Migraines

headaches, migraines, cephalgia

Interview between:

  • Amy Bruno, PhD, ANP-BC

  • Andrew Cunningham, MD

A migraine headache is a unique type of headache that causes moderate-to-severe pain, usually accompanied by other symptoms like nausea, vomiting, and light or sound sensitivity. Migraine is thought to be a complex neurological condition.

Cases Per Year (US)

It is estimated that 1 in 4 US households include someone who suffers from migraine-type headaches.

General Frequency

Approximately 18% of women, 10% of children, and 6% of men are affected by migraine headaches each year.

Risk

Genetic and hereditary characteristics along with lifestyle influences affect a person’s propensity for migraine headaches.

Context and Symptoms

How common are migraine headaches? 

The World Health Organization (WHO) has estimated that one out of every seven adults is affected by migraine, and worldwide prevalence is believed to be more than 10%. Migraines are three times more common in women than men.

What causes migraine headaches?

Migraine headaches are believed to be caused by a combination of various genetic and environmental factors. They are likely precipitated by various triggers, and sufferers are likely to have a genetically determined reduced threshold for these triggers. This means that the brain is essentially more sensitive to things like hormonal changes and exposure to certain chemicals or products. 

The proposed mechanisms that cause migraine headaches are not well understood. Changes in brain metabolism, activation of nerve networks, and the release of inflammatory chemicals are believed to cause the pain and accompanying symptoms experienced during a migraine.

What makes a migraine headache different from other headaches?

Migraines are different from other headache types because they tend to be very painful and have other associated symptoms, which are often debilitating. The term migraine headache is often misused for severe headaches of other types, but migraines are recurrent and have distinguishing features. 

Nausea, vomiting, light-or-sound sensitivity, and activity intolerance are common migraine features. They tend to be one-sided more often than tension headaches, and a sensory aura precedes or accompanies the pain for some who suffer from them. Migraines are also associated with a high degree of impairment and are the third leading cause of global disability in people under age 50.

Are migraine headaches hereditary (do they run in families)?

It is believed that migraines are likely inherited in most cases, although no clear inheritance pattern has been identified. More than half of all people who suffer from migraines report having a family member who also has been affected by these headaches. 

The common forms of migraines probably involve multiple genes plus environmental factors. Specific genes identified that are linked with these types of headaches are the KCNK18 and CSNK1D genes.

A form of migraine called “familial hemiplegic migraine (FHM)” does exist and is associated with mutations in a few specific genes. A sporadic form of hemiplegic migraine also exists. Hemiplegic migraines are rare, and symptoms involve a migraine headache and weakness on one side of the body. Individuals typically also have other neurological signs and symptoms including migraine aura, vision loss, and speech changes. 

What is meant by the term “atypical” migraines?

An atypical or “complex” migraine usually has a prolonged aura in which an individual will experience neurological symptoms. Typically, a migraine aura will last less than one hour and symptoms completely resolve during this time. 

An aura can include vision changes such as seeing colors or shapes, sensory changes, and less often, language difficulties or motor issues, like weakness to one side of the body. When someone suffers from an atypical or complex migraine, they may experience neurological symptoms like weakness or vision loss that lasts over an hour and can be confused for stroke symptoms or even a seizure. 

It is important to note that people who do experience atypical or complex migraines should be seen in person for a complete neurological examination and testing, if indicated.

What are red flag symptoms, things that when associated with a headache require urgent evaluation?

There are several symptoms that would warrant an emergeny evaluation if they occur with a headache, including fever, chills, vomiting, body aches, weight loss, and night sweats. Individuals who develop an acute headache and have a history of cancer, immune system dysfunction (including HIV), or who are pregnant or in the immediate postpartum period should be evaluated promptly. New onset headaches in individuals older than age 50 should be further investigated.

If there are neurological signs and symptoms such as weakness on one side of the body, numbness, speech or vision changes, confusion, or difficulty walking, urgent evaluation is advised. In addition, headaches that come on very suddenly and reach maximum severity in a few minutes are called thunderclap headaches and require an emergency evaluation. 

Other concerning characteristics are changes in normal headache pattern; progression in severity, frequency, or clinical features; pain that does not go away; pain that changes significantly with positional changes; and pain that increases substantially with physical exertion (exercise or sex) or valsalva maneuvers (sneezing, coughing, and/or straining).

When should someone with chronic headaches get further diagnostic testing or see a headache specialist?

If an individual experiences any of the aforementioned “red flag” symptoms or has headache features that suggest a secondary headache, imaging with a head CT or MRI may be advised. 

A consultation with a neurologist or headache specialist is recommended when headaches become very frequent or disabling, when a person experiences multiple medication failures, or when the diagnosis is not clear cut.

Prevention

What are some general lifestyle practices that will reduce the risk of getting headaches?

There are several lifestyle practices that can reduce headaches.

  • Maintain a regular sleep schedule, and go to bed and wake up at about the same time every day.

  • Exercise regularly. These tips can help.

  • Eat regular meals and do not skip meals.

  • Keep well hydrated.

  • Reduce overall stress. Try relaxation techniques, meditation, or deep breathing.

  • Keep a headache diary to monitor headache frequency, associated characteristics, and possible triggers.

Be aware of the various triggers that may increase the risk of headache onset, and actively work to reduce these as much as possible.

Treatment

How do you treat migraine headaches?

Migraine headaches are best treated with a combination of lifestyle modifications, pharmacological therapy, and non-pharmacological therapy. Pharmacological therapy includes abortive drugs, which are medications taken on an acute and as-needed basis to reduce the migraine pain and associated symptoms. 

For individuals who experience more frequent and severe migraines or who suffer from attacks that cause significant disability or reduced quality of life, migraine preventive agents are highly recommended. Preventive medications are also indicated for people who are at risk for medication-overuse headache or menstrual migraine, as well as for those who have existing contraindications to abortive therapies.

Abortive medications

Selection of acute relief medications depends on severity and prior success. Medicating a migraine early in the symptom course (in the first hour) is more likely to yield success, so it is helpful for migraine sufferers to have their medication easily available. Darkness and quiet make migraines more tolerable.

For many migraines, especially when non-severe, over-the-counter analgesics such as acetaminophen, NSAIDS, aspirin, and combination products that contain an analgesic and caffeine are an effective choice. 

If these are not effective, there are several prescription options. 

  • Triptans (ex: sumatriptan, rizatriptan): These migraine-specific agents block certain pain pathways to the brain, and they are by far the most common migraine therapy besides the over-the-counter analgesics. They are available in oral form, nasal spray, and as an injection under the skin. NSAIDs and triptans together may be superior to either alone. Multiple unique triptans sometimes need to be trialed to determine which is best for an individual. Triptans should not be used in people with a history of stroke, heart attack, or uncontrolled high blood pressure.

  • Antiemetic medications (ex. metoclopramide): For people who have significant nausea and/or vomiting with their migraines, these medications can not only help reduce those symptoms, but also lessen the pain associated with the headache. 

  • Dihydroergotamines (ex. DHE): These are available in an injection or nasal spray and work best for acute migraines when given with an antiemetic. People with coronary artery disease or a history of stroke, heart attack, uncontrolled high blood pressure, or kidney and liver disease should not use this class of medications.

  • Lasmitidan and ubrogepant: Lasmitidan belongs to a newer class and binds to a specific serotonin receptor. This kind of medication can be safely used in individuals with a history of cardiovascular disease. Ubrogepant is a novel oral medication approved for acute migraine with or without aura. It is a calcitonin gene-related peptide (CGRP) antagonist. CGRP is believed to be a chemical that is associated with pain during a migraine headache. 

  • Opioid and barbiturate medications: Narcotic pain medication such as oxycodone or hydrocodone and medications that contain butalbital (ex: Fioricet™) should not be used in the management of acute migraines. Most research has shown these agents are not very effective. There is also potential for medication abuse and these drugs can lead to medication overuse headaches.

How can migraine headaches be prevented or reduced?

There are a variety of pharmacological and nonpharmacological therapies that can be effective for reducing headaches. It is important to understand that no single therapy can effectively prevent migraine headaches completely, although a combination of approaches can significantly reduce frequency, severity, and improve quality of life.

What are some common foods or dietary ingredients that may trigger migraines for some people?

There are several foods and dietary ingredients that are believed to be migraine triggers, and this is very individualized. The following may trigger migraines in certain people:

  • Caffeine

  • Alcohol

  • Chocolate

  • Aged cheeses

  • Food preservatives such as:

    • Artificial sweeteners like aspartame

    • Nitrites (found in some preserved meats)

    • Monosodium glutamate (MSG)

    • Tyramine (found in red wine and certain cheeses)

  • Dehydration and skipping meals may also trigger migraines in some people.

Do hormonal changes trigger migraines in women?

The hormonal changes surrounding a woman’s menstrual cycle are a big migraine trigger in many women. This is due largely to the hormone estrogen. Levels of this hormone drop right before a woman’s period begins, and this change can cause a migraine attack. 

Women are advised to monitor when their migraines are occurring, because if there is an identifiable clear pattern associated with the menstrual cycle, there are specific treatments recommended for menstrual migraines.

Pharmacological Options for Migraine Prevention:

Prescription Drugs:

The variety of medication classes that have been shown to reduce frequency of migraine recurrences reflects current understanding that migraine causes are multifactorial in origin. Preventive daily medications are selected based on comorbidities, side effect profiles, and experience of the patient and prescriber. Classes considered here include antihypertensives (blood pressure medicines), antidepressants, anticonvulsants (medicines used to prevent seizures), botox injections, and CGRP antagonists. 

Supplements and herbs:

  • Butterbur: An extract from butterbur called Petadolex has some quality evidence favoring its preventive effect in a subset of migraine sufferers. It’s important to note that some preparations of this herb may contain  compounds that are linked to liver damage, so a reputable supplier is essential if this botanical is taken long-term.

  • Feverfew: While this may still be recommended, evidence is lacking that this is really an effective migraine preventative.

  • Magnesium: A few studies have shown magnesium supplementation to be effective as a migraine prophylaxis agent. Diarrhea and gastrointestinal discomfort were the most commonly reported side effects in these trials.

  • Riboflavin (vitamin B2): Studies are mixed regarding the effectiveness of this vitamin in reducing migraines. However, it is usually very well tolerated. Doses of 400 mg daily were found to improve headaches in some of these studies.

  • Melatonin: One study found that 3 mg of melatonin in immediate release formulation was more effective than placebo in reducing migraines.

Non-pharmacological therapies:

There are several non-drug options to decrease migraines. These include regular exercise, biofeedback, relaxation techniques, cognitive behavioral therapy, acupuncture, and stress reduction. One study found transcutaneous supraorbital nerve stimulation (t-SNS) to be an effective and well-tolerated treatment for migraines.

Connect with our physicians

Amy Bruno, PhD, ANP-BC and Andrew Cunningham, MD are both members of the Galileo Clinical Team. Connect with one of our physicians about Migraines or any of the many other conditions we treat.

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