Migraine attacks may come on suddenly without warning, or they may be preceded by certain known triggers, such as skipping a meal, being exposed to smoke or air pollution, or experiencing a change in hormone levels as part of the menstrual cycle. Most migraine attacks last from 4 to 72 hours, although effective treatment can shorten them to a matter of hours. On the other hand, some migraine attacks can last even longer than 72 hours. An estimated 1 billion people worldwide, and 39 million Americans, have migraine. While a variety of triggers can set off migraine attacks, they don’t directly cause the attacks or the underlying disease. There are still gaps in doctors’ understanding of what causes migraine. However, some doctors describe the migraine brain as hyperactive, or supersensitive, by which they mean that the brain of someone with migraine reacts more strongly to environmental stimuli such as stress or sleep disturbance than the brain of someone who doesn’t have migraine, resulting in the symptoms known as a migraine attack. Identifying what type of migraine you have may help you and your doctor choose the right treatment for you. It can be essential if you want to participate in clinical trials.
Migraine Without Aura
Formerly known as common migraine, migraine without aura is characterized by a headache that’s usually on one side of the head, has a pulsating quality, is worsened by physical activity, and is accompanied by nausea or light and sound sensitivity. Migraine without aura may have a prodrome, or warning, phase, in which a person experiences symptoms such as depression, food cravings, difficulty focusing, uncontrollable yawning, and others. It can also have a postdrome phase, when the headache pain has receded, but a person feels tired and achy and has trouble concentrating. Alternatively, a person may feel elated and even euphoric after the headache phase of a migraine has passed.
Migraine With Aura
Sensory disturbances may include a feeling of pins and needles or numbness in a part of the body, face, or tongue. In some cases, aura symptoms occur with no headache accompanying or following them.
Given the frequency of symptoms in chronic migraine, it can be impossible to determine when one migraine attack ends and another begins. It can also be difficult to determine whether an individual in fact has chronic migraine or has another condition, such as medication-overuse headache, that would be expected to cause daily or near-daily head pain. Cyclical vomiting syndrome In cyclical vomiting syndrome, an individual experiences attacks of severe nausea and vomiting lasting an hour or more for up to 10 days at a time. Between attacks, which occur on a regular cycle, the person has no symptoms of nausea or vomiting. Benign paroxysmal vertigo In this syndrome, otherwise healthy children experience recurrent brief attacks of vertigo that come on without warning and resolve spontaneously without loss of consciousness. During the attacks, a child may have nystagmus (uncontrolled horizontal or vertical eye movement), impaired balance or coordination (called ataxia), vomiting, pale skin, and fearfulness. Benign paroxysmal torticollis Occurring in infants and small children, this syndrome causes the head to tilt to one side, with or without slight rotation, and stay tilted for minutes to days before spontaneously resuming its normal position. During the attack, the infant or child may be pale and irritable, seem uncomfortable or generally unwell, vomit, or in older children, have impaired balance or coordination.
Other Types of Headaches
Other rare types of headaches include these varieties:
Cluster headache These intensely painful headaches last 15 to 180 minutes without treatment and happen in cycles, or clusters.Paroxysmal hemicranias Severe, sometimes throbbing pain on one side of the face or around the eyes lasts 2 to 30 minutes and occurs more than 5 times a day.Ice-pick headache As the name implies, an ice-pick headache is a migraine characterized by stabbing pain. Fortunately, it is relatively uncommon and typically short in duration.Intractable headache Any headache, including migraine, that doesn’t respond to treatment.Occipital neuralgia This disorder causes pain in the back of the head and upper neck.
While head pain is a symptom of both migraine and tension headache, migraine attacks are often accompanied by nausea and are made worse with routine physical activity, while tension-type headache is not. In addition, headaches caused by migraine typically occur on one side of the head, while tension headaches typically affect both sides. And migraine tends to have a pulsating or throbbing quality, while the pain of a tension-type headache is described as pressing or tightening. Having one type of primary headache disorder doesn’t rule out having another. In fact, many people have both migraine and tension-type headache. The most common symptom of migraine is head pain — often characterized as an intense throbbing sensation, usually on one side of the head but sometimes on both sides of the head, and sometimes starting on one side of the head and moving to the other side. However, migraine attacks have four stages, with somewhat different symptoms at each stage: Aura stage Up to a third of people experience the aura phase, which can last five minutes to an hour and increase in intensity over time. Aura may involve seeing bright spots or patterns of light, and numbness or tingling in various areas of the body but not paralysis. Headache phase Pain comes with the headache phase, which can last several hours and up to three days. The throbbing pain may start on one side of the head and move to include both sides. It may be accompanied by nausea and vomiting as well as blurred vision and sensitivity to certain stimuli such as light and noise. People typically seek out a quiet, dark room to rest or sleep during this phase of a migraine attack. Postdrome, or hangover, stage In the last phase of a migraine attack, when the headache pain has eased, fatigue and body aches may occur. You may have trouble concentrating and may still be hypersensitive to certain stimuli.
Light sensitivity, called photophobia, which contributes to the desire to seek out a dark space during attacksSound sensitivity, or phonophobia, which can make ordinary noises unbearableTouch hypersensitivity, called allodynia, or pain resulting from gentle touches such as brushing one’s hair or touching one’s face to a pillowcaseNausea and vomitingAura symptomsHeadache, often with a pulsating or throbbing qualityNeck pain or stiffnessFatigueBrain fog, or difficulty concentrating, remembering, or performing other mental tasksLight-headedness, dizziness, or vertigoDepression or anxietyRinging in the ears, or tinnitusTearing of the eyesSinus painDiarrheaAversion to odors
Colds hands or feetConstipationDifficulty speaking clearlyDifficulty understanding written or spoken informationEarachesFacial swellingFood cravingsFrequent urinationIncreased thirstJaw painNight sweatsNightmaresNumbness or tingling in the hands, feet, or facePhysical weaknessSmelling odors (usually unpleasant ones) that aren’t really thereStuffy nose
Learn More About Signs and Symptoms of Migraine Researchers have identified several key risk factors for developing migraine, including the following.
Heredity
Age
Gender
Some women find that hormonal medications such as contraceptives or hormone replacement therapy worsen migraine, while others find that they lessen the frequency of their headaches. Learn More About Migraine Causes and Risk Factors
Prognosis of Migraine
Migraine has a highly variable long-term prognosis. Some people have fewer and less severe migraine attacks over time, while others have more attacks, sometimes transitioning from episodic migraine to chronic migraine. Still others have long periods of remission, during which they have no migraine attacks. Researchers are still exploring the natural history of migraine, as well as what may contribute to both decreases and increases in migraine attacks over the long term. Learn More About Migraine Diagnosis
Medications to Treat and Prevent Migraine Attacks
Medical treatment options for migraine are twofold: drugs that work to alleviate symptoms once an attack has started, and medications that prevent attacks from happening or reduce their frequency and severity. Over-the-counter medications include:
Acetaminophen (Tylenol)Ibuprofen (Advil, Motrin IB)Naproxen (Aleve, Naprosyn)
Almotriptan malateEletriptan hydrobromide (Relpax)Frovatriptan (Frova)Naratriptan (Amerge)Sumatriptan (Imitrex, Onzetra Xsail, Sumatriptan Succinate, Tosymra, Zembrace Symtouch)Rizatriptan (Maxalt, Maxalt-MLT)Zolmitriptan (Zomig, Zomig-ZMT)
Triptans are all available in pill form. Zolmitriptan and sumatriptan are also available as nasal sprays. In addition, sumatriptan is available as an injection. Antinausea medications include:
ChlorpromazineMetoclopramide (Gimoti, Reglan)Prochlorperazine (Compro)
Metoclopramide and chlorpromazine are available in tablet and liquid form, or by injection. Metoclopramide is also available as a nasal spray. Prochlorperzine is given by tablet, suppository, or injection. These days, ergots aren’t prescribed as often as the newer triptans, which tend to be more effective and have fewer side effects. Ergots include:
Dihydroergotamine (D.H.E. 45, Migranal, Trudhesa)Ergotamine (Ergomar)
Dihydroergotamine can be given by intravenous (IV) injection or taken as a nasal spray. Ergotamine is available as a pill or a suppository. Dexamethasone (Dexamethasone Intensol) is a steroid medication given by IV or injection that, when given with another acute migraine treatment, can reduce the risk of recurrence. It is also available in a tablet. Another category of abortive migraine treatments is the calcitonin gene-related peptide (CGRP) receptor antagonists, which suppress pain. They include the oral medicines ubrogepant (Ubrelvy), and rimegepant (Nurtec ODT). Another abortive migraine treatment is lasmiditan (Reyvow), which is taken as an oral tablet and is the only approved drug in the 5-HT1F receptor agonist class. Preventive medications Most of the medications that have a preventive, or prophylactic, effect on migraine weren’t developed specifically for migraine; they’re primarily used to treat cardiovascular conditions, seizures, and depression. Preventive treatment is usually recommended for patients who have very severe or frequent long-lasting migraine headaches. Your healthcare provider will usually start you off with a low dose and gradually increase it until you notice an effect. Furthermore, some people may require both preventive treatment and acute treatment in order to control their headaches. Beta-blockers include:
Metoprolol tartrate (Lopressor)Propranolol (InnoPran XL)Timolol
Metoprolol is available taken by tablet or capsule or given by injection. Propranolol is given by capsule, liquid, or injection. Timolol is instilled as an eye drop. Antidepressants include:
Amitriptyline (Elavil)Nortriptyline (Pamelor)Venlafaxine
Amitriptyline and venlafaxine are taken as pills. Antiseizures include:
ValproateValproic acid (Depakene)Topiramate (Topamax, Trokendi XR, Qudexy XR)
These drugs, which aim to block pain, are generally prescribed when symptoms don’t improve with standard preventive migraine medications such as beta-blockers, antidepressants, and anti-seizure medications. These medications have been shown to reduce migraine days in both episodic and chronic migraine.
The CGRP antagonists, rimegepant (Nurtec ODT) and atogepant (Qulipta) are available as oral medications. Injections of onabotulinumtoxinA (Botox) every 12 weeks may also help prevent migraine in some people with chronic migraine. Some pharmacological treatments that help with chronic migraine are not effective when it comes to episodic migraine. Treatment will depend on what type of migraine you have. They are unlikely to replace medications in a person’s migraine management plan, but they may help control pain when used alongside meds. Side effects from nerve stimulation tend to be mild and mainly include redness, irritation, or muscle twitching at the site of the stimulation. The main drawback of nerve stimulation devices may be that they’re expensive and not always covered by health insurance plans. Learn More About Nerve Stimulation Devices for Migraine Treatment
Complementary Therapies
In addition to medications, lifestyle changes (such as getting enough sleep, eating right, and managing stress) can help you avoid certain triggers, potentially preventing some migraine attacks. Practicing relaxation exercises, such as yoga and meditation, may ease migraine pain. While the evidence isn’t definitive, some people with migraine have found that home remedies and alternative therapies such as acupuncture and biofeedback are effective. Consult with your healthcare provider to find an approach that works for you. According to MedlinePlus, you should see your doctor if there are changes in your headache pattern, if treatments you’ve been using stop working, if your headaches are more severe when you’re lying down, or if you have bothersome side effects from your medication. You should call 911 if you have problems with speech, vision, movement, paralysis, or loss of balance, particularly if you’ve never had these symptoms before with a migraine. If your headache starts suddenly, it may be an emergency. Learn More About Treatment for Migraine: Medication, Alternative and Complementary Therapies, and More
Migraine Triggers
While there’s no way to completely prevent migraine, some people are able to control their exposure to certain triggers that can prompt an episode. Often you need several triggers to lead to a migraine attack, not just one. Common triggers for migraine attacks include the following:
Changes in the Weather
Many people report that changes in the weather, particularly changes in barometric pressure, trigger migraine attacks. Other weather-related migraine triggers include heat, humidity, wind, and reduced light exposure. Poor air quality, from wildfires or other sources of air pollution, can also be a trigger for some people.
Lights, Sounds, or Smells
Loud noises and strong smells (from perfume, cleaning products, or secondhand smoke) are also associated with migraine onset.
Medications
Dehydration
According to the American Migraine Foundation, about one-third of people cite dehydration as a migraine trigger. Make sure you’re drinking enough water throughout the day.
Disrupted Sleep
Getting too little or too much sleep can trigger migraine in some people, as can changes in your sleep-wake pattern, such as jet lag.
Foods and Food Additives
Certain foods and beverages, particularly alcoholic beverages, can be triggers. The flavor enhancer monosodium glutamate can also be a trigger, as can caffeine. Foods containing the amino acid tyramine have been associated with migraine onset. Examples include aged cheese, smoked fish, chicken livers, figs, certain beans, and red wine. The nitrates in cured meats such as bacon, hot dogs, salami, and other lunch meats are a trigger for some. Research has also suggested that the artificial sweeteners aspartame and sucralose can be triggers. And for some people, fruits such as avocados, bananas, and citrus as well as some nuts and seeds can trigger migraine. Missing or skipping meals can trigger attacks, too. One approach to discovering migraine food triggers is to try an elimination diet, in which certain foods are eliminated from the diet for a few weeks, then reintroduced one at a time to see whether a migraine attack occurs. For that reason, most experts recommend consulting your physician before trying an elimination diet for migraine and, if you do decide to try it, working with a registered dietitian to maintain good nutrition.
Stress or Relief From Stress
Of course, the prevalence of a disease doesn’t tell the whole story. A paper in the Journal of the National Medical Association looked into the experience of headache among Black Americans and found that compared with white people with headache, “African American headache patients are more likely to (i) be diagnosed with comorbid depressive disorders; (ii) report headaches that are more frequent and severe in nature; (iii) have their headaches underdiagnosed and/or undertreated; and (iv) discontinue treatment prematurely, regardless of socioeconomic status.”
Only 47 percent of Black individuals with headaches have an official headache diagnosis, compared with 70 percent of white individuals.Latinos with headaches are 50 percent less likely to receive a migraine diagnosis than white individuals.Only 14 percent of Black patients with headache receive prescriptions for acute migraine medications, compared with 37 percent of white patients with headache.
Dr. Kiarashi also noted that BIPOC communities were underrepresented in migraine and headache research, based on the sample of studies on headache and migraine that her team reviewed. Learn More About Healthcare Disparities in the Migraine Community on MigraineAgain
Mental Health Disorders People who experience migraine are also more likely to have depression, bipolar disorder, anxiety disorder, or panic disorder.Stroke Studies have shown that people who have migraine have a slightly higher risk of having a stroke at some point.Seizures Scientists don’t completely understand the relationship between seizures and migraine, but research suggests they may be linked.Heart Disease Some studies show that people who have migraine might have a higher risk for heart-related events.Endometriosis Migraine is more prevalent in women with endometriosis compared with women without endometriosis.Irritable Bowel Syndrome People who have migraine have a higher incidence of irritable bowel syndrome than the general public.
The good news is there’s no reason to think people with migraine are at any greater risk of acquiring COVID-19 than the general public. However, anecdotal reports suggest that those who do get COVID-19 are likely to develop headache as a symptom and possibly very severe headache. How to avoid this? For most people, the best way to avoid a COVID-19 infection is to get one of the COVID-19 vaccines. While headache, fever, fatigue, muscle pain, and joint pain are possible side effects of all three of the vaccines currently authorized in the United States, those side effects last only a short time and should not discourage you from getting vaccinated. RELATED: What You Need to Know About the COVID-19 Vaccine if You Have Migraine Beyond vaccination, tried and true ways to avoid communicable infections include washing your hands frequently, keeping your distance from other people, and wearing a face covering when you’re in close contact with people who might be infected, particularly in indoor spaces. Seeing your doctor via telemedicine — meaning by phone, video call, or email — may be an option if you’re concerned about the safety of going out in public or into a medical facility. When you talk to your healthcare provider, ask about the safety of your migraine treatment regimen. Are there particular medications you should be cautious about taking? Are there treatments or procedures you won’t be able to get because your doctor’s office isn’t seeing patients in person? If so, what can you use instead to prevent or treat migraine attacks? As you navigate the practical safety concerns of living through a pandemic, pay attention to your mood. Mental health and migraine health go hand in hand, and while it’s normal to feel some anxiety at this time, it’s also important to seek help if you’re feeling depressed or your anxiety is severe. Reach out to your mental health therapist if you have one, or ask your migraine specialist or primary care doctor for a mental healthcare referral. Learn More About Living With Migraine During the COVID-19 Pandemic Learn More About Migraine Resources
Favorite Orgs for Essential Migraine Info
American Headache Society (AHS) The AHS is specifically dedicated to helping healthcare providers stay up to date on treatments for headaches and face pain, but patients will also find a wealth of information on new migraine therapies as well as colorful infographics that present a range of tips. American Migraine Foundation (AMF) Working alongside the American Headache Society, this nonprofit organization strives to connect people with migraine with the care and support they need. The website features a handy doctor-locator tool and guidance on a range of issues, including managing migraine at work, identifying types of headaches, applying for Social Security disability income, and handling emergency room visits related to migraine. Association of Migraine Disorders (AMD) AMD recognizes that migraine is a full-body condition, with a broad spectrum of symptoms. In addition to providing extensive educational materials, the organization hosts Shades for Migraine, a campaign in which participants raise migraine awareness and address the stigma associated with the disease by wearing sunglasses in unexpected places. Migraine Research Foundation (MRF) While the MRF’s main mission may be raising money for migraine research, the foundation’s website serves as a source for migraine news, information, and contact details for certified headache specialists, children’s headache doctors, and comprehensive headache centers. Migraine at Work The Migraine at Work campaign aims to help employees with migraine stay employed and productive on the job, and to help employers support and accommodate those employees. The website offers articles, taped webcasts, newsletters, and links to more information. Migraine at Work is a project of the World Health Education Foundation.
Favorite Migraine Publications
My Chronic Brain This online magazine for people with chronic migraine is put together by volunteers who want to connect readers with helpful real stories from patients, sources of treatment, nutritional advice, and news related to migraine care. The INvisible Project The INvisible Project, the flagship program of the U.S. Pain Foundation, produces online magazines with real stories and photographs of people coping with chronic pain. Several editions are dedicated to people with migraine, who share how they deal with pain-related challenges in their everyday lives. Migraine Again Migraine Again calls itself a lifestyle website for people with migraine and the people who love them. It features expert information and advice, tips and personal stories from people who have migraine, and articles on just about every aspect of living with migraine. Migraine Patient Toolkit: A Guide to Your Care The downloadable resource was created by the Society for Women’s Health Research to assist those with migraine in getting the care they need, dealing with health insurance issues, and incorporating wellness practices into their lives.
Favorite Migraine Apps
iHeadache This app gets strong ratings from people with headache and migraine who use it to track medications, disability, and triggers, and share data with their doctors. The app also analyzes your data to determine the type of headache you’re having. Migraine Buddy Designed with neurologists and data scientists, this graphic-heavy app makes it easy to record and monitor migraine. The technology helps patients identify likely triggers associated with their migraine and prevent future headaches. The website also features interesting articles on the effect of alcohol on migraine, how pets may help, migraine auras, and other topics.
Favorite Migraine Diaries
The Migraine Trust This British organization dedicated to supporting people affected by migraine offers a pdf of this handy guide and chart for tracking attacks and any drug treatment you may be taking. Finding patterns in migraine can help with treatment. Hartford Healthcare Headache Center Migraine Diary The pdf from this center for headache care gives a comprehensive system for recording episodes and medicines. A key helps pinpoint types of triggers and evaluate migraine severity.
Favorite Migraine Blogs
The Counterfactual Brain Beth Morton shares her experiences with chronic headaches, including how she deals with symptoms of nausea, light sensitivity, sound sensitivity, trouble articulating thoughts, mood swings, and fatigue. The site not only presents blog entries but also links to her Twitter chats with other people with migraine. The Daily Migraine As someone who regularly experiences migraine, Lisa Jacobson created this site as a forum for everyone with migraine to come together to help heal themselves through knowledge, shared experience, and humor. More than a quarter million people with migraine have connected through her Facebook, Instagram, and Twitter feeds.
