Medical experts aren’t sure what exactly causes migraines, but they do know that this neurological disorder involves way more than headaches. They also know that this chronic condition affects 39 million Americans—adults and children—and that it’s inherited, too. So if you have migraines, thank your dad or, most likely, your mom for passing on a brain that’s sensitive to the internal and external stimuli that’s involved in a migraine attack.
We went to some of the nation’s top experts in migraines to bring you the most up-to-date information possible.
Marius Birlea, M.D.Assistant Professor of Neurology; Director, Headache Fellowship
Joel R. Saper, M.D.Director
Stewart J. Tepper, M.D.Professor of Neurology
What Happens During a Migraine, Again?
Well, there are three distinct stages, and the first phase can start a few hours or even a couple of days before, in what’s known as the prodrome phase. You might feel more tired than usual or get cravings for sweet or salty foods. During the actual attack, nerves inside the brain start sending signals to other parts. That releases a flood of chemicals, including serotonin, glutamate, and calcitonin gene-related peptide (CGRP), which leads to inflammation in brain’s covering, called the meninges, as well as in its blood vessels, causing them to dilate. The inflammation and dilation cause the throbbing pain you feel.
With those chemicals and pathways firing, your brain amplifies all sorts of sensory information. That’s why you might start to see colors or patterns if you have a migraine with auras, feel queasy or dizzy, or become extra-sensitive to light, sound, or smells.
After the migraine is over—anywhere from four to 72 hours later—you enter the last stage, or the postdrome phase. You feel wiped out and actually brain dead, which isn’t surprising given all your body has gone through. That can last for a few hours or even several days.
This series of events can happen once a month or many times a month. If you have 14 or fewer attacks per month you have episodic migraines. More than 15 and you have chronic migraines.
Medical experts might not know exactly what sets off the chain of events in the brain, but they do know there are certain risk factors that can make people more susceptible to migraines, or make them worse.
Migraines tend to run in families, and about 80% to 90% of those who have attacks either have a first-degree relative (usually a parent) who had them or someone else in their family who got them. Those genes may influence the way the blood vessels in the brain dilate. There are other genes that regulate your levels of glutamate and serotonin, the chemicals that send messages between brain cells. If yours allow for abnormal production, you may be at higher risk.
Women are three times more likely to have migraines than men. They also tend to have more migraines that last longer and are more intensely painful than men. (Yep, totally unfair.) The culprit is estrogen—studies show that while boys and girls both have migraines at the same rate during childhood that changes when puberty hits. So what’s the deal between estrogen and migraines? Researchers know that sudden drops of the hormone can set off attacks, since many women get migraines a couple of days before their period and up to three days after it starts, which is when estrogen is at its lowest levels. Those quick drops in estrogen could be affecting the trigeminal nerve, the large nerve that carries sensations from your face to your brain, in a way that makes it more sensitive to migraine triggers, Spanish researchers speculate. Or they could be affecting serotonin and other neurotransmitter levels.
Another clue that estrogen plays a key role: If you get migraines, they tend to get better when you’re pregnant: You don’t get them as often, they’re less debilitating, or they might even disappear, at least for about 75% of women, according to the Migraine Research Foundation. The same is true when you’re breastfeeding and have gone through menopause. The connection: These are all times when your estrogen levels are relatively stable (or, in the case of menopause, nearly nonexistent).
Serotonin and Other Brain Chemicals
People with migraines tend to have abnormal levels of serotonin, but what role this neurotransmitter plays in this condition isn’t exactly clear. It could be that serotonin activates the release of CGRP, which affects the blood vessels and causes pain, or simply plays a role in activating the parts of the brain before an attack. Glutamate is another neurotransmitter that plays a role in migraines. People who have auras during migraines have trouble regulating glutamate, causing it to build up and activate the occipital cortex, the visual-processing center of the brain.
Structural Brain Changes
Women who have more frequent migraine attacks have thicker areas in their brain than women who don’t have the condition; these areas are also thicker compared to male migraineurs. These regions, like the insula and the posterior insular cortices, are the ones that process pain and sensory information, like nausea. But it’s tough to say whether there’s a cause and effect—did the areas become thicker because women had migraines and their brains adapted (the more migraines with nausea you have, the thicker the area becomes) or did the structural changes predispose women to migraines? Experts still aren’t sure.
Poor Quality Sleep
People who don’t get enough Zzz’s are at risk of having migraines and vice versa—people with migraines are up to eight times more likely to develop a disorder like insomnia or sleep apnea. One study found that half of all those who had chronic migraines had sleep apnea as did a third of people with episodic migraines.
Sleeping badly—from not being able to drift off to waking up too early or too often at night—is also a common complaint as are chaotic sleep schedules (getting too little one night, too much the next). All this can affect the number of headaches you have (the worse you sleep, the more migraines you have), and it can make the pain worse.
One reason why too little shut-eye can lead to neurological disorders: Researchers from Boston discovered that during those periods of deep dreamless sleep, the fluid in your brain and spinal cord (the cerebrospinal fluid) essentially flushes out the toxic waste in your brain, cleaning it out.
Having a high BMI may not up your risk of having migraines, but it could be making them worse. Researchers at Brown University in Providence, RI, found that 20% of severely obese patients (and 13% of obese patients) reported more migraines than those people who had a normal BMI.
Being overweight is also a risk factor when people transition from having episodic migraines to chronic ones. The connection might have something to do with inflammation—being obese increases inflammation in the body, which in turn might be making the inflammatory response when you have a migraine worse, leading to more severe and frequent attacks. Interestingly enough, obesity may only be a risk factor for women under age 55, another study found.
The Role of Triggers in Migraines
About 76% of people with migraines have triggers—typically factors in their life or the environment—that set off their attack. Triggers may stimulate temporary changes in the chemicals and areas of the brain (like the hypothalamus) that get activated during an attack. And it usually takes two or three of them to set off a migraine.
The most common ones people cite are:
stress or something bad happening
sleep (too little or too much)
smells (like perfume)
the weather (too hot or too stormy)
specific foods and drinks (such as red wine or pepperoni)
But you can have different triggers at different times of the months. For instance, you could have a glass of red wine most Friday nights and not have a migraine on Saturday, but if you’re just about to get your period that glass of red wine could do you in. Or it could be that your brain was already in its preliminary migraine phase and you would have had an attack anyway.
Sometimes it’s a good idea to keep a migraine diary to find out what your triggers are and when they occur, especially if you’re avoiding something enjoyable for fear of setting off a migraine (like trips to the beach if bright sunlight is a problem) and bring them up to a provider. It could be that preventative medications or even lifestyle changes will bring about the changes in the brain that may make these triggers less of a, well, headache.
What Are the Signs of a Migraine?
There are four phases of migraines, depending on whether you have an aura or not. The symptoms for each can overlap.
More than three-quarters of people who have migraines (77%) report symptoms for the first stage, which can be hours or days before an actual attack, according to Finnish researchers. Signs include:
Feeling tired. In one study, about 75% of patients reported feeling more exhausted than usual. Yawning more than usual is another symptom.
Having trouble focusing. About half of all patients reported this. Mood changes are another common sign (feeling more anxious or tense than usual).
Stiff neck. Again, about half of all patients reported this symptom.
Cravings for sweet or salty foods
The Aura, or Second Phase:
Only about 20% of migraine patients have auras, usually anywhere from five to 60 minutes before the pain starts. Most patients have more than one type of auras, with 96% of people reporting having one type at a time. Sometimes an aura can feel like stroke (the tingling, the numbness on one side) and having auras can increase your risk of having one. If you do have an aura for the first time, let your provider know so you can get checked out to rule out the possibility. Signs of aura include:
Seeing things. About 99% have what’s called a visual aura, seeing patterns like zigzags, curves, dots or shimmering. They typically start off to the side and then move to the center of your vision. Sometimes you can see shimmering colors. Other times you can get blind spots or tunnel vision.
Feeling things. A little more than half of migraine patients (54%) have what’s called a sensory aura, which means they feel tingling or pins and needles in a hand or their face. Usually, people feel that on one side of their body. Sometimes your tongue feels numb, sometimes a leg.
Trouble speaking. Because your tongue feels numb, you may slur your words. Or feel like you can’t get words out. This affects about a third of people.
The Migraine Attack or Acute Phase:
This is the most prolonged phase, lasting anywhere from four to 72 hours. This is the time to take your rescue meds to decrease the headache, preferably within the first hour (sooner is better). The signs of this phase include:
Head pain. About 60% of people feel a throbbing pain on one side of their head, and 15% of those people always get the pain on the same side. Forty percent feel pain on both sides. Sometimes your head doesn’t feel like its throbbing, but you still feel pain. It’s usually moderate to severe, but not every migraine comes with a headache (and sometimes it’s mild or indistinct). In fact, some people who also have auras just have the visual or sensory disturbances, and yes, that needs to be treated too.
Nausea or vomiting. Three-quarters of women and 65% of men report feeling queasy, and about 31% of women throw up compared to 28% of men.
Sensitivity to light and noise. Eighty-three percent of women and 76% of men can’t tolerate too much light or feel as if the lights have suddenly become too bright. Noise is also unbearable: 70% of men and 78% of women feel as if sounds have become too loud.
Pain that gets worse when you move, even for routine activities like doing chores or walking up the stairs. In fact, about half of people with migraines (men and women) report that they have trouble doing chores during a migraine.
The Postdrome or Final Phase:
The most reported symptoms are trouble concentrating (or feeling brain dead) and fatigue, like you got run over by a truck.
When Should I Treat My Migraines?
If migraines are disrupting your life, even sporadically, and you’ve had at least five attacks, it’s time to see a doctor. That means you’re missing work, or family events, or you’re just finding it hard to focus on the days before or after an attack. Your primary doctor may be fine, especially if you have occasional headaches that can be stopped by pain relievers, either OTC meds like Aleve (naproxen) or prescription-only triptans. But if you’ve cycled through many medications or you have more than 15 migraines a month, then try to find a neurologist or, even better, a headache specialist or center. These are M.D.s and neurologists who specialize in treating tough cases and will probably come up with a plan that can treat all your symptoms (including sleep issues).
That plan will probably include preventative medications, either something you take every day, like a magnesium supplement or an antidepressant like Pamelor (nortriptyline) or injections that you take once a month or every three months, like Aimovig (erenumab) or Botox. And since even the most effective preventative meds can’t stop headaches entirely (though they can cut the frequency in half or even more), you’ll get another prescription for a medication to take when you do get an attack, like Maxalt (rizatriptan) or Ubrelvy (ubrogepant), one of the newer meds on the market.
Frequently Asked QuestionsMigraine Symptoms and Causes
When I get headaches, I also feel nauseated and sometimes throw up. Could those be migraines?
Possibly. To get a diagnosis, you have to have two of the following criteria: Your pain must be moderately to severely intense, it has to get worse during routine activity, it occurs on one side, and your head feels like it’s throbbing. Then you also have to feel queasy and/or vomit or be sensitive to light. There’s another type of migraine called probable migraine, which just needs to meet one of those criteria. But they have to be recurrent (in other words, you’ve had to have at least five of them in your life) and the pain has to have been moderately severe.
Can you get migraines without having a headache?
Yes, you can have silent migraines. You have all the signs of an aura—the shimmering lights or patterns, the tingling—without the throbbing headache that comes afterwards. But since those are also disruptive (who wants to drive or do anything when you’re bombarded by flashing colors), you’ll need to see a doctor, who may suggest a preventative medication.
Why do foods like red wine or aged cheese trigger migraines in certain people?
It could be that these foods are high in chemicals (like tyramine in cheddar or Gouda, sulfites in red wine) that can activate the chemicals (like neurotransmitters) and areas of the brain responsible for migraines. But triggers usually come in pairs or threesomes, so you’d need other things—like a stressful situation, lack of sleep, or a missed meal—to set off an attack.
I heard that migraines get better during pregnancy, but mine have gotten worse! What gives?
It happens, though you are in the minority. Most women find that they have fewer migraines during pregnancy and less painful ones too. But 15% of women find that their attacks get worse, especially during the first trimester, when hormones are fluctuating. But if your migraines are particularly bad or get worse, be sure to bring it up with your OB. Sometimes moms-to-be with migraines are at risk for pregnancy complications, including preeclampsia and giving birth too early.
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