Migraine Headaches

What’s a migraine? What does a migraine feel like?

A migraine is a common neurological disease that causes a variety of symptoms, most notably a throbbing, pulsing headache on one side of your head. Your migraine will likely get worse with physical activity, lights, sounds or smells. It may last at least four hours or even days. About 12% of Americans have this genetic disorder. Research shows that it’s the sixth most disabling disease in the world.

What are the types of headaches? What type of headache is a migraine?

There are over 150 types of headaches, divided into two categories: primary headaches and secondary headaches. A migraine is a primary headache, meaning that it isn’t caused by a different medical condition. Primary headache disorders are clinical diagnoses, meaning there’s no blood test or imaging study to diagnose it. A secondary headache is a symptom of another health issue.

What is an aura?

An aura is a group of sensory, motor and speech symptoms that usually act like warning signals that a migraine headache is about to begin. Commonly misinterpreted as a seizure or stroke, it typically happens before the headache pain, but can sometimes appear during or even after. An aura can last from 10 to 60 minutes. About 15% to 20% of people who experience migraines have auras.

Aura symptoms are reversible, meaning that they can be stopped/healed. An aura produces symptoms that may include:

• Seeing bright flashing dots, sparkles, or lights.
• Blind spots in your vision.
• Numb or tingling skin.
• Speech changes.
• Ringing in your ears (tinnitus).
• Temporary vision loss.
• Seeing wavy or jagged lines.
• Changes in smell or taste.
• A “funny” feeling.

What are the types of migraines?

There are several types of migraines, and the same type may go by different names:

• Migraine with aura (complicated migraine): Around 15% to 20% of people with migraine headaches experience an aura.
• Migraine without aura (common migraine): This type of migraine headache strikes without the warning an aura may give you. The symptoms are the same, but that phase doesn’t happen.
• Migraine without head pain: “Silent migraine” or “acephalgic migraine,” as this type is also known as, includes the aura symptom but not the headache that typically follows.
• Hemiplegic migraine: You'll have temporary paralysis (hemiplegia) or neurological or sensory changes on one side of your body. The onset of the headache may be associated with temporary numbness, extreme weakness on one side of your body, a tingling sensation, a loss of sensation and dizziness or vision changes. Sometimes it includes head pain and sometimes it doesn’t.
• Retinal migraine (ocular migraine): You may notice temporary, partial or complete loss of vision in one of your eyes, along with a dull ache behind the eye that may spread to the rest of your head. That vision loss may last a minute, or as long as months. You should always report a retinal migraine to a healthcare provider because it could be a sign of a more serious issue.
• Chronic migraine: A chronic migraine is when a migraine occurs at least 15 days per month. The symptoms may change frequently, and so may the severity of the pain. Those who get chronic migraines might be using headache pain medications more than 10 to 15 days a month and that, unfortunately, can lead to headaches that happen even more frequently.
• Migraine with brainstem aura. With this migraine, you'll have vertigo, slurred speech, double vision or loss of balance, which occur before the headache. The headache pain may affect the back of your head. These symptoms usually occur suddenly and can be associated with the inability to speak properly, ringing in the ears and vomiting.
• Status migrainosus. This is a rare and severe type of migraine that can last longer than 72 hours. The headache pain and nausea can be extremely bad. Certain medications, or medication withdrawal, can cause you to have this type of migraine.

What are the four stages or phases of a migraine? What’s the timeline?

The four stages in chronological order are the prodrome (pre-monitory), aura, headache and postdrome. About 30% of people experience symptoms before their headache starts.

The phases are:

1. Prodrome: The first stage lasts a few hours, or it can last days. You may or may not experience it as it may not happen every time. Some know it as the “preheadache” or “premonitory” phase.
2. Aura: The aura phase can last as long as 60 minutes or as little as five. Most people don’t experience an aura, and some have both the aura and the headache at the same time.
3. Headache: About four hours to 72 hours is how long the headache lasts. The word “ache” doesn’t do the pain justice because sometimes it’s mild, but usually, it’s described as drilling, throbbing or you may feel the sensation of an icepick in your head. Typically it starts on one side of your head and then spreads to the other side.
4. Postdrome: The postdrome stage goes on for a day or two. It’s often called a migraine “hangover” and 80% of those who have migraines experience it.

It can take about eight to 72 hours to go through the four stages.

How common are migraine headaches?

Experts estimate that nearly half of the adult population experiences headaches and 12% of Americans get migraine headaches. Women are about three times more likely than men to experience migraines.

Who gets migraines? What are the risk factors?

It’s difficult to predict who may get a migraine and who may not, but there are risk factors that may make you more vulnerable. These risk factors include:

• Genetics: Up to 80% of people who get migraine headaches have a first-degree relative with the disease.
• Gender. Migraine headaches happen to women more than men, especially women between the ages of 15 and 55. It’s likely more common in women because of the influence of hormones.
• Stress level. You may get migraines more often if you’re high-stress. Stress can trigger a migraine.
• Smoking.

How often do migraines happen?

The frequency of a migraine could be once a year, once a week or any amount of time in between. Having two to four migraine headaches per month is the most common.

Are migraines hereditary?

Migraines tend to run in families. As many as four out of five people with migraines have a family history. If one parent has a history of migraines, their child has a 50% chance of having them. If both parents have a history of migraines, the risk jumps to 75%. Again, up to 80% of people with migraines have a first-degree relative with the disease.

Can children get migraines?

Yes, but pediatric migraines are often shorter and there are more stomach symptoms.

Who should I see about my migraine pain?

Discuss your symptoms with your primary care provider first. They can diagnose migraine headaches and start treatment. You may require a referral to a headache specialist.

Do migraines cause permanent brain damage? If I have migraines, does that mean I’ll get another disease?

No. Migraines don’t cause brain damage.

There is a tiny risk of stroke in people who get migraines with aura – 1 or 2 people out of 100,000.

What are the symptoms of migraines?

The primary symptom of migraine is a headache. Pain is sometimes described as pounding or throbbing. It can begin as a dull ache that develops into pulsing pain that is mild, moderate or severe. If left untreated, your headache pain will become moderate to severe. Pain can shift from one side of your head to the other, or it can affect the front of your head, the back of your head or feel like it’s affecting your whole head. Some people feel pain around their eye or temple, and sometimes in their face, sinuses, jaw or neck.

Other symptoms of migraine headaches include:

• Sensitivity to light, noise and odors.
• Nausea and vomiting, upset stomach and abdominal pain.
• Loss of appetite.
• Feeling very warm (sweating) or cold (chills).
• Pale skin color (pallor).
• Feeling tired.
• Dizziness and blurred vision.
• Tender scalp.
• Diarrhea (rare).
• Fever (rare).

Most migraines last about four hours, although severe ones can last much longer.

Each phase of the migraine attack can come with different symptoms:

Prodrome symptoms:

• Problems concentrating.
• Irritability and/or depression.
• Difficulty speaking and reading.
• Difficulty sleeping. Yawning.
• Nausea.
• Fatigue.
• Sensitivity to light and sound.
• Food cravings.
• Increased urination.
• Muscle stiffness.

Aura symptoms:

• Numbness and tingling.
• Visual disturbances. You might be seeing the world as if through a kaleidoscope, have blurry spots or see sparkles or lines.
• Temporary loss of sight.
• Weakness on one side of the body.
• Speech changes.

Headache symptoms:

• Neck pain, stiffness.
• Depression, giddiness and/or anxiety.
• Sensitivity to light, smell and sound.
• Nasal congestion.
• Insomnia.
• Nausea and vomiting.

Postdrome symptoms:

• Inability to concentrate.
• Depressed mood.
• Fatigue.
• Lack of comprehension.
• Euphoric mood.

What causes a migraine?

The cause of migraine headaches is complicated and not fully understood. When you have a headache it’s because specific nerves in your blood vessels send pain signals to your brain. This releases inflammatory substances into the nerves and blood vessels of your head. It’s unclear why your nerves do that.

What triggers a migraine?

Migraine attacks can be triggered by a variety of factors. Common triggers include:

• Emotional stress. Emotional stress is one of the most common triggers of migraine headaches. During stressful events, certain chemicals in the brain are released to combat the situation (known as the "flight or fight" response). The release of these chemicals can bring on a migraine. Other emotions like anxiety, worry and excitement can increase muscle tension and dilate blood vessels. That can make your migraine more severe.
• Missing a meal. Delaying a meal might also trigger your migraine headache.
• Sensitivity to specific chemicals and preservatives in foods. Certain foods and beverages such as aged cheese, beverages containing alcohol, chocolate and food additives such as nitrates (found in pepperoni, hot dogs and luncheon meats) and fermented or pickled foods may be responsible for triggering up to 30% of migraines.
• Caffeine. Having too much caffeine or withdrawal from caffeine can cause headaches when the caffeine level abruptly drops. Your blood vessels seem to become sensitized to caffeine and when you don't get it, a headache may occur. Caffeine is sometimes recommended by healthcare providers to help with treating acute migraine attacks but should not be used frequently.
• Daily use of pain-relieving medications. If you use medicine meant to relieve headache pain too often, that can cause a rebound headache.
• Hormonal changes in women. Migraines in women are more common around the time of their menstrual periods. The abrupt drop in estrogen that triggers menses can also trigger migraines. Hormonal changes can also be brought on by birth control pills and hormone replacement therapy. Migraines are generally worse between puberty andmenopause since these estrogen fluctuations generally don’t occur in young girls and post-menopausal women. If your hormones are a strong factor in your migraines, you may have fewer headaches after menopause. Hormonal changes do not appear to trigger migraines in men.
• Light. Flashing lights, fluorescent lights, light from the TV or computer and sunlight can trigger you.

Other possible triggers include:

• Changing weather conditions such as storm fronts, barometric pressure changes, strong winds or changes in altitude.
• Being overly tired. Overexertion.
• Dieting, or not drinking enough water.
• Changes in your normal sleep pattern.
• Loud noises.
• Exposure to smoke, perfumes or other odors.
• Certain medications cause blood vessels to swell.

What’s a migraine journal?

• Keeping a migraine journal is not only beneficial to you, but it helps your healthcare provider with the diagnosis process. Your journal should be detailed and updated as much as possible before, during and after a migraine attack. Consider keeping track of the following:
• The date and time of when the migraine began – specifically when the prodrome started, if you’re able to tell it’s happening. Track time passing. When did the aura phase begin? The headache? The postdrome? Do your best to tell what stage you’re in and how long it lasts. If there’s a pattern, that may help you anticipate what will happen in the future.
• What are your symptoms? Be specific.
• Note how many hours of sleep you got the night before it happened and your stress level. What’s causing your stress?
• Note the weather.
• Log your food and water intake. Did you eat something that triggered the migraine? Did you miss a meal?
• Describe the type of pain and rate it on a one to 10 scale with 10 being the worst pain you’ve ever experienced.
• Where is the pain located? One side of your head? Your jaw? Your eye?
• List all of the medications you took. This includes any daily prescriptions, any supplements and any pain medication you took.
• How did you try to treat your migraine, and did it work? What medicine did you take, at what dosage, at what time?
• Consider other triggers. Maybe you played basketball in the sunlight? Maybe you watched a movie that had flashing lights? If you’re a woman, are you on your period?

There are some smartphone apps you can use to keep a migraine journal if you don’t want to use pen and paper.

How are migraines diagnosed?

To diagnose a migraine, your healthcare provider will get a thorough medical history, not just your history of headaches but your family’s, too. Also, they'll want to establish a history of your migraine-related symptoms, likely asking you to:

• Describe your headache symptoms. How severe are they?
• Remember when you get them. During your period, for example?
• Describe the type and location of your pain. Is the pain pounding? Pulsing? Throbbing?
• Remember if anything makes your headache better or worse.
• Tell how often you get migraine headaches.
• Talk about the activities, foods, stressors or the situations that may have brought on the migraine.
• Discuss what medications you take to relieve the pain and how often you take them.
• Tell how you felt before, during and after the headache.
• Remember if anyone in your family gets migraine headaches.

Your healthcare provider may also order blood tests and imaging tests (such as a CT scan or a MRI) to make sure there are no other causes for your headache. An electroencephalogram (EEG) may be ordered to rule out seizures.

What symptoms must you have to be diagnosed with a migraine?

Migraine with aura (complicated migraine). This is a headache, plus:

• Visual symptoms (seeing spots, sparkles, or lines) or vision loss.
• Sensory symptoms (feeling pins and needles, for example).

Migraine without aura (common migraine). A common migraine is a headache and:

• The attacks included pain on one side of your head.
• You’ve had at least five attacks, each lasting between four and 72 hours.

Plus, you’ve experienced at least one of the following:

• Nausea and/or vomiting.
• Lights bother you and/or you avoid light.
• Sounds bother you and/or you avoid sounds.

Are migraines misdiagnosed?

Sometimes you or your healthcare provider may assume that the pain you’re feeling is a sinus headache or a tension-type headache. Show your healthcare provider your migraine journal so that they can learn about your unique situation.

How are migraines treated?

Migraine headaches are chronic. They can’t be cured, but they can be managed and possibly improved. There are two main treatment approaches that use medications: abortive and preventive.

• Abortive medications are most effective when you use them at the first sign of a migraine. Take them while the pain is mild. By possibly stopping the headache process, abortive medications help stop or decrease your migraine symptoms, including pain, nausea, light sensitivity, etc. Some abortive medications work by constricting your blood vessels, bringing them back to normal and relieving the throbbing pain.
• Preventive (prophylactic) medications may be prescribed when your headaches are severe, occur more than four times a month and are significantly interfering with your normal activities. Preventive medications reduce the frequency and severity of the headaches. Medications are generally taken on a regular, daily basis to help prevent migraines.

What medications are used to relieve migraine pain?

Over-the-counter medications are effective for some people with mild to moderate migraines. The main ingredients in pain relieving medications are ibuprofen, aspirin, acetaminophen, naproxen and caffeine.

Three over-the-counter products approved by the Food and Drug Administration for migraine headaches are:

• Excedrin® Migraine.
• Advil® Migraine.
• Motrin® Migraine Pain.

Be cautious when taking over-the-counter pain relieving medications. Sometimes overusing them can cause analgesic-rebound headaches or a dependency problem. If you're taking any over-the-counter pain medications more than two to three times a week, report that to your healthcare provider. They may suggest prescription medications that may be more effective.

Prescription drugs for migraine headaches include:

Triptan class of drugs (these are abortives):

• Sumatriptan.
• Zolmitriptan.
• Naratriptan.

Calcium channel blockers:

• Verapamil.

Calcitonin gene-related (CGRP) monoclonal antibodies:

• Erenumab.
• Fremanezumab.
• Galcanezumab.
• Eptinezumab.

Beta blockers:

• Atenolol.
• Propranolol.
• Nadolol.

Antidepressants:

• Amitriptyline.
• Nortriptyline.
• Doxepin.
• Venlafaxine.
• Duloxetine.

Antiseizure drugs:

• Valproic acid.
• Topiramate.

Other:

• Steroids.
• Phenothiazines.
• Corticosteroids.

Your healthcare provider might recommend vitamins, minerals, or herbs, including:

• Riboflavin (vitamin B2).
• Magnesium.
• Feverfew.
• Butterbur.
• Co-enzyme Q10.

Drugs to relieve migraine pain come in a variety of formulations including pills, tablets, injections, suppositories and nasal sprays. You and your healthcare provider will discuss the specific medication, combination of medications and formulations to best meet your unique headache pain.

Drugs to relieve nausea are also prescribed, if needed.

All medications should be used under the direction of a headache specialist or healthcare provider familiar with migraine therapy. As with any medication, it's important to carefully follow the label instructions and your healthcare provider’s advice.

Alternative migraine management methods, also known as home remedies, include:

• Resting in a dark, quiet, cool room.
• Applying a cold compress or washcloth to your forehead or behind your neck. (Some people prefer heat.)
• Massaging your scalp.
• Yoga.
• Applying pressure to your temples in a circular motion.
• Keeping yourself in a calm state. Meditating.
• Biofeedback.

What’s biofeedback?

Biofeedback is the use of special equipment strapped to your head. The equipment measures the physical tension in your body and alerts you when you need to control your stress, which changes the physical processes related to stress. You won’t have to use the equipment forever because you’ll learn how to detect the tension on your own. The device works on children as well as adults.

Are there surgical procedures that relieve migraines?

Surgical treatments are not generally recommended for migraine headaches.

What are the treatment options for migraine headaches during pregnancy?

Avoid medications for migraines when you’re pregnant, or if you think you may be pregnant. They can negatively affect your baby. With your healthcare provider’s permission, you may be able to take a mild pain reliever like acetaminophen.

Can migraine headaches be prevented?

There is no cure for migraine headaches, but you can take an active role in managing them, maybe reducing how often you get them and possibly controlling how severe they are by following these tips:

• Keep a migraine diary. Take notes about any foods and other triggers that you think may have caused you to develop a migraine. Make changes in your diet and avoid those triggers as much as possible.
• Get a prescription for CGRP monoclonal antibodies. This injection was created specifically to help with migraines.
• Get seven to nine hours of sleep a night.
• Eat at regular intervals. Don't skip meals. Drink plenty of water.
• Exercise regularly and maintain a healthy weight.
• Learn techniques tocontrol stress such as meditation, yoga, relaxation training, or mindful breathing.
• Take medications as directed by your healthcare provider. Preventative medications include antidepressants, anti-seizure medications, calcitonin gene-related peptides, medicines that lower blood pressure and Botox injections. You might be prescribed timolol, amitriptyline, topiramate and divalproex sodium. Notice that some of the same medications that can help you manage a migraine may also help prevent one.
• Talk to your healthcare provider about hormone therapy if your migraines are thought to be linked to your menstrual cycle.
• Consider trying a transcutaneous supraorbital nerve stimulation device. This battery-powered electrical stimulator device is approved by the Food and Drug Administration to prevent migraines. The device, worn like a headband or on your arm, emits electrical charges. The charge stimulates the nerve that transmits some of the pain experienced in migraine headaches. (The device may not be covered by your health insurance.)
• Get counseling from a therapist for help controlling your stress. Ask your healthcare provider for a referral.

What is the prognosis (outlook) for people with migraines?

Migraines are unique to each individual. Likewise, how migraines are managed is also unique. The best outcomes are usually achieved by learning and avoiding personal migraine triggers, managing symptoms, practicing preventive methods, following the advice of your healthcare provider and reporting any significant changes as soon as they occur.

Is there a cure for migraines?

Although there isn’t a cure, there are treatments that may help you manage the symptoms.

How long will I have migraine headaches?

You may experience migraine headaches for the rest of your life. If your migraines are caused by your period, you may stop having them when menopause starts.

When should I seek immediate help, or contact my healthcare provider?

Call 911 or go to an emergency department right away if:

• You are experiencing the “worst headache of my life.”
• You are having neurologic symptoms that you’ve never had before, including speaking difficulty, balance problems, vision problems, mental confusion, seizures or numbing/tingling sensations.
• Your headache comes on suddenly.
• You have a headache after experiencing a head injury.

Schedule a visit with your healthcare provider if:

• The number or severity of your headaches increase or your headache pattern changes.
• Your medications no longer seem to be working or you’re experiencing new or different side effects.

What questions should I ask my healthcare provider?

• Will my child grow out of their migraines?
• What medications do you recommend for me?
• What should I change about my lifestyle to prevent my migraine headaches?
• Should I get tested?
• What type of migraine do I have?
• What can my friends and family do to help?
• Are my migraines considered chronic?

A note from Cleveland Clinic

Migraine headaches can be devastating and make it impossible to go to work, school or experience other daily activities. Fortunately, there are some ways to possibly prevent a migraine and other ways to help you manage and endure the symptoms. Work with your healthcare provider to keep migraines from ruling your life.