Article updated and reviewed by Peter B. Kang, MD, Assistant in Neurology, Children's Hospital Boston, and Instructor in Neurology, Harvard Medical School, Boston, MA on March 30, 2005.
A migraine is a specific and common form of headache that has been known since antiquity. It has traditionally been classified as a vascular headache due to the belief that it is due to abnormal changes in blood vessel tone, although the mechanism now appears to be more complicated than that.
Migraines affect approximately 28 million people in the United States, roughly 75 percent of them women. The headaches typically begin in adolescence or early adulthood, but onset may be earlier or later in some cases. There is clustering in families, suggesting a genetic component.
The older model of migraine development suggested that it begins with the release of serotonin, an important neurotransmitter. When serotonin is released, the blood vessels constrict (narrow). This is followed by a reactive dilation (expansion) of blood vessels that is the direct cause of pain. A more current model suggests that when the visual aura is present, it is caused by changes in blood flow patterns in the brain and cortical spreading depression (CSD), which refers to decreased activity on the surface of the brain. The headache portion of the migraine is caused by a complex process involving, blood vessel dilation, decreased cerebral blood flow, and abnormal activity of the trigeminal nerve causing local inflammation. Evidence also suggests that pain control centers in the brainstem may be dysfunctional in migraine patients.
There are two predominant types of migraines - common migraine and classic migraine. Both typically last four to 72 hours. There may be a combination of one or more of the following phases: prodromal, aura, headache, and resolution. There are rare variants in which an aura occurs, but not a headache.
The common migraine is one that does not involve an aura.
The classic migraine is one that involves an aura.
During the prodrome stage, the person may feel fatigued, irritable, have decreased concentration or experience depression. This stage will develop about 24 hours prior to the aura stage.
The aura may involve visual, sensory, or motor phenomena. The visual aura is typically a slowly expanding area of blindness surrounded by a sparkling edge that increases to involve up to one half of the field of vision of each eye. Visual auras may also involve flashing lights, colors or zig-zags of light. The sensory aura may include a prickly or burning sensation. The motor aura typically involves muscle weakness on one side of the body.
The headache itself is usually a severe throbbing pain on one side of the head that is often exaggerated by bright light or noise and may be accompanied by nausea, vomiting, and anorexia. Occasionally the pain occurs on both sides of the head. The headache is often relieved by sleep.
The fourth stage is resolution, which is characterized by exhaustion and fatigue.
The other types of migraines are: hemiplegic migraine, which involves muscle weakness or partial paralysis lasting less than an hour; ophthalmoplegic migraine, which involves temporary eye dysfunction, such as droopy eyelid or pupillary changes, lasting from several days to weeks; basilar artery migraine, which involves neurological spasm lasting for about six to eight hours; and status migranosus; which involves a severe migraine attack, lasting longer than 24 hours.
A migraine can be triggered by a number of factors. These factors can be stress-related (such as anger, depression, shock, excitement, or changes in routine), food-related (such as chocolate, cheese, red wine, or fried foods), or sensory-related (such as bright lights, strong odors, or loud noises).
Additionally, migraines can be medication-related (medicines including nitroglycerin, lithium, and certain anti-hypertensive, anti-inflammatory, and bronchodilating drugs), or hormone-related (such as menstrual periods, hormonal treatments, or birth control pills).
Patients often have a family history of migraine.
The symptoms of a migraine may include:
- Throbbing or dull aching pain on one or both sides of the head
- Changes in how a person sees, including blurred vision or blind spots, zig-zags of light or light flashes
- Sensitivity to light, noise and odors
- Nasal congestion
- Feeling cold or sweating
- Stiff or tender neck
- Anxious or restlessness
- Tender scalp
- Cold hands and feet
No tests are available to reliably diagnose a migraine. The doctor will make a determination, based on a physical examination and a thorough medical history, including triggers, symptoms and family history.
Treatment of migraines is directed at preventing attacks (prophylactic or preventive therapy) and alleviating them when they occur (abortive therapy).
Prophylactic therapy includes:
- eliminating the controllable triggers, such as chocolate or red wine
- improving the person's physical, mental and emotional health by exercising, biofeedback, relaxation techniques, rest and stress reduction
- taking medications to prevent the onset of an attack
Preventive medications are indicated when migraines occur on a regular basis. Different physicians and patients will have different thresholds for determining when migraines are occurring often enough to justify such medications. Preventive medications must be taken every day, whether there is a headache present or not. They will not be helpful if taken only when an attack strikes.
The most widely used preventive drugs are beta blockers, such as propranolol hydrochloride (Inderal), nadolol (Corgard), timolol maleate (Blocadren), atenolol (Tenormin), and metoprolol tartrate (Lopressor, Toprol-XL). Beta blockers have an indirect effect on serotonin, preventing dilation of the blood vessels and decreasing overstimulating impulses from the brain.
Another commonly used class of preventive medications consist of the tricyclic antidepressants, primarily amitriptyline (Elavil) and nortriptyline (Pamelor). Newer antidepressants, including the selective serotonin reuptake inhibitors fluoxetine (Prozac) and sertraline (Zoloft), have also been used to a lesser extent.
A third class of preventive medications includes calcium channel blockers, , such as verapamil and diltiazem hydrochloride (Cardizem).
These medications are only available by prescription. Side effects and precautions should be discussed with a physician.
Once the migraine has set in, there are two methods of reducing the pain: non-drug and drug-based methods. The non-drug methods include:
- • sleep, which will often relieve the headache
- massage or acupuncture
The drug-based treatment includes analgesics such as aspirin, acetaminophen (Tylenol), ibuprofen (Advil, Motrin), naproxen (Naprosyn), naproxen sodium (Anaprox), and ketorolac (Toradol). In many cases of mild migraine, acetaminophen or ibuprofen plus sleep will be enough to stop the headache. Prescription medications are not always needed.
The serotonin receptor agonists (“triptans”) include almotriptan (Axert), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig). These can be very effective in certain patients. They should not be used in basilar, hemiplegic, and ophthalmoplegic migraine due to potentially serious side effects.
Ergot derivatives are older medications that are today usually used only for severe intractable headaches.
The prescription medications may have serious side effects, which should be discussed with a physician prior to treatment. There is a limit to how frequently they may be used in any given period. If this limit becomes a problem, preventive medications should be considered.
What type of migraine is it?
What type of migraine is it?
Is this a symptom of another condition(s)?
What can be done to prevent a reoccurrence?
What medications can be taken to relieve the pain?
What are the side effects of the medication?
Should I keep a supply of migraine medication at home?
How long before the pain subsides?
Are there things that should be avoided (such as food, bright lights, exercise, etc.)?
Editorial review provided by VeriMed Healthcare Network.