagnosis.

Different categories of migraines have different diagnostics criteria as recommended by the International Headache Society (IHS). Diagnostic criteria listed by the IHS International Classification of Headache Disorders 3rd Edition (ICHD-3) for each category are listed as follows:

Migraines with Auras

A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms:

Visual
Sensory
Speech and/or language
Motor
Brainstem
Retinal

C. At least three of the following six characteristics:

At least one aura symptom spreads gradually over 5 or more minutes
Two or more aura symptoms occur in succession
Each individual aura symptom lasts between 5-60 minutes
At least one aura symptom is restricted to one side of the head
At least one aura symptom is positive
The aura is accompanied, or followed within 60 minutes, by headache

D. Not better accounted for by another ICHD-3 diagnosis

Migraines without Auras

These criteria can be remembered as the “5, 4, 3, 2, 1 Criteria.” The criteria are as follows:

At least 5 attacks which have the following characteristics:
1. Lasting 4 hours to 3 days (72 hours)
2. Has 2 of the following characteristics
  1. Localized to one side of the head
  2. Pulsating or throbbing sensation
  3. Moderate to severe pain
  4. Aggravated by normal activity, or results in avoidance of normal physical activity such as walking
3. During the headache, at least 1 of the following symptoms occurs:
  1. Nausea or vomiting
  2. Sensitivity to light or sound
4. Not better accounted for by another ICHD-3 diagnosis

Chronic Migraines

Headache on 15 or more days/month for at least 3 months, and fulfilling criteria B and C
Occurring in a patient who has had at least five attacks fulfilling criteria Migraine without aura and/or criteria Migraine with aura
On 8 or more days/month for at least months, meeting one or more of the following:
1. criteria Migraine without aura
2. criteria Migraine with aura
3. believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative (see Treatment section below)
Not better accounted for by another ICHD-3 diagnosis

Complications of Migraine

This category includes multiple subcategories of conditions which may be related to migraines. This group may depend on advanced diagnostics such as a magnetic resonance imaging (MRI) to fulfill the diagnostic criteria.

Status Migrainosus

A headache attack fulfilling criteria B and C
Occurring in a patient with Migraine without aura and/or Migraine with aura, and typical of previous attacks except for its duration and severity
Both of the following characteristics:

1. Lasts for at least 72 hours without interruption

2. Debilitating

Not better accounted for by another ICHD-3 diagnosis.

Persistent Aura without Infarction

Aura as described under Migraine with Aura
Occurring in a patient with Migraine with aura and typical of previous auras except that one or more aura symptoms lasts for more than 1 week.
No evidence of infarction/stroke based on imaging studies
Not better accounted for by another ICHD-3 diagnosis.

Migrainous Infarction

Meets criteria for Migraine with Aura attack
Occurring in a patient with Migraine with aura and similar to previous attacks except that one or more aura symptoms persists for 60 minutes or more.
A relevant area with impaired blood supply (ischemic region) is found on imaging studies
Not better accounted for by another ICHD-3 diagnosis.

Migraine Aura-Triggered Seizure

A seizure fulfilling diagnostic criteria for an epileptic attack, and:
Occurring in a patient with Migraine with aura, and the seizure occurs either during the attack or within 1 hour immediately following the attack
Not better accounted for by another ICHD-3 diagnosis

Probable Migraine

Some attacks may be lacking all of the criteria listed above, but have other features which may be suspicious for migraines. These may be classified as “probable migraines” and have the following criteria:

Migraine-like attacks fulfilling all but one of criteria Migraine without aura, or all but one of criteria for Migraine with aura
Not fulfilling ICHD-3 criteria for any other headache disorder
Not better accounted for by another ICHD-3 diagnosis.

Episodic Syndromes Associated with Migraines

These are syndromes that occur mostly in children which may be associated with migraines. Note that the recurrent gastrointestinal disturbances are not necessarily associated with headaches. This is a somewhat controversial classification, however there is some thought that it is another manifestation of “functional” pain which occurs without any evidence of other diseases to explain it.

Recurrent gastrointestinal disturbance

At least five attacks with distinct episodes of abdominal pain, discomfort, nausea, and/or vomiting
Normal gastrointestinal examination and evaluation
Not attributed to another disorder.

Benign Paroxysmal Vertigo

At least five attacks fulfilling criteria 1 and 2 below:
1. Vertigo (dizziness) occurring suddenly and resolving spontaneously after minutes to hours without loss of consciousness. Peak severity is at onset.
2. At least one of the following five associated symptoms or signs:
  1. Nystagmus (flicking of the eyes)
  2. Difficulty walking/ambulating
  3. Vomiting
  4. Pale/clammy skin
  5. Feelings of fear/confusion
Normal neurological examination and no evidence of middle or inner ear disease between attacks
Not attributed to another disorder.

Benign Paroxysmal Torticollis (tilting of head to one side)

Recurrent attacks in a young child, fulfilling criteria 1 and 2
1. Tilt of the head to either side, with or without slight rotation, resolving spontaneously minutes to days after onset
2. At least one of the following five associated symptoms or signs:
  1. Pale skin
  2. Irritability
  3. Feeling unwell/sick/tired
  4. Nausea and/or vomiting
  5. Difficulty walking/ambulating
Normal neurological examination between attacks
Not attributed to another disorder

Other Diagnostics

Although advanced diagnostics are often not required for migraines, your doctor may recommend additional diagnostics if your combination of symptoms is unusual, or if there are other potential health concerns. Additional diagnostics recommended may include:

Blood work
Magnetic resonance imaging (MRI)
Computerized tomography (CT) scans
Cerebrospinal fluid analysis

These tests can be helpful in ruling out other conditions which can mimic migraines, such as strokes, tumors, infections of the brain (meningitis), or toxin exposures.

TREATMENT OPTIONS

Whether or not treatment is required depends on each individual’s pain tolerance and the severity of each attack. Some individuals find relief from going to sleep in a dark, quiet place. Other individuals may need varying degrees of pain control. Most treatment options will work best if taken as soon as possible when symptoms of a migraine are first noticed.

Pharmaceuticals:

Non-Steroidal Anti-Inflammatories (NSAIDs): These drugs can be helpful in mild/moderate migraines, and are often very helpful for typical, non-debilitating headaches. Although the majority of these are over-the-counter medications in the United States, they can be dangerous if used inappropriately or combined with alcohol or other drugs. Use as directed and follow all precautions listed. Some are also available in stronger forms by prescription only.
1. Ibuprofen (Advil, Motrin IB)
2. Naproxen (Aleve)
3. Aspirin (Bayer, Excedrin)
4. Diclofenac (prescription-only)
Analgesics
1. Acetaminophen (Tylenol)
Caffeine
1. This is sometimes combined with another drug such as an NSAID (Excedrin Migraine, for example) and help provide relief for mild to moderate migraines.
Triptans: This class of medications is available by prescription-only in the United States but can be effective at stopping migraines. The active specific serotonin receptors in the brain and blood vessels which may be involved in the development of migraines. These are usually prescribed after drugs like NSAIDs have failed. They cross the blood-brain barrier well, but are not effective are preventing migraines from occurring. They help stop migraines by causing
1. Causing constriction of blood vessels in the brain associated with migraines,
2. Preventing the release of specific neuro-active compounds, and
3. Blocking transmission of pain sensations in the brain stem and spinal column.
4. Examples of triptans include:
  1. Sumatriptan (Imitrex)
  2. Naratriptan (Amerge)
  3. Rizatriptan (Maxalt)
  4. Almotriptan (Axert)
  5. Eletriptan (Relpax)
  6. Frovatriptan (Frova)
  7. vii.Zolmitriptan (Zomig)
Ergotamine: Often used in combination with caffeine, ergotamine structurally resembles some neurotransmitters such as dopamine, serotonin, and epinephrine and also works to constrict blood vessels. Generally considered less effective than triptans, ergotamine-based drugs may be helpful in patients with long-lasting migraines lasting 48 hours or more. Examples of ergotamine drugs include:
1. Ergotamine tartrate/Caffeine (Cafergot, Migergot)
2. Dihydroergotamine mesylate (Migranal)
Chlorpromazine: This is an anti-psychotic medication, which, while not developed or labeled for use in migraines, can be helpful for some individuals. Chlorpromazine has antagonistic activity at many receptor sites, including some serotonin receptors and histamine receptors. Because of this, it can may many side effects as well such as sedation, dry mouth, low blood pressure, and muscle stiffness. This medication may also be prescribed for anti-nausea effects.
Tramadol: This is an opioid medication which may help some migraine sufferers as well. In addition to activating certain opioid receptors in the brain, it also blocks the re-uptake of serotonin and norepinephrine in the brain as well.
Valproate: This medication is mainly used for the treatment of epilepsy and bipolar disorders; however, it is also useful against migraines as well has received FDA approval in the United States for this use. This is one of the medications available for migraine prevention, however it is also available as an IV form and can be helpful during acute attacks. The mechanism of action is not well-understood and it is an area of ongoing research.
Anti-nausea medications: Due to the severe nausea associated with migraines, these medications can provide additional relief during an attack.
1. Metoclopramide (Reglan)
2. Chlorpromazine
3. Prochlorperazine (Compro)
Magnesium: Studies have shown that IV magnesium sulfate was superior to placebo in patients suffering from migraines with an aura. In patients without an aura, there was no difference in relief compared to placebo.

Non-Pharmaceutic Approaches

Acupuncture: Acupuncture can be an effective source of relief for some migraine sufferers. The evidence behind this traditional medicine is strong enough to receive endorsement from the World Health Organization as a treatment for many types of chronic pain.
Electromyographic/Bio Feedback: This is a technique which allows a person to visualize a biologic parameter (like muscle tension) and helps them develop skills to manage that particular issue. This allows a person to reduce their own pain, and eventually, manage it without external visualization of their tension or pain.
Massage Therapy
Chiropractic Therapy
Transcutaneous Electrical Nerve Stimulation (TENS) – Cefaly Device: FDA-approved device that provides electrical-stimulation of the trigeminal nerve without the use of drugs.
Aromatherapy: Some essential oils such as lavender and peppermint oil can helpful in relieving migraine attacks.
Supplements:
1. Magnesium: Although IV magnesium is not available for at-home use, magnesium supplements such as magnesium citrate, magnesium glycinate, and magnesium threonate can be taken orally. Avoid magnesium oxide, which is not well-absorbed. Magnesium citrate is well-absorbed, but be warned, it is an effective laxative if too much is taken.
2. Butterbur: This is an herbal remedy for headaches and migraines which may be helpful as a treatment. There are concerns about potential for liver toxicity, so take this into consideration, particularly if you have a history of liver disease or predisposing conditions.
3. Ginger: In addition to helping with nausea, ginger may be as effective as sumatriptan in the relief of migraines.
Sleeping: For some people, going to sleep for several hours is effective at terminating the attack.
Oxygen therapy: Oxygen therapy can also be helpful in relieving migraines, probably through its effects on relaxing blood vessels. Medical-grade oxygen tanks require a prescription – do not use tanks intended for industrial use, as they may contain toxic compounds in them. Oxygen tanks are also an explosion hazard, and proper precautions should be taken if keeping one at home.
Heat/Cold Therapy: Applying a warm or cold pack (or sometimes alternating these) can help some migraine sufferers end an attack. This may provide relief by affecting nervous conduction and/or blood flow to the head.
Caffeine: This is an easy, non-prescription approach which may help. As mentioned before, some headache medications contain caffeine, but you may be able to simply drink a cup of coffee or tea to help find relief. However, for some people, caffeine worsens migraines.

PREVENTION

Like treatment, there are pharmaceutical approaches and non-pharmaceutic approaches to migraine prevention. Additionally, avoiding triggers can also help reduce the frequency of migraines for some individuals.

Pharmaceutical Approaches to Prevention

Erenumab (Aimovig): This is an anti-body medication which binds to the calcitonin gene-related peptide receptor (CGRPR). It is delivered as a once-monthly injection and has only recently been approved in the United States as a migraine prophylactic medication. This medication is expensive, but is likely going to be the first among other similar drugs which target the CGRPR for migraine relief.
Beta blockers: Commonly considered cardiovascular medications, beta blockers have been found to be helpful for prevention of migraines. These may work by preventing dilation of arteries of the brain and preventing the release of vasoconstricting compounds from platelets.
1. Propranolol
2. Metoprolol
3. Timolol
Calcium channel blockers: Another class of medications mainly used for cardiovascular problems, these again likely work on blood vessels to prevent the development of migraines. The most useful calcium channel blockers are:
1. Verapamil (Calan)
2. Nimodipine (Nimotop)
Lisinopril: Yet another cardiovascular medication, lisinopril is an angiotensin-converting enzyme inhibitor (ACE inhibitor) which has been shown to have use as a migraine preventative.
Anti-depressant medications: Tricyclic anti-depressants (TCAs) and one serotonin-norepinephrine reuptake inhibiting (SNRI) drug may be useful in preventing migraines. These drugs likely work through their effects on serotonin levels.
1. Amitriptyline (TCA)
2. Venlafaxine (Effexor XR, SNRI)
Anti-seizure medications: Valproate, mentioned previously, and topiramate are medications which are intended for epilepsy, but also may reduce the frequency of migraine attacks.
NSAIDs: While commonly used during an attack, use of NSAIDs before a migraine occurs may also be helpful. In particular, naproxen can be helpful.
Botox: Surprisingly, Botox injections may also be useful in preventing migraines. Injections in the head and neck performed every 3 months can help control migraines. It may work by blocking pain signals from reaching the nerves of the head and neck, but the definitive mechanism is uncertain.

Non-pharmaceutical Approaches to Prevention

Supplements
1. Magnesium: Magnesium again! It can be taken as a daily supplement. Studies show that most Americans are deficient in magnesium, and supplementation is safe (provided you don’t have underlying kidney disease) and cheap. It may be helpful in the prevention of migraines.
2. Feverfew: This is another herbal remedy which may be helpful in preventing migraines. It can take weeks to begin working, however.
3. Butterbur: Just as it can be helpful during an attack, it may be helpful in preventing the development of migraines.
4. Riboflavin: A B-vitamin, it is safe and may be helpful in preventing migraines
5. Coenzyme Q10:
6. Melatonin: May be helpful in helping to regulate sleeping patterns rather than being directly helpful in preventing migraines.
7. Vitamin D3
Sleep hygiene: Maintaining a regular sleep schedule and getting adequate sleep can help reduce the frequency of migraines
Eat Well
1. Avoid skipping meals
2. Avoid foods which trigger migraines (caffeine, alcohol, chocolate, processed foods, etc.)
3. Try a Low Tyramine Diet
Regular exercise: Natural endorphins release in exercise are effective pain-relievers and help manage stress. Additionally, being overweight increases risk of headaches.
Stress management
1. Meditation
2. Yoga
Maintaining a Migraine Diary: This can help identify triggers from migraines and help you learn to cope with them rather than avoid them.
Maintain dental hygiene

CAUSES

The cause of migraines is unclear and triggers seem to be highly individualized. There are certainly genetic factors, as migraines do tend to run in families. However, there are also certain lifestyle factors which will impact each individual person as well. These include diet, alcohol consumption, stress, changes to routine and sleeping habits, and activity level. It is likely a combination of internal factors (like genetics or underlying nervous or vascular system disorders) and external factors such as those mentioned which result in migraines. Whatever the cause, these factors combine to result in changes in blood flow in the brain. It is still not clear if this change in blood initiates a migraine, or occurs in response to a migraine.

Although migraines can appear at any age, they are most likely to appear during puberty, and they usually will start to improve after 30 years of age. There seem to be sex-specific factors as well, but these change as we grow older. During childhood, boys are more likely to suffer migraines than girls, but after puberty, women are more likely to be affected. This has led to hypotheses that estrogen, which varies significantly during the life of a woman, may play a strong role in migraine development.

Common triggers for migraines include:

Stress
Allergies
Weather changes
Processed foods
Tyramine in foods
Monosodium glutamate (flavor enhancer)
Alcohol
Caffeine
Lack of sleep
Bright lights
Hormonal shifts (menstruation)

Bacterial may also play a role in the development of migraines, both from systemic infections, as well as from perturbation of the microbiome in the intestines. Bacteria may secrete a variety of toxins and compounds which can act as neurotransmitters, interfering with receptors which respond to serotonin, dopamine, and other important molecules involved in neuronal signaling. These compounds can be absorbed through the intestine or secreted into the blood during infections, leading to chronic migraines or headache symptoms. Eradication of the infection or restoration of the microbiome balance through the use of probiotics and dietary modifications may help relieve these kinds of migraines as well. Certain foods high in nitrates and nitrites (like preserved meats) may be converted into nitric oxide by gut bacteria as well. Nitric oxide is a potent vasodilator and may also be responsible for migraines.