It’s easy to think of migraines as just “really bad headaches,” but they’re far from that simple. First of all, not every migraine is the same. In the fact, there are multiple types. Some are determined by the number of attacks you have. Others are characterized by the kind of symptoms you experience or whether you even have headaches. And just to keep things interesting, you might have different symptoms with each attack (or they may change over time). For example, you might see shimmering lights and hear sounds but have only mild discomfort. But after a year or two you might develop throbbing headaches after these visual disturbances. Getting a handle on the type of migraines you’re suffering now, can help you get the relief you need. We’re here to show you the way.
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 Is a Migraine Again?
To repeat: A migraine is more than a headache. It’s a neurological disorder, usually inherited, that makes your brain more hypersensitive to certain triggers, those in the outside world and those inside your body. When something sets off an attack—not enough sleep, a glass of wine, a drop in estrogen—the neural pathways in your brain get activated in abnormal ways and release chemicals that set off the cascade of symptoms associated with an attack.
Even without the head pain (it can happen!), these attacks can totally derail your day or at least keep you from driving for a couple of hours. So it’s no wonder that migraines are the sixth most debilitating condition in the world, according to the Migraine Research Foundation. And they’re very common—in the U.S., about one in four households has a person who suffers from migraines living in it. Because there’s a strong family history for the condition, children of any age can get them, possibly even babies. Among adults, three times as many women have migraines than men, and, yes, hormones have something to do with it, at least as triggers.
Episodic migraines, which means you have fewer than 15 attacks per month
Chronic migraines, which means you have 15 or more attacks a month
Migraines with auras, which are the neurological disturbances that involve lights, sounds, and sometimes speech
Migraines without auras, which are much more common than those with
Plus, there are a few subtypes within these categories. The main differences are in some of the symptoms and the frequency of attacks, not in what happens in your brain. Except for Botox shots, which are reserved for people with chronic migraines, the treatment all types of migraines is the same—drugs, non-drug devices, and lifestyle changes that can stop an attack or prevent one.
To get diagnosed with episodic and chronic migraines without auras, which always include headache pain, a doctor follows the criteria set out by the International Headache Society. Your attack must have at least two of these four features:
The pain is moderate to severe.
It usually occurs on one side.
Your head throbs or pulses.
The pain gets worse with physical activity.
It also needs to have one of these features:
You can’t tolerate light or noise.
You feel nauseous and/or you actually vomit.
Finally, you have to have had at least five attacks in your lifetime that included these criteria and the doctor must have ruled out any reason for the migraines (a tumor, say), either with an exam or an imaging test.
Most people with migraines have episodic ones, which means they have fewer than 15 attacks per month. In one survey of roughly 13,000 migraneurs (as migraine patients are known), 91% had episodic migraines. Don’t be fooled, though. You still must meet the criteria of symptoms, which means that even though migraines are more sporadic, they can still knock you out.
In landmark survey, nine out of 10 Americans who had the condition reported that they couldn’t “function normally” on the days they had an attack, which could mean anything from missing a social event to missing work. About half of migraineurs can’t even tackle their household chores, which makes sense given that even the most routine activities can make your headache worse.
Every year, 2.5% of people with episodic migraines develop more headaches, going from one attack per month to a few per week. What makes their condition progress? Surprisingly enough, taking too many headache meds, whether it’s over-the-counter pain relievers or actual prescription pain killers (though doctors are wary about prescribing them the way they once did). Overdoing the recommended dose or taking them several times a week to stop your pain can cause rebound headaches. And they can even make your sensitive brain even more susceptible to migraine attacks.
Two percent of all Americans have chronic migraines, defined as more than 15 attacks per month. Among those who have migraines already, the percentage is 8%. Americans with chronic migraine are different from those with fewer headaches in other ways, too.
Their pain is more severe and intense, for one thing, and lasts longer even with meds. Their lives are also affected much more, according to the survey respondents. About 9.5% of those with chronic migraines said they’d put off having or had fewer kids because of their headaches, three times more than those who had episodic migraines.
Nearly double the number of chronic migraineurs said their careers had been affected (58% vs. 30%).
There are differences in health as well. Almost a third of people with chronic migraines have depression and anxiety, compared to 17% and 18% of those with episodic attacks. And they are slightly more likely to be obese, too—one in four chronic migraine sufferers versus one in five of those with fewer headaches, according to American and German researchers.
The good news is that you can reverse chronic migraines and get back to episodic ones, as about a quarter of migraine sufferers do. The key? A good headache specialist who will work with you to get the right treatment.
Migraines With Auras
About 20% of people with migraines have auras before the pain starts (although some people don’t have headaches at all). Auras are disturbances in the brain that last anywhere from five to 60 minutes and can produce any number of effects that seem scarily similar to stroke, including:
Seeing flashing or shimmering lights or colors or patterns, like zigzags, curves, or spots that gradually move along your field of vision.
What you see gets progressively more blocked—you get tunnel vision, or you see holes, like Swiss cheese, in your field of vision, or your visual field is cut in half.
You feel numb or have a pins-and-needles sensation in your hands or face, or sometimes in your legs or chest.
Your tongue feels numb, usually on one side.
You may start to slur your words or have trouble finding words or even understanding them.
Having migraines with auras can increase your risk of a certain type of stroke called a transient ischemic attack (TIA). TIAs typically don’t last as long as auras, but duration isn’t a reliable way to tell the difference. If you’ve just had an aura for the first time, you’re older than 40, your vision was obscured, and the aura was very short or longer than an hour, call your provider or go to an urgent care clinic to get it checked out sooner rather than later.
Visual auras are the most common—one study found that 99% of those people who had auras had this symptom. You can have more than one aura symptom. Sometimes the signs of an aura come one after another and sometimes they come all together.
Even though auras are warning signs for the headache to come, you need to wait to take the pain reliever (either the OTC kind or the Rx your doctor gave you). Taking meds during an aura is usually not effective, though no one understands why.
There are some subtypes that come under migraines with auras. They include:
These are migraines with auras but without the headache pain. In other words, you have see the flashing lights, zigzags or other visual disturbances, but without the throbbing pain that typically follows the aura. You can also feel queasy and be extra sensitive to lights and sounds. Your triggers may be the same as people who get other types of migraines and you can have this type along with other types (i.e. migraines without auras).
Even without the pain, silent migraines can be disruptive (all those flashing lights and queasy feelings aren’t conducive to getting work done or getting in a car). A doctor can recommend a daily magnesium supplement, which blocks glutamate, a brain chemical that gets overproduced in people with migraines with auras to help prevent these disturbances. Certain anti-seizure drugs, like Topamax (topiramate) also block glutamate.
These types of migraines are very rare (they affect about 1 in every 10,000 people). They feel more like strokes—one side of your body goes numb and you feel weak. Other symptoms include:
Visual disturbances (lights, colors)
Confusion or going into a coma
Trouble with coordination
Sometimes headache pain
Hemiplegic migraines run in families, and children can have them. Because they are so similar to strokes (or seizures), see a doctor as soon as possible to rule out some underlying condition if you’ve never had one before. That will help reassure you and helps the doctor spot a pattern to your attacks (or a family history). Your doctor will probably recommend a preventative like anti-seizure drugs or the newer monthly injections, which can decrease these attacks.
Migraines Without Auras
These types of attacks are exactly what they sound like—migraines without the visual or other events. These are the most common, with about 80% of all migraine patients having these types of attacks. And while you have a pretty good idea about the pain that’s coming once you experience an aura, the pain with this type of migraine comes without any warning at all, unless you are very savvy about the early signaling as your brain gets ready for the attack (see below).
If you have migraine-like headaches but are missing a key symptom—light doesn’t bother you, say, or your head doesn’t throb when it aches—you might have what doctors call probable migraines (PM). You can have an aura along with PMs. About 5% of Americans have probable migraines, and while these headaches tend to be less severe than migraines, they are still disabling. If you have them more than a couple times a month, consider going to a doctor to ask about preventative meds or treatments.
What Are the Different Phases of Migraines?
Migraines are also divided into phases, but not everybody cycles through all four. They include:
The prodrome or premonitory phase: Think of this as your brain’s warm-up stage, which can start as early as three days before the actual migraine. The signals are so subtle that you can miss them.
Some people may start yawning more for no reason, others get sensitive to lights, experience food cravings, or mood changes. Everyone’s signs are different, and you might confuse them with your triggers. For instance, if you think bright lights set off your headaches, it may be that you were just more sensitive to them that day because you were in this phase.
Scientists think the hypothalamus—the part of the brain that’s responsible for regulating hormones, sleep cycles, and body temperature among other things—gets involved by at this stage, sending out signals that will activate the pain pathways and chemicals during the actual migraine.
The aura: If you have auras, then that becomes the second stage of your migraine. It lasts five to 60 minutes.
The headache: Again, not everyone gets head pain, though for the majority of migraine patients, this is the worst phase—and the time that most reach for their meds. You can be in this corner of hell for four to 72 hours.
The postdrome: After your attack is over, you may feel exhausted, as if you were run over by a truck. This is the final stage of the migraine. You probably need at least several hours to recover.
Getting the Right Treatment for Your Migraines
Most people with migraines, even those with chronic ones, only take pain relievers during the actual attack. But headache specialists think more people should be taking preventative measures (only about 12% actually do, according to studies) and there are now many more options than there used to be. These include non-drug devices that you put on your forehead or the back of your head that send pulses to your brain and cut down the number of attacks you have a month. There are also new classes of medications that target a particular molecule in your brain called calcitonin gene-related peptide (CGRP) that causes much of the pain you feel. These come in the form of injections that you take every month, either by injecting yourself or at the doctor’s office.
There are older medications as well, including antidepressants, birth control pills, and anti-seizure meds. These tend to have more side effects and are effective for some people but not others. Even with these preventative medications, you’ll still have attacks and you’ll still need a pain reliever. But you’ll have fewer headaches and they won’t be as painful, and with the newer meds, you may even be able to get away with taking an over-the-counter one.
While most people go to their primary doctor, if your headaches are keeping you home and not letting you enjoy the things you love, make an appointment with a neurologist or, better still, a dedicated headache doctor or clinic, which you can find by going to the Migraine Research Foundation’s site.
Frequently Asked QuestionsMigraine Types
I have really bad headaches every month. Could I have migraines?
Yes—and if you’re a woman, those headaches could be tied to your menstrual cycle and estrogen could be the trigger. Or you might have probable migraines (PM) if your headaches come with nausea, sensitivity to lights or sounds, or don’t let you focus or concentrate. Either way, check in with a doctor who will take your medical history and do an exam to rule out any other causes (like an old case of whiplash, for instance). The doctor can recommend medications you can take every day or during an attack to lessen the pain.
I get dizzy and see shimmering lights, but my head doesn’t hurt. What’s going on?
You could be having a silent migraine. These aren’t as common as the head pain ones, but people who have them get auras, or neurological disturbances, without the agony that usually comes afterward. But they are also considered migraines and should be treated by a doctor. After all, they can disrupt your life since you may be driving when you get one or trying to do a presentation at work. A daily magnesium supplement could be all you need to take.
My dad had migraines with auras. But I just get a throbbing headache and feel nauseous. Am I having migraines too?
Most likely. Think of migraines as a brain disease that you’ve inherited from your dad, which makes it more sensitive. When something triggers an attack—a sleepless night, overly bright sunlight—your brain activates cells and chemicals that produce pain and a queasy stomach, and for some people like your dad, neurological disturbances that involve lights, colors, and even tingling feelings in their hands, arms, or face.
Last week I thought I was having a stroke because one side of my face went numb during my migraine? What’s up with that?
You could be having a hemiplegic migraine. These are relatively rare migraines that come with visual auras but make you feel weak on one side. You may also have trouble talking, get confused, or feel totally uncoordinated. But you need to have your doctor check you out as soon as possible, even if you’re feeling ok now, just in case it was a stroke and not a migraine.
Chronic Migraines:Headache. (2019). “Life With Migraine: Effects on Relationships, Career, and Finances From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study.” ncbi.nlm.nih.gov/pubmed/31407321
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