migraine disease and treatment
A migraine can cause severe throbbing pain or a pulsing sensation, usually on just one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound.
Migraine attacks can cause significant pain for hours to days and can be so severe that the pain is disabling.
Warning symptoms known as aura may occur before or with a headache. These can include flashes of light, blind spots, or tingling on one side of the face or in your arm or leg.
Medications can help prevent some migraines and make them less painful. Talk to your doctor about different migraine treatment options if you can't find relief. The right medicines, combined with self-help remedies and lifestyle changes, may help.
Migraines often begin in childhood, adolescence or early adulthood. Migraines may progress through four stages: prodrome, aura, headache and post-drome, though you may not experience all stages.
One or two days before a migraine, you may notice subtle changes that warn of an upcoming migraine, including:
- Mood changes, from depression to euphoria
- Food cravings
- Neck stiffness
- Increased thirst and urination
- Frequent yawning
Aura may occur before or during migraines. Most people experience migraines without aura.
Auras are symptoms of the nervous system. They are usually visual disturbances, such as flashes of light or wavy, zigzag vision.
Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Your muscles may get weak, or you may feel as though someone is touching you.
Each of these symptoms usually begins gradually, builds up over several minutes and lasts for 20 to 60 minutes. Examples of migraine aura include:
- Visual phenomena, such as seeing various shapes, bright spots or flashes of light
- Vision loss
- Pins and needles sensations in an arm or leg
- Weakness or numbness in the face or one side of the body
- Difficulty speaking
- Hearing noises or music
- Uncontrollable jerking or other movements
Sometimes, a migraine with aura may be associated with limb weakness (hemiplegic migraine).
A migraine usually lasts from four to 72 hours if untreated. The frequency with which headaches occur varies from person to person. Migraines may be rare, or strike several times a month. During a migraine, you may experience:
- Pain on one side or both sides of your head
- Pain that feels throbbing or pulsing
- Sensitivity to light, sounds, and sometimes smells and touch
- Nausea and vomiting
- Blurred vision
- Lightheadedness, sometimes followed by fainting
The final phase, known as post-drome, occurs after a migraine attack. You may feel drained and washed out, while some people feel elated. For about 24 hours, you may also experience:
- Sensitivity to light and sound
When to see a doctor
Migraines are often undiagnosed and untreated. If you regularly experience signs and symptoms of migraine attacks, keep a record of your attacks and how you treated them. Then make an appointment with your doctor to discuss your headaches.
Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.
See your doctor immediately or go to the emergency room if you have any of the following signs and symptoms, which may indicate a more serious medical problem:
- An abrupt, severe headache like a thunderclap
- A headache with fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or trouble speaking
- A headache after a head injury, especially if a headache gets worse
- A chronic headache that is worse after coughing, exertion, straining or a sudden movement
- New headache pain if you're older than 50
If you have migraines or a family history of migraines, a doctor trained in treating headaches (neurologist) will likely diagnose migraines based on your medical history, symptoms, and a physical and neurological examination.
Your doctor may also recommend more tests to rule out other possible causes for your pain if your condition is unusual, complex or suddenly becomes severe.
- Blood tests. Your doctor may order these to test for blood vessel problems, infections in your spinal cord or brain, and toxins in your system.
- Magnetic resonance imaging (MRI). An MRI uses a powerful magnetic field and radio waves to produce detailed images of the brain and blood vessels.
MRI scans help doctors diagnose tumors, strokes, bleeding in the brain, infections, and other brain and nervous system (neurological) conditions.
- Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed cross-sectional images of the brain. This helps doctors diagnose tumors, infections, brain damage, bleeding in the brain and other possible medical problems that may be causing headaches.
- Spinal tap (lumbar puncture). Your doctor may recommend a spinal tap (lumbar puncture) if he or she suspects infections, bleeding in the brain or another underlying condition.
In this procedure, a thin needle is inserted between two vertebrae in the lower back to remove a sample of cerebrospinal fluid for analysis in a lab
Migraine treatments can help stop symptoms and prevent future attacks.
Many medications have been designed to treat migraines. Some drugs often used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:
- Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms.
- Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.
Your treatment strategy depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions.
Some medications aren't recommended if you're pregnant or breast-feeding. Some medications aren't given to children. Your doctor can help find the right medication for you.
Take pain-relieving drugs as soon as you experience signs or symptoms of a migraine for the best results. It may help if you rest or sleep in a dark room after taking them. Medications include:
- Pain relievers. Aspirin or ibuprofen (Advil, Motrin IB, others) may help relieve mild migraines.
Acetaminophen (Tylenol, others), also may help relieve mild migraines in some people.
Drugs marketed specifically for migraines, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraine pain. They aren't effective alone for severe migraines.
If taken too often or for long periods of time, these medications can lead to ulcers, gastrointestinal bleeding and medication-overuse headaches.
The prescription pain reliever indomethacin may help thwart a migraine and is available in suppository form, which may be helpful if you're nauseated
- These medications are often used in treating migraines. Triptans make blood vessels constrict and block pain pathways in the brain.
Triptans effectively relieve the pain and other symptoms that are associated with migraines. They are available in pill, nasal spray and injection form.
Triptan medications include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax).
Side effects of triptans include reactions at the injection site, nausea, dizziness, drowsiness and muscle weakness. They aren't recommended for people at risk of strokes and heart attacks.
A single-tablet combination of sumatriptan and naproxen sodium (Treximet) has proved to be more effective in relieving migraine symptoms than either medication on its own.
- Ergots. Ergotamine and caffeine combination drugs (Migergot, Cafergot) are less effective than triptans. Ergots seem most effective in those whose pain lasts for more than 48 hours. Ergots are most effective when taken soon after migraine symptoms start.
Ergotamine may worsen nausea and vomiting related to your migraines, and it may also lead to medication-overuse headaches.
Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine. It's also less likely to lead to medication-overuse headaches. It's available as a nasal spray and in injection form.
- Anti-nausea medications. Medication for nausea is usually combined with other medications. Frequently prescribed medications are chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro).
- Opioid medications. Opioid medications containing narcotics, particularly codeine, are sometimes used to treat migraine pain for people who can't take triptans or ergots. Narcotics are habit-forming and are usually used only if no other treatments provide relief.
- Glucocorticoids (prednisone, dexamethasone). A glucocorticoid may be used with other medications to improve pain relief. Glucocorticoids shouldn't be used frequently to avoid side effects.
You may be a candidate for preventive therapy if:
- You have four or more debilitating attacks a month
- Attacks last more than 12 hours
- Pain-relieving medications aren't helping
- Your migraine signs and symptoms include a prolonged aura or numbness and weakness
Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. It may take several weeks to see improvements in your symptoms.
Your doctor may recommend daily preventive medications, or only when a predictable trigger, such as menstruation, is approaching.
Preventive medications don't always stop headaches completely, and some drugs cause serious side effects. If you have had good results from preventive medicine and your migraines are well-controlled, your doctor may recommend tapering off the medication to see if your migraines return without it.
Preventive migraine medications include:
- Cardiovascular drugs. Beta blockers, which are commonly used to treat high blood pressure and coronary artery disease, may reduce the frequency and severity of migraines.
The beta blockers propranolol (Inderal LA, Innopran XL, others), metoprolol tartrate (Lopressor) and timolol (Betimol) have proved effective for preventing migraines. Other beta blockers are sometimes used for the treatment of migraine. You may not notice improvement in symptoms for several weeks after taking these medications.
If you are older than age 60, use tobacco, or have certain heart or blood vessel conditions, your doctor may recommend a different type of medication.
Another class of cardiovascular medications (calcium channel blockers) used to treat high blood pressure also may be helpful in preventing migraines and relieving symptoms. Verapamil (Calan, Verelan, others) is a calcium channel blocker that may help prevent migraines with aura.
In addition, the angiotensin-converting enzyme inhibitor lisinopril (Zestril) may be useful in reducing the length and severity of migraines.
- Antidepressants. Tricyclic antidepressants may be effective in preventing migraines, even in people without depression.
Tricyclic antidepressants may reduce the frequency of migraines by affecting the level of serotonin and other brain chemicals. Amitriptyline is the only tricyclic antidepressant proved to effectively prevent migraines. Other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline.
These medications can cause sleepiness, dry mouth, constipation, weight gain and other side effects.
SSRIs haven't been proved to be effective for migraine prevention. These drugs may even worsen or trigger headaches.
However, research suggests that one serotonin and norepinephrine reuptake inhibitor, venlafaxine (Effexor XR), may be helpful in preventing migraines.
- Anti-seizure drugs. Some anti-seizure drugs, such as valproate (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraines.
In high doses, however, these anti-seizure drugs may cause side effects. Valproate may cause nausea, tremor, weight gain, hair loss and dizziness. Don't use valproate if you are pregnant or may become pregnant.
Topiramate may cause diarrhea, nausea, weight loss, memory difficulties and concentration problems.
- Pain relievers. Taking nonsteroidal anti-inflammatory drugs, especially naproxen (Naprosyn), may help prevent migraines and reduce symptoms.
- OnabotulinumtoxinA (Botox). OnabotulinumtoxinA, which is administered by your doctor during an office visit, has been shown to be helpful in treating chronic migraines in adults.
During this procedure, onabotulinumtoxinA is injected into the muscles of the forehead and neck. When this is effective, the treatment usually needs to be repeated every 12 weeks.
- Erenumab-aooe (Aimovig). This once-monthly, self-injected drug is the first in a new class of drugs. Erenumab-aooe inhibits the activity of a molecule known to play a role in migraines.