What is a migraine headache?
A migraine headache is a form of vascular headache. Migraine headache is caused by vasodilatation (enlargement of blood vessels) that causes the release of chemicals from nerve fibers that coil around the large arteries of the brain. Enlargement of these blood vessels stretches the nerves that coil around them and causes the nerves to release chemicals. The chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the arteries magnifies the pain.
Migraine attacks commonly activate the sympathetic nervous system in the body. The sympathetic nervous system is often thought of as the part of the nervous system that controls primitive responses to stress and pain, the so-called "fight or flight" response, and this activation causes many of the symptoms associated with migraine attacks; for example, the increased sympathetic nervous activity in the intestine causes nausea, vomiting, and diarrhea.
Sympathetic activity also delays emptying of the stomach into the small intestine and thereby prevents oral medications from entering the intestine and being absorbed.
The impaired absorption of oral medications is a common reason for the ineffectiveness of medications taken to treat migraine headaches.
The increased sympathetic activity also decreases the circulation of blood, and this leads to pallor of the skin as well as cold hands and feet.
The increased sympathetic activity also contributes to the sensitivity to light and sound sensitivity as well as blurred vision.
Migraine afflicts 28 million Americans, with females suffering more frequently (17%) than males (6%). Missed work and lost productivity from migraine create a significant public burden. Nevertheless, migraine still remains largely underdiagnosed and undertreated. Less than half of individuals with migraine are diagnosed by their doctors.
What are the symptoms of migraine headaches?
Migraine is a chronic condition with recurrent attacks. Most (but not all) migraine attacks are associated with headaches.
Migraine headaches usually are described as an intense, throbbing or pounding pain that involves one temple. (Sometimes the pain is located in the forehead, around the eye, or at the back of the head).
The pain usually is unilateral (on one side of the head), although about a third of the time the pain is bilateral (on both sides of the head).
The unilateral headaches typically change sides from one attack to the next. (In fact, unilateral headaches that always occur on the same side should alert the doctor to consider a secondary headache, for example, one caused by a brain tumor).
A migraine headache usually is aggravated by daily activities such as walking upstairs.
Nausea, vomiting, diarrhea, facial pallor, cold hands, cold feet, and sensitivity to light and sound commonly accompany migraine headaches. As a result of this sensitivity to light and sound, migraine sufferers usually prefer to lie in a quiet, dark room during an attack. A typical attack lasts between 4 and 72 hours.
An estimated 40%-60% of migraine attacks are preceded by premonitory (warning) symptoms lasting hours to days. The symptoms may include:
sleepiness,
irritability,
fatigue,
depression or euphoria,
yawning, and
cravings for sweet or salty foods.
Patients and their family members usually know that when they observe these warning symptoms that a migraine attack is beginning.
Causes:
Although much about the cause of migraines isn't understood, genetics and environmental factors seem to both play a role.
Migraines may be caused by changes in the trigeminal nerve, a major pain pathway. Imbalances in brain chemicals, including serotonin — which helps regulate pain in your nervous system — also may be involved.
Serotonin levels drop during migraines. This may trigger your trigeminal system to release substances called neuropeptides, which travel to your brain's outer covering (meninges). The result is headache pain.
Migraine triggers
Whatever the exact mechanism of the headaches, a number of things may trigger them. Common migraine triggers include:
Hormonal changes in women. Fluctuations in estrogen seem to trigger headaches in many women with known migraines. Women with a history of migraines often report headaches immediately before or during their periods, when they have a major drop in estrogen. Others have an increased tendency to develop migraines during pregnancy or menopause. Hormonal medications — such as oral contraceptives and hormone replacement therapy — also may worsen migraines, though some women find it's beneficial to take them.
Foods. Some migraines appear to be triggered by certain foods. Common offenders include alcohol, especially beer and red wine; aged cheeses; chocolate; aspartame; overuse of caffeine; monosodium glutamate — a key ingredient in some Asian foods; salty foods; and processed foods. Skipping meals or fasting also can trigger migraines.
Stress. Stress at work or home can instigate migraines.
Sensory stimuli. Bright lights and sun glare can produce migraines, as can loud sounds. Unusual smells — including pleasant scents, such as perfume, and unpleasant odors, such as paint thinner and secondhand smoke, can also trigger migraines.
Changes in wake-sleep pattern. Either missing sleep or getting too much sleep may serve as a trigger for migraine attacks in some individuals, as can jet lag.
Physical factors. Intense physical exertion, including sexual activity, may provoke migraines.
Changes in the environment. A change of weather or barometric pressure can prompt a migraine.
Medications. Certain medications can aggravate migraines.
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 physical exam. But if your headaches are unusual, severe or sudden, your doctor may recommend a variety of tests to rule out other possible causes for your pain.
Computerized tomography (CT). This imaging procedure uses a series of computer-directed 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 causing your headaches.
Magnetic resonance imaging (MRI). MRIs use radio waves and a powerful magnet to produce very detailed cross-sectional views of your brain. MRI scans help doctors diagnose tumors, strokes, aneurysms, neurological diseases and other brain abnormalities. An MRI can also be used to examine the blood vessels that supply the brain.
Spinal tap (lumbar puncture). If your doctor suspects an underlying condition, such as meningitis — an inflammation of the membranes (meninges) and cerebrospinal fluid surrounding your brain and spinal cord — he or she may recommend a spinal tap (lumbar puncture). 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 analysis.
Treatments and drugs
A variety of drugs have been specifically designed to treat migraines. In addition, some drugs commonly used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:
Pain-relieving medications. Also known as acute or abortive treatment, these types 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 migraines.
Choosing a strategy to manage your migraines depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions.
Some medications aren't recommended if you're pregnant or breast-feeding. Some aren't used for children. Your doctor can help 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 migraine. It may help if you rest or sleep in a dark room after taking them:
Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibuprofen (Advil, Motrin, others) or aspirin, may help relieve mild migraines. Drugs marketed specifically for migraine, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraines but aren't effective alone for severe migraines. If taken too often or for long periods of time, NSAIDs can lead to ulcers, gastrointestinal bleeding and rebound headaches.
Triptans. For many people with severe migraine attacks, triptans are the drug of choice. They are effective in relieving the pain, nausea and sensitivity to light and sound that are associated with migraines. Medications include sumatriptan (Imitrex), rizatriptan (Maxalt), naratriptan (Amerge), zolmitriptan (Zomig), almotriptan (Axert), frovatriptan (Frova) and eletriptan (Relpax). Side effects of triptans include nausea, dizziness and muscle weakness. They aren't recommended for people at risk for strokes and heart attacks. A new, single-tablet combination of sumatriptan and naproxen sodium (Treximet) became available in 2008. It's more effective in relieving migraine symptoms than either medication on its own.
Ergot. Ergotamine (Migergot, Cafergot) is much less expensive, but also less effective, than triptans. It seems most effective in those whose pain lasts for more than 48 hours. Dihydroergotamine (Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine.
Anti-nausea medications. Because migraine attacks are often accompanied by nausea with or without vomiting, medication for nausea is appropriate and is usually combined with other medications. Frequently prescribed medications are metoclopramide (oral) or prochlorperazine (oral or suppository).
Butalbital combinations. Medications that combine the sedative butalbital with aspirin or acetaminophen (Butapap, Phrenlin Forte) are sometimes used to treat migraine attacks. Some combinations also include caffeine or codeine (Esgic-Plus, Fioricet). These medications, however, have a high risk of rebound headaches and withdrawal symptoms so should be used infrequently.
Opiates. Medications containing narcotics, particularly codeine, are sometimes used to treat migraine pain when people can't take triptans or ergot. Narcotics are habit-forming and are usually used only as a last resort.
Preventive medications
Nearly half of those who get migraines could benefit from preventative medication, yet only about 1 in 10 people take it. You may be a candidate for preventive therapy if you have two or more debilitating attacks a month, if pain-relieving medications aren't helping, or if your migraine signs and symptoms include a prolonged aura or numbness and weakness.
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 menstruation, is approaching.
In most cases, preventive medications don't eliminate headaches completely, and some cause serious side effects. If you have had good results from preventative medicine and have been migraine-free for six months to a year, your doctor may recommend tapering off the medication to see if your migraines return without it.
For best results, take these medications as your doctor recommends:
Cardiovascular drugs. Beta blockers — commonly used to treat high blood pressure and coronary artery disease — can reduce the frequency and severity of migraines. These drugs are considered among first-line treatment agents. Calcium channel blockers, another class of cardiovascular drugs, especially verapamil (Calan, Isoptin), also may be helpful in preventing migraines and relieving symptoms from aura. In addition, the antihypertensive medications lisinopril (Prinivil, Zestril) and candesartan (Atacand) are useful in reducing the length and severity of migraines. 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 to prevent some types of headaches, including migraines. Most effective are tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and protriptyline (Vivactil). These medications are considered among first-line treatment agents and may reduce migraines by affecting the level of serotonin and other brain chemicals. You don't have to have depression to benefit from these drugs. Other classes of antidepressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), haven't been proven as effective for migraine prevention. However, preliminary research suggests that one SNRI, venlafaxine (Effexor), may be helpful in preventing migraines.
Anti-seizure drugs. Some anti-seizure drugs, such as divalproex (Depakote) and topiramate (Topamax), and gabapentin (Neurontin), seem to reduce the frequency of migraines. In high doses, however, these anti-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 preventive measure.
Botulinum toxin type A (Botox). Botulinum toxin type A is sometimes used for treatment of chronic migraines. Studies have had mixed results with respect to effectiveness. However, some headache specialists believe that it can be helpful for some people. Injections are made in muscles of the forehead and neck. When this is effective, the treatment typically needs to be repeated every three months.
A migraine headache is a form of vascular headache. Migraine headache is caused by vasodilatation (enlargement of blood vessels) that causes the release of chemicals from nerve fibers that coil around the large arteries of the brain. Enlargement of these blood vessels stretches the nerves that coil around them and causes the nerves to release chemicals. The chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the arteries magnifies the pain.
Migraine attacks commonly activate the sympathetic nervous system in the body. The sympathetic nervous system is often thought of as the part of the nervous system that controls primitive responses to stress and pain, the so-called "fight or flight" response, and this activation causes many of the symptoms associated with migraine attacks; for example, the increased sympathetic nervous activity in the intestine causes nausea, vomiting, and diarrhea.
Sympathetic activity also delays emptying of the stomach into the small intestine and thereby prevents oral medications from entering the intestine and being absorbed.
The impaired absorption of oral medications is a common reason for the ineffectiveness of medications taken to treat migraine headaches.
The increased sympathetic activity also decreases the circulation of blood, and this leads to pallor of the skin as well as cold hands and feet.
The increased sympathetic activity also contributes to the sensitivity to light and sound sensitivity as well as blurred vision.
Migraine afflicts 28 million Americans, with females suffering more frequently (17%) than males (6%). Missed work and lost productivity from migraine create a significant public burden. Nevertheless, migraine still remains largely underdiagnosed and undertreated. Less than half of individuals with migraine are diagnosed by their doctors.
What are the symptoms of migraine headaches?
Migraine is a chronic condition with recurrent attacks. Most (but not all) migraine attacks are associated with headaches.
Migraine headaches usually are described as an intense, throbbing or pounding pain that involves one temple. (Sometimes the pain is located in the forehead, around the eye, or at the back of the head).
The pain usually is unilateral (on one side of the head), although about a third of the time the pain is bilateral (on both sides of the head).
The unilateral headaches typically change sides from one attack to the next. (In fact, unilateral headaches that always occur on the same side should alert the doctor to consider a secondary headache, for example, one caused by a brain tumor).
A migraine headache usually is aggravated by daily activities such as walking upstairs.
Nausea, vomiting, diarrhea, facial pallor, cold hands, cold feet, and sensitivity to light and sound commonly accompany migraine headaches. As a result of this sensitivity to light and sound, migraine sufferers usually prefer to lie in a quiet, dark room during an attack. A typical attack lasts between 4 and 72 hours.
An estimated 40%-60% of migraine attacks are preceded by premonitory (warning) symptoms lasting hours to days. The symptoms may include:
sleepiness,
irritability,
fatigue,
depression or euphoria,
yawning, and
cravings for sweet or salty foods.
Patients and their family members usually know that when they observe these warning symptoms that a migraine attack is beginning.
Causes:
Although much about the cause of migraines isn't understood, genetics and environmental factors seem to both play a role.
Migraines may be caused by changes in the trigeminal nerve, a major pain pathway. Imbalances in brain chemicals, including serotonin — which helps regulate pain in your nervous system — also may be involved.
Serotonin levels drop during migraines. This may trigger your trigeminal system to release substances called neuropeptides, which travel to your brain's outer covering (meninges). The result is headache pain.
Migraine triggers
Whatever the exact mechanism of the headaches, a number of things may trigger them. Common migraine triggers include:
Hormonal changes in women. Fluctuations in estrogen seem to trigger headaches in many women with known migraines. Women with a history of migraines often report headaches immediately before or during their periods, when they have a major drop in estrogen. Others have an increased tendency to develop migraines during pregnancy or menopause. Hormonal medications — such as oral contraceptives and hormone replacement therapy — also may worsen migraines, though some women find it's beneficial to take them.
Foods. Some migraines appear to be triggered by certain foods. Common offenders include alcohol, especially beer and red wine; aged cheeses; chocolate; aspartame; overuse of caffeine; monosodium glutamate — a key ingredient in some Asian foods; salty foods; and processed foods. Skipping meals or fasting also can trigger migraines.
Stress. Stress at work or home can instigate migraines.
Sensory stimuli. Bright lights and sun glare can produce migraines, as can loud sounds. Unusual smells — including pleasant scents, such as perfume, and unpleasant odors, such as paint thinner and secondhand smoke, can also trigger migraines.
Changes in wake-sleep pattern. Either missing sleep or getting too much sleep may serve as a trigger for migraine attacks in some individuals, as can jet lag.
Physical factors. Intense physical exertion, including sexual activity, may provoke migraines.
Changes in the environment. A change of weather or barometric pressure can prompt a migraine.
Medications. Certain medications can aggravate migraines.
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 physical exam. But if your headaches are unusual, severe or sudden, your doctor may recommend a variety of tests to rule out other possible causes for your pain.
Computerized tomography (CT). This imaging procedure uses a series of computer-directed 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 causing your headaches.
Magnetic resonance imaging (MRI). MRIs use radio waves and a powerful magnet to produce very detailed cross-sectional views of your brain. MRI scans help doctors diagnose tumors, strokes, aneurysms, neurological diseases and other brain abnormalities. An MRI can also be used to examine the blood vessels that supply the brain.
Spinal tap (lumbar puncture). If your doctor suspects an underlying condition, such as meningitis — an inflammation of the membranes (meninges) and cerebrospinal fluid surrounding your brain and spinal cord — he or she may recommend a spinal tap (lumbar puncture). 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 analysis.
Treatments and drugs
A variety of drugs have been specifically designed to treat migraines. In addition, some drugs commonly used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:
Pain-relieving medications. Also known as acute or abortive treatment, these types 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 migraines.
Choosing a strategy to manage your migraines depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions.
Some medications aren't recommended if you're pregnant or breast-feeding. Some aren't used for children. Your doctor can help 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 migraine. It may help if you rest or sleep in a dark room after taking them:
Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibuprofen (Advil, Motrin, others) or aspirin, may help relieve mild migraines. Drugs marketed specifically for migraine, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraines but aren't effective alone for severe migraines. If taken too often or for long periods of time, NSAIDs can lead to ulcers, gastrointestinal bleeding and rebound headaches.
Triptans. For many people with severe migraine attacks, triptans are the drug of choice. They are effective in relieving the pain, nausea and sensitivity to light and sound that are associated with migraines. Medications include sumatriptan (Imitrex), rizatriptan (Maxalt), naratriptan (Amerge), zolmitriptan (Zomig), almotriptan (Axert), frovatriptan (Frova) and eletriptan (Relpax). Side effects of triptans include nausea, dizziness and muscle weakness. They aren't recommended for people at risk for strokes and heart attacks. A new, single-tablet combination of sumatriptan and naproxen sodium (Treximet) became available in 2008. It's more effective in relieving migraine symptoms than either medication on its own.
Ergot. Ergotamine (Migergot, Cafergot) is much less expensive, but also less effective, than triptans. It seems most effective in those whose pain lasts for more than 48 hours. Dihydroergotamine (Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine.
Anti-nausea medications. Because migraine attacks are often accompanied by nausea with or without vomiting, medication for nausea is appropriate and is usually combined with other medications. Frequently prescribed medications are metoclopramide (oral) or prochlorperazine (oral or suppository).
Butalbital combinations. Medications that combine the sedative butalbital with aspirin or acetaminophen (Butapap, Phrenlin Forte) are sometimes used to treat migraine attacks. Some combinations also include caffeine or codeine (Esgic-Plus, Fioricet). These medications, however, have a high risk of rebound headaches and withdrawal symptoms so should be used infrequently.
Opiates. Medications containing narcotics, particularly codeine, are sometimes used to treat migraine pain when people can't take triptans or ergot. Narcotics are habit-forming and are usually used only as a last resort.
Preventive medications
Nearly half of those who get migraines could benefit from preventative medication, yet only about 1 in 10 people take it. You may be a candidate for preventive therapy if you have two or more debilitating attacks a month, if pain-relieving medications aren't helping, or if your migraine signs and symptoms include a prolonged aura or numbness and weakness.
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 menstruation, is approaching.
In most cases, preventive medications don't eliminate headaches completely, and some cause serious side effects. If you have had good results from preventative medicine and have been migraine-free for six months to a year, your doctor may recommend tapering off the medication to see if your migraines return without it.
For best results, take these medications as your doctor recommends:
Cardiovascular drugs. Beta blockers — commonly used to treat high blood pressure and coronary artery disease — can reduce the frequency and severity of migraines. These drugs are considered among first-line treatment agents. Calcium channel blockers, another class of cardiovascular drugs, especially verapamil (Calan, Isoptin), also may be helpful in preventing migraines and relieving symptoms from aura. In addition, the antihypertensive medications lisinopril (Prinivil, Zestril) and candesartan (Atacand) are useful in reducing the length and severity of migraines. 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 to prevent some types of headaches, including migraines. Most effective are tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and protriptyline (Vivactil). These medications are considered among first-line treatment agents and may reduce migraines by affecting the level of serotonin and other brain chemicals. You don't have to have depression to benefit from these drugs. Other classes of antidepressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), haven't been proven as effective for migraine prevention. However, preliminary research suggests that one SNRI, venlafaxine (Effexor), may be helpful in preventing migraines.
Anti-seizure drugs. Some anti-seizure drugs, such as divalproex (Depakote) and topiramate (Topamax), and gabapentin (Neurontin), seem to reduce the frequency of migraines. In high doses, however, these anti-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 preventive measure.
Botulinum toxin type A (Botox). Botulinum toxin type A is sometimes used for treatment of chronic migraines. Studies have had mixed results with respect to effectiveness. However, some headache specialists believe that it can be helpful for some people. Injections are made in muscles of the forehead and neck. When this is effective, the treatment typically needs to be repeated every three months.
