Migraine

Definition
A migraine can be disabling — with symptoms so severe, all you can think about is
finding a dark, quiet place to lie down. Up to 17 percent of women and 6 percent
of men have experienced a migraine. In some cases, these painful headaches are
preceded or accompanied by a sensory warning sign (aura), such as flashes of lig
ht, blind spots or tingling in your arm or leg. A migraine is also often accompa
nied by other signs and symptoms, such as nausea, vomiting, and extreme sensitiv
ity to light and sound. Migraine pain can be excruciating and may incapacitate y
ou for hours or even days. Fortunately, management of migraine pain has improved
dramatically in the last decade. If you've seen a doctor in the past and had no
success, it's time to make another appointment. Although there's still no cure,
medications can help reduce the frequency of migraine and stop the pain once it
has started. The right medicines combined with self-help remedies and changes i
n lifestyle may make a tremendous difference for you.
Symptoms
A typical migraine attack produces some or all of these signs and symptoms:

Moderate to severe pain, which may be confined to one side of the head or may af
fect both sides Head pain with a pulsating or throbbing quality Pain that worsen
s with physical activity Pain that interferes with your regular activities Nause
a with or without vomiting Sensitivity to light and sound
When left untreated, a migraine typically lasts from four to 72 hours, but the f
requency with which headaches occur varies from person to person. You may have m
igraines several times a month or just once or twice a year. Not all migraines a
re the same. Most people experience migraines without auras, which were previous
ly called common migraines. Some, however, have migraines with auras, which were
previously called classic migraines. If you're in the second group, you'll like
ly have an aura about 15 to 30 minutes before your headache begins. Auras may co
ntinue after your headache starts or even occur after your headache begins. When
you're experiencing an aura, you may:

See sparkling flashes of light Perceive dazzling zigzag lines in your field of v
ision Experience slowly spreading blind spots in your vision
Feel tingling, pins and needles sensations in one arm or leg Rarely, experience
weakness or language and speech problems
Whether or not you have auras, you may have one or more sensations of premonitio
n (prodrome) several hours or a day or so before your headache actually strikes,
including:

Feelings of elation or intense energy Cravings for sweets Thirst Drowsiness Irri
tability or depression
Migraine symptoms in children Migraines typically begin in childhood, adolescenc
e or early adulthood and may become less frequent and less intense as you grow o
lder. In addition to physical suffering, severe headaches often mean missed scho
ol days and trips to the emergency department, as well as lost work time for anx
ious parents. Children's migraines tend to last for a shorter time. But the pain
can be disabling and can be accompanied by nausea, vomiting, lightheadedness an
d increased sensitivity to light. A migraine tends to occur on both sides of the
head in children. Children may also have all of the signs and symptoms of a mig
raine — nausea, vomiting, increased sensitivity to light and sound — but no head pai
n. These "abdominal migraines" can be especially difficult to diagnose. The good
news is that some of the same medications that are effective for adults also wo
rk for children. Your child doesn't have to go through the pain and disruption o
f migraines. If your child has headaches, talk to your pediatrician. He or she m
ay want to refer your child to a pediatric neurologist.
Causes
Although much about headaches still isn't understood, some researchers think mig
raines may be caused by functional changes in the trigeminal nerve system, a maj
or pain pathway in your nervous system, and by imbalances in brain chemicals, in
cluding serotonin, which plays a regulatory role for pain messages going through
this pathway. During a headache, serotonin levels drop. Researchers believe thi
s causes the trigeminal nerve to release substances called neuropeptides, which
travel to your brain's outer covering (meninges). There they cause blood vessels
to become dilated and inflamed. The result is headache pain. Migraine triggers
Whatever the exact mechanism of headaches, a number of things may trigger them.
Common migraine triggers include:
Hormonal changes. Although the exact relationship between hormones and headaches
isn't clear, fluctuations in estrogen seem to trigger headaches in many women w
ith known migraines. Women with a history of migraines often report headaches im
mediately before or during their periods, and this corresponds to a major drop i
n estrogen. Others have an increased tendency to develop migraines during pregna
ncy or menopause. Hormonal medications, such as contraceptives and hormone repla
cement therapy, also may worsen migraines. Foods. Certain foods appear to trigge
r headaches in some people. Common offenders include alcohol, especially beer an
d red wine; aged cheeses; chocolate; fermented, pickled or marinated foods; aspa
rtame; overuse of caffeine; monosodium glutamate — a key ingredient in some Asian
foods; certain seasonings; and many canned and processed foods. Skipping meals o
r fasting also can trigger migraines. Stress. A hard week at work followed by re
laxation may lead to a weekend migraine. Stress at work or home also can instiga
te migraines. Sensory stimuli. Bright lights and sun glare can produce head pain
. So can unusual smells — including pleasant scents, such as perfume and flowers,
and unpleasant odors, such as paint thinner and secondhand smoke. Changes in wak
e-sleep pattern. Either missing sleep or getting too much sleep may serve as a t
rigger for migraine attacks in some individuals. Physical factors. Intense physi
cal exertion, including sexual activity, may provoke migraines. Changes in the e
nvironment. A change of weather, season, altitude level, barometric pressure or
time zone can prompt a migraine. Medications. Certain medications can aggravate
migraines.
Risk factors
Many people with migraines have a family history of migraine. If both your paren
ts have migraines, there's a good chance you will too. Even if only one of your
parents has migraines, you're still at increased risk of developing migraines. Y
ou also have a relatively higher risk of migraines if you're young and female. I
n fact, women are three times as likely to have migraines as men are. Headaches
tend to affect boys and girls equally during childhood but increase in girls aft
er puberty. If you're a woman with migraines, you may find that your headaches b
egin just before or shortly after onset of menstruation. They may also change du
ring pregnancy or menopause. Many women report improvement in their migraines la
ter in pregnancy, but others report that their migraines worsened during the fir
st trimester. If pregnancy or menstruation affects your migraines, your headache
s are also likely to worsen if you take birth control pills or hormone replaceme
nt therapy (HRT).
When to seek medical advice
Migraines are a chronic disorder, but they're often undiagnosed and untreated. I
f you experience signs and symptoms of migraine, track and record your attacks a
nd how
you treated them. Then make an appointment with your doctor to discuss your head
aches and decide on a treatment plan. Even if you have a history of headaches, s
ee your doctor if the pattern changes or your headaches suddenly feel different.
See your doctor immediately or go to the emergency room if you have any of the
following signs and symptoms, which may indicate other, more serious medical pro
blems:

An abrupt, severe headache like a thunderclap Headache with fever, stiff neck, r
ash, mental confusion, seizures, double vision, weakness, numbness or trouble sp
eaking Headache after a head injury, especially if the headache gets worse A chr
onic headache that is worse after coughing, exertion, straining or a sudden move
ment New headache pain if you're older than 50
Tests and diagnosis
If you have typical migraines or a family history of migraines, your doctor will
likely diagnose the condition on the basis of your medical history and a physic
al exam. But if your headaches are unusual, severe or sudden, your doctor may re
commend a variety of tests to rule out other possible causes for your pain. Comp
uterized tomography (CT) This imaging procedure uses a series of computer-direct
ed X-rays that provides a cross-sectional view of your brain. This helps doctors
diagnose tumors, infections and other possible medical problems that may be cau
sing your headaches. Magnetic resonance imaging (MRI) MRIs use radio waves and a
powerful magnet to produce very detailed cross-sectional views of your brain. M
RI scans help doctors diagnose tumors, strokes, aneurysms, neurological diseases
and other brain abnormalities. An MRI can also be used to examine the blood ves
sels that supply the brain. Spinal tap (lumbar puncture) If your doctor suspects
that an underlying condition, such as meningitis or subarachnoid hemorrhage, is
the cause of your headaches, he or she may recommend a spinal tap (lumbar punct
ure). In this procedure, a thin needle is inserted between two vertebrae in your
lower back to extract a sample of cerebrospinal fluid (CSF) for laboratory anal
ysis. The procedure takes about 30 minutes. You may feel pressure while the flui
d is extracted and have a headache afterward because of a drop in CSF pressure.
Complications
Sometimes your efforts to control your pain cause problems. Nonsteroidal antiinf
lammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others) and aspirin,
may cause abdominal pain, bleeding and ulcers — especially if taken in large dose
s or for a long period of time.
In addition, if you take over-the-counter or prescription headache medications m
ore than two or three times a week or in excessive amounts, you may be setting y
ourself up for a serious complication known as rebound headaches. Rebound headac
hes occur when medications not only stop relieving pain, but actually begin to c
ause headaches. You then use more pain medication, which traps you in a vicious
cycle. Serotonin syndrome A potentially life-threatening drug interaction — called
serotonin syndrome — can occur if you take migraine medicines called triptans, su
ch as sumatriptan (Imitrex) or zolmitriptan (Zomig), along with antidepressants
known as selective serotonin reuptake inhibitors (SSRIs) or selective serotonin
and norepinephrine reuptake inhibitors (SNRIs). Some common SSRIs include Zoloft
, Prozac and Paxil. SNRIs include Cymbalta and Effexor. Fortunately, serotonin s
yndrome is exceedingly uncommon.
Treatments and drugs
A variety of drugs have been specifically designed to treat migraines. In additi
on, some drugs commonly used to treat other conditions also may help relieve or
prevent migraines. Medications used to combat migraines fall into two broad cate
gories:

Pain-relieving medications. Also known as acute or abortive treatment, these typ

es of drugs are taken during migraine attacks and are designed to stop symptoms
that have already begun. Preventive medications. These types of drugs are taken
regularly, often on a daily basis, to reduce the severity or frequency of migrai
nes.
Choosing a strategy to manage your migraines depends on the frequency and severi
ty of your headaches, the degree of disability your headaches cause, and your ot
her medical conditions. You may be a candidate for preventive therapy if you hav
e two or more debilitating attacks a month, if you use pain-relieving medication
s more than twice a week, if pain-relieving medications aren't helping, or if yo
ur migraine signs and symptoms include a prolonged aura or numbness and impaired
movement on one side of your body. Some medications aren't recommended if you'r
e pregnant or breast-feeding. Some aren't used for children. Your doctor can hel
p find the right medication for you. Pain-relieving medications For best results
, take pain-relieving drugs as soon as you experience signs or symptoms of a mig
raine. It may help if you rest or sleep in a dark room after taking them:

Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibupro

fen (Advil, Motrin, others) or aspirin, may help relieve mild migraines. Drugs m
arketed specifically for migraine, such as the combination of acetaminophen, asp
irin and caffeine (Excedrin Migraine), also may ease moderate migraines, but are
n't effective alone for severe migraines. If overthe-counter medications don't h
elp, your doctor may suggest a stronger,
prescription-only version of the same drug. If taken too often or for long perio
ds of time, NSAIDs can lead to ulcers, gastrointestinal bleeding and rebound hea
daches. Triptans. For many people with severe migraine attacks, triptans are the
drug of choice. They are effective in relieving the pain, nausea and sensitivit
y to light and sound that are associated with migraines. Sumatriptan (Imitrex) w
as the first drug specifically developed to treat migraines. Related medications
include rizatriptan (Maxalt), naratriptan (Amerge), zolmitriptan (Zomig), almot
riptan (Axert), frovatriptan (Frova) and eletriptan (Relpax). Side effects of tr
iptans include nausea, dizziness, muscle weakness and, rarely, stroke and heart
attack. In recent studies, a single-tablet combination of sumatriptan and naprox
en sodium relieved migraine symptoms more effectively than did either individual
medication. This combination tablet will likely be marketed soon. Ergots. Ergot
amine (Ergomar) has been in use for more than 60 years and was a common prescrip
tion for migraine before triptans were introduced. Ergotamine is much less expen
sive, but also less effective, than triptans. Dihydroergotamine is an ergot deri
vative that is more effective and has fewer side effects than ergotamine. Anti-n
ausea medications. Since migraine attacks are often accompanied by nausea with o
r without vomiting, medication for treatment of these symptoms is appropriate an
d is usually combined with other medications. Frequently prescribed medications
are metoclopramide (oral) or prochlorperazine (oral or rectal suppository). Buta
lbital combinations. Medications that combine the sedative butalbital with aspir
in or acetaminophen are sometimes used to treat migraine attacks. Some combinati
ons also include caffeine or codeine. These medications, however, have a high ri
sk of rebound headaches and withdrawal symptoms and accordingly should be used i
nfrequently. Opiates. Medications containing narcotics, particularly codeine, ar
e sometimes used to treat migraine pain when people can't take triptans or ergot
s. These drugs are habit-forming and are usually used only as a last resort.
Preventive medications Preventive medications can reduce the frequency, severity
and length of migraines and may increase the effectiveness of symptom-relieving
medicines used during migraine attacks. Your doctor may recommend that you take
preventive medications daily, or only when a predictable trigger, such as menst
ruation, is approaching. In most cases, preventive medications don't eliminate h
eadaches completely, and some can have serious side effects. For best results, t
ake these medications as your doctor recommends:

Cardiovascular drugs. Beta blockers — which are commonly used to treat high blood
pressure and coronary artery disease — can reduce the frequency and severity of mi
graines. These drugs are considered among first-line treatment agents. Calcium c
hannel blockers, another class of cardiovascular drugs, especially verapamil (Ca
lan, Isoptin), also may be helpful. In addition, the antihypertensive medication
s lisinopril (Prinivil, Zestril) and candesartan (Atacand) are useful migraine p
revention medications. Researchers don't
understand exactly why all of these cardiovascular drugs prevent migraines. Side
effects can include dizziness, drowsiness or lightheadedness. Antidepressants.
Certain antidepressants are good at helping prevent all types of headaches, incl
uding migraines. Most effective are tricyclic antidepressants, such as amitripty
line, nortriptyline (Pamelor) and protriptyline (Vivactil). These medications ar
e considered among first-line treatment agents and may reduce migraines by affec
ting the level of serotonin and other brain chemicals. You don't have to have de
pression to benefit from these drugs. Newer antidepressants, however, generally
aren't as effective for migraine prevention. Anti-seizure drugs. Although the re
ason is unclear, some anti-seizure drugs, such as divalproex sodium (Depakote) a
nd topiramate (Topamax), which are used to treat epilepsy and bipolar disease, s
eem to prevent migraines. Gabapentin (Neurontin), another anti-seizure medicatio
n, is considered a second-line treatment agent. In high doses, however, these an
ti-seizure drugs may cause side effects, such as nausea and vomiting, diarrhea,
cramps, hair loss and dizziness. Cyproheptadine. This antihistamine specifically
affects serotonin activity. Doctors sometimes give it to children as a preventi
ve measure. Botulinum toxin type A (Botox). Some people receiving Botox injectio
ns for their facial wrinkles have noted improvement of their headaches. The mech
anism by which Botox might prevent migraines is unclear, although the drug may c
ause changes in your nervous system that modify your tendency to develop migrain
es. Studies using Botox injections for migraines have had mixed results. Additio
nal research is necessary. Still, if several other preventive medications have f
ailed to control your headaches, you might talk to your doctor about trying Boto
x.
Prevention
Whether or not you take preventive medications, you may benefit from lifestyle c
hanges that can help reduce the number and severity of migraines. One or more of
these suggestions may be helpful for you:

Avoid triggers. If certain foods seem to have triggered your headaches in the pa
st, eat something else. If certain scents are a problem, try to avoid them. In g
eneral, establish a daily routine with regular sleep patterns and regular meals.
In addition, try to control stress. Exercise regularly. Regular aerobic exercis
e 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. Reduce t
he effects of estrogen. If you're a woman with migraines and estrogen seems to t
rigger or make your headaches worse, you may want to avoid or reduce the amount
of medications you take that contain estrogen. These medications include birth c
ontrol pills and hormone replacement therapy. Talk with your doctor about the be
st alternatives or dosages for you.
Lifestyle and home remedies
Self-care measures can help ease the pain of a migraine. Try these headache help
ers:

Keep a diary. A diary can help you determine what triggers your migraines. Note
when your headaches start, how long they last and what, if anything, provides re
lief. Be sure to record your response to any headache medications you take. Also
pay special attention to foods you ate in the 24 hours preceding attacks, any u
nusual stress, and how you feel and what you're doing when headaches strike. If
you're under stress, tell your doctor. Try muscle relaxation exercises. Progress
ive muscle relaxation, meditation and yoga don't require any equipment. You can
learn them in classes or at home using books or tapes. Or spend at least a half-
hour each day doing something you find relaxing — listening to music, gardening, t
aking a hot bath or reading. Get enough sleep, but don't oversleep. The average
adult needs seven to nine hours of sleep a night. Rest and relax. If possible, r
est in a dark, quiet room when you feel a headache coming on. Place an ice pack
wrapped in a cloth on the back of your neck and apply gentle pressure to painful
areas on your scalp.
Alternative medicine
Nontraditional therapies may be helpful if you have chronic headache pain:

Acupuncture. In this treatment, a practitioner inserts many thin, disposable nee

dles into several areas of your skin. The penetration is so shallow and the need
les are so thin that acupuncture generally causes little or no pain or discomfor
t. A number of clinical trials have found acupuncture may be helpful for headach
e pain, but evidence from these trials isn't strong enough for experts to routin
ely recommend this treatment. Biofeedback. Biofeedback appears to be especially
effective in relieving migraine pain. This relaxation technique uses special equ
ipment to teach you how to monitor and control certain physical responses, such
as muscle tension. This technique can be combined with preventive medications. M
assage. Although massage is a wonderful way to reduce stress and relieve tension
, its value in treating headaches hasn't been fully determined. For people who h
ave tight, tender muscles in the back of the head, neck and shoulders, massage m
ay help relieve headache pain. Herbs, vitamins and minerals. There is some evide
nce that the herbs feverfew and butterbur may prevent migraines or reduce their
severity. A high dose of riboflavin (vitamin B-2) also may prevent migraines by
correcting tiny deficiencies in the brain cells. There is also some evidence tha
t coenzyme Q10 supplements may be helpful in some individuals. Oral magnesium su
lfate supplements may reduce the frequency of headaches in some people, although
studies don't all agree on this issue. In addition, infusions of magnesium sulf
ate seem to help some people during an acute headache, and they seem to relieve
migraine pain in people with magnesium deficiencies. Ask your doctor if these tr
eatments are right for you. Don't use feverfew or butterbur if you're pregnant.
Cervical manipulation. There are no scientifically valid studies that prove that
chiropractic or other spine-manipulation treatments are effective in the treatm
ent of migraine.