Everyone gets headaches from time to time, but migraines are different. For an estimated 15% to 18% of women and 6% of men with migraine, they endure not just intense pain in their head but also nausea; an inability to tolerate light, noise, or odors; confusion; overwhelming fatigue, and more—to the point that they are unable to keep working or be present with family and friends. This inability to function separates migraines from headaches.
The good news is that knowledge about them and treatments for them have increased exponentially to the point that most migraine sufferers are able to enjoy meaningful relief that allows them to go about their lives in a fairly normal way.
Doctors may prescribe medications, behavioral treatments and lifestyle changes, and even electrical stimulation devices. Learning to distinguish warning signs of an impending migraine from what have traditionally been called “triggers” can greatly improve someone’s ability to manage these episodes.
“The understanding of migraine biology and the treatments available have exploded in the last decade; with proper education, consistent use of the tools available can improve the lives of most migraine patients,” says Christopher Gottschalk, MD, a Yale Medicine neurologist and director of Yale Medicine's Headache and Facial Pain Center.
“Unfortunately, migraine remains underdiagnosed, undertreated, and underestimated—according to reports, migraine causes more disability than all other neurological conditions combined. But learning to identify the early signs of a migraine attack and intervene quickly and effectively can provide patients with a level of control they never thought was possible,” he says.
What is migraine?
Migraine is a neurologic disorder that causes moderate-to-severe headaches along with other symptoms that make it difficult for people to function normally. People experience migraine differently. Many have throbbing headaches while others have steady headache pain. Although migraine pain can occur on both sides of the head, it’s common for the pain to be isolated on one side or the other across multiple attacks.
It’s important to know that migraine attacks encompass more than just the timeframe when someone has a headache; for most people, the attacks involve several—usually three—phases with distinct features.
- Prodrome phase. This can occur hours or days before a migraine headache. During this phase, many people feel tired or start yawning unexpectedly, experience low mood or irritability, or have trouble concentrating. They may also have neck pain; sensitivity to smells, light, or noises; nausea; or loss of appetite. Some even crave unusual foods.
- Aura phase. During the aura phase, some people report seeing zigzag lines or bright splotches across their field of vision, or experience other types of visual disturbance. They may also feel dizzy, experience vertigo, have trouble speaking, or notice that their extremities are numb or tingling. This phase may last for up to an hour and is followed by a headache.
- Headache phase. Although many people believe that migraine is synonymous with headache, the headache phase is only one part of migraine. The headache itself may last anywhere from 4 to 72 hours, and it may be accompanied by nausea or sensitivity to light, sound, or smells, as well as difficulty concentrating.
- Postdrome phase. Once a migraine headache subsides, it’s common for people to feel fatigued or “washed out” or “hungover,” in a low mood, and have trouble concentrating for several hours, as they recover.
Only about 25% of people with migraine experience an aura. Some people experience aura during a headache, rather than before headache onset. Some migraine patients will have an aura without a headache following it at least some of the time.
What causes migraine?
Although the cause of migraine isn’t fully understood, it’s thought that genes may play a role; about 42% of people with migraine have a family history of the condition.
Experts believe that migraine pain is linked to abnormal activation or “sensitization” of the trigeminal nerve, which is responsible for the unpleasant sensations that people feel in their head and neck.
Why the trigeminal nerve becomes sensitized repeatedly in migraine patients is unknown. It is clear that the “aura” of migraine is very similar to a focal seizure that slowly progresses across the brain, and this abnormal activity can lead to trigeminal sensitization. What happens in people who don’t experience an aura is less clear.
Researchers believe that monthly hormonal changes are the main reason women are more likely to have migraines than men. However, before puberty, more boys have migraine than girls. Some women reliably experience migraine at the start of a menstrual period, while others report that ovulation can predict attacks. Many find that headaches worsen at the start of menopause and then improve after.
What are the symptoms of migraine?
The symptoms of migraine set it apart from a “regular” or tension-type headache. People with migraine often have moderate-to-severe head pain and throbbing, accompanied by any or all of the following:
- Sensitivity to light, noise, movement of physical activity, odors, and/or touch
- Dizziness or light-headedness
- Mood changes
- Scalp pain or tenderness
- Neck pain
- Numbness or tingling in the hands, face or other body parts
- Visual disturbances
- Speech disturbances
- Inability to perform normal activities
What are the risk factors for migraine?
Anyone may experience migraine, including children, but it’s more common among women, younger adults, and people with a family history of migraine.
People may be at increased risk of migraine if they have other health conditions, such as:
- Obesity, especially when associated with obstructive sleep apnea (OSA)
- Pain disorders (such as fibromyalgia, irritable bowel syndrome, or interstitial cystitis)
How is migraine diagnosed?
When you visit the doctor with chronic headaches or suspected migraine, he or she will want to know as much as possible about your pain and other symptoms to make an accurate diagnosis.
Your doctor will ask about personal and family medical history, getting details about how frequently you experience headaches and whether they’re accompanied by sensitivity to light, sound and/or movement or other common migraine symptoms. Additionally, your doctor will ask about the presence or absence of an aura.
This is usually followed by a neurological exam to check for abnormalities in mental status, speech, gait, muscle strength and tone, reflexes, and to look for signs of increased pressure in the back of the eye, any of which may indicate neurological problems other than migraine.
Because migraine can’t be diagnosed with a specific test, doctors conclude that someone has migraine when they’ve had at least five headaches with migraine-like symptoms and when it’s determined that they don’t have another condition that may cause similar symptoms.
To rule out other conditions, you may undergo other tests such as:
- CT scan, to check for brain hemorrhages
- MRI, to look for brain lesions, vascular abnormalities, or signs of abnormal pressure
- Blood tests that may identify another condition that can cause severe headaches
- A spinal tap, to check the cerebrospinal fluid for abnormalities
How is migraine treated?
There are a variety of treatments that may help to reduce the burden of migraine. Some are designed to help eliminate the symptoms of a migraine attack quickly when it occurs; other treatments work to reduce the number of attacks, their severity, or duration. Options include:
- Over-the-counter pain medication, including acetaminophen plus caffeine, or non-steroidal anti-inflammatory drugs (NSAIDs), which may be effective when migraine pain is in the mild-to-moderate range
- Triptans, prescription medications, introduced in the 1990s, that may relieve moderate-to-severe migraine symptoms, including headache and nausea
- Nurtec, Ubrelvy, and Reyvow, which are newer agents that target different receptors, do not involve constriction of blood vessels, and have lower rates of side effects than other medications
- Nonselective receptor agonists, used primarily by headache medicine specialists. These include ergotamine and dihydroergotamine, and are useful for treating moderate-to-severe migraine attacks when other agents don’t work or cause side effects.
- Antiemetics, which not only reduce nausea, but also improve the absorption of other medications and directly treat migraine itself; they are often used in combination with other agents.
- Neurostimulation devices. Devices that use small electrical impulses or magnetic pulses to stimulate the trigeminal nerve or other parts of the brain may be used to prevent migraines from occurring or to alleviate pain after a migraine has started.
The following treatments may be offered to reduce the number and severity of future migraine episodes among people who have more than one attack per week (sometimes less), including:
- Tricyclic antidepressants
- Beta blockers
- Certain anticonvulsant drugs
- Botulinum toxin (commonly known as Botox injections)
- Calcitonin-gene related peptide (CGRP) antagonists, a new class of agents that block the effects of a molecule known as calcitonin-gene-related peptide. Studies suggest that CGRP plays an important role in migraines and that the levels of this molecule may increase during migraine attacks and in people who have chronic migraines.
For patients with very frequent migraine, called “chronic migraine” (meaning more than half of the days in a month), adopting lifestyle changes can help. Possible lifestyle changes include:
- Limiting alcohol and/or caffeine
- Eating meals on a schedule, rather than skipping meals
- Following a healthy diet and getting regular physical activity
- Getting enough (and consistent) sleep
- Reducing stress by learning biofeedback and other stress coping skills
- Practicing yoga or meditation
What is the outlook for people with migraine?
There is no cure for migraine, but most people who receive treatment should experience relief from symptoms. It’s helpful to target acute attacks and take preventive measures to reduce migraine frequency.
What makes Yale Medicine unique in its treatment of migraine?
“The Yale Headache and Facial Pain program offers a large number of highly trained and experienced clinicians whose primary aim is to provide compassionate, individualized care. Our approach is to empower patients with the skills, tools, and knowledge they need to gain control of a potentially disabling condition,” says Dr. Gottschalk. “We also have a wide range of advanced diagnostic techniques available to identify less common conditions like intracranial hypertension [“pseudotumor”] or CSF leaks, and specialize in the treatment of post-traumatic headaches, trigeminal neuralgia, and related disorders.”