Migraine Headaches

A migraine headache is a throbbing or pulsating headache that is often one sided (unilateral) and associated with nausea; vomiting; sensitivity to light, sound, and smells; sleep disruption; and depression. Migraine attacks are often recurrent and tend to become less severe as the migraine sufferer ages.

Types of Migraines

Migraines are classified according to the symptoms they produce. The two most common types are migraine with aura and migraine without aura. Less common types include the following:

  • Abdominal migraine
  • Basilar artery migraine
  • Carotidynia
  • Headache-free migraine (auro without migraine)
  • Ophthalmoplegic migraine/Ocular migraine
  • Status migrainosus

Some women experience migraine headaches just prior to or during menstruation. These headaches, which are called menstrual migraines, may be related to hormonal changes and often do not occur or lessen during pregnancy. Other women develop migraines for the first time during pregnancy or after menopause.

Migraine with aura is characterized by a neurological phenomenon (aura) that is experienced 10 to 30 minutes before the headache. Most auras are visual and are described as bright shimmering lights around objects or at the edges of the field of vision (called scintillating scotomas) or zigzag lines, castles (teichopsia), wavy images or hallucinations. Others experience temporary vision loss. Nonvisual auras include

  • motor weakness
    speech or language abnormalities
    dizziness, vertigo
    tingling or numbness (parasthesia) of the face, tongue or extremities

Migraine without aura is the most prevalent type and may occur on one or both sides (bilateral) of the head. Tiredness or mood changes may be experienced the day before the headache. Nausea, vomiting, and sensitivity to light (photophobia) often accompany migraine without aura.

Abdominal migraine is most common in children with a family history of migraine. Symptoms include abdominal pain without a gastrointestinal cause (may last up to 72 hours), nausea, vomiting, and flushing or paleness (pallor). Children who have abdominal migraine often develop typical migraine as they age.

Basilar artery migraine involves a disturbance of the basilar artery in the brainstem. Symptoms include severe headache, vertigo, double vision, slurred speech and poor muscle coordination. This type occurs primarily in young people.

Carotidynia, also called lower-half headache or facial migraine, produces deep, dull, aching, and sometimes piercing pain in the jaw or neck. There is usually tenderness and swelling over the carotid artery in the neck. Episodes can occur several times weekly and last a few minutes to hours. This type occurs more commonly in older people. Doppler ultrasound studies of the carotid arteries are normal.

Headache-free migraine is characterized by the presence of aura without headache. This occurs in patients with a history of migraine with aura.

Ophthalmoplegic migraine begins with a headache felt in the eye and is accompanied by vomiting. As the headache progresses, the eyelid droops (ptosis) and nerves responsible for eye movement become paralyzed. Ptosis may persist for days or weeks.

Status migraine is a rare type involving intense pain that usually lasts longer than 72 hours. The patient may require hospitalization.

Migraine Incidence and Prevalence

Migraines afflict about 30 million people in the United States. They may occur at any age, but usually begin between the ages of 10 and 40 and diminish after age 50. Some people experience several migraines a month, while others have only a few migraines throughout their lifetime. Approximately 75 percent of migraine sufferers are women.

Causes of Migraines

The cause of migraine is unknown. The condition may result from a series of reactions in the central nervous system caused by changes in the body or in the environment. There is often a family history of the disorder, suggesting that migraine sufferers may inherit sensitivity to triggers that produce inflammation in the blood vessels and nerves around the brain and scalp, causing pain.

Triggers for Migraines

A trigger is any stimulus that initiates a process or reaction. Commonly identified migraine triggers include the following:

  • Alcohol (e.g., red wine)
  • Environmental factors (e.g., weather, altitude, time zone changes)
  • Exertion
  • Foods that contain caffeine (e.g., coffee, chocolate), monosodium glutamate (MSG; used to enhance flavor in several processed foods and in Chinese food), nitrates (found in processed foods, hot dogs), and artificial sweeteners (e.g., aspartame)
  • Glare, contrasting patterns
  • Hormonal changes in women
  • Hunger
  • Lack of sleep
  • Medications (over-the-counter and prescription)
  • Perfume
  • Stress

Signs and Symptoms of Migraines

Migraine headache pain is often described as throbbing or pulsating pain that is intensified by routine physical activity, coughing, straining, or lowering the head. The headache is often so severe that it interferes with daily activity and may awaken the person. The attack is debilitating, and migraine sufferers are often left feeling tired and weak once the headache has passed.

A migraine headache typically begins in a specific area on one side of the head, then spreads and builds in intensity over 1 to 2 hours and then gradually subsides. It can last up to 24 hours, and in some cases, several days.

There may be accompanying symptoms such as nausea, vomiting, sensitivity to light (photophobia), or sensitivity to sound (phonophobia). Hands and feet may feel cold and sweaty and unusual odors may be intolerable.

Diagnosis of Migraines

Diagnosis of migraine is based on the history of symptoms, physical examination, and neurological tests. The tests are performed to rule out other neurological and cerebrovascular conditions, including the following:

  • Bleeding within the skull (intracranial hemorrhage)
  • Blood clot within the membrane that covers the brain (cerebral venous sinus thrombosis)
  • Cerebral stroke (infarct)Dilated blood vessel in the brain (cerebral aneurysm)
  • Excess cerebrospinal fluid in the brain (hydrocephalus)
  • Inflammation of the membranes of the brain or spinal cord (meningitis)
  • Low level of cerebral spinal fluid (CSF)
  • Nasal sinus blockage
  • Postictal headache, which occurs after a stroke or seizure
  • Tumor

Acute Migraine Treatment

The goal of abortive, or acute, treatment for migraines is to relieve headache pain once it has begun. In some cases, mild, infrequent migraines can be relieved using over-the-counter (OTC) medication, but severe headaches and migraines with accompanying symptoms usually require prescription medication. Generally, acute medications are more effective if they are taken as soon as possible after symptoms develop.

During a migraine headache, it may help to rest or sleep alone in a dark, quiet room. Applying cold packs to the head or pressing on the bulging artery in front of the ear on the painful side of the head may provide temporary pain relief.

Medications to Treat Migraines

  • OTC analgesics (e.g., aspirin, ibuprofen, acetaminophen) provide symptomatic relief from headache pain and should be taken at the first sign of a migraine. They are most effective for infrequent migraines (less than 3 a month) and breakthrough headaches (i.e., headaches that occur despite using prophylactic medications).Frequent use of analgesics (i.e., more than 4 times a week) can cause rebound headaches and may interfere with prophylactic migraine treatment. Acetaminophen is sometimes combined with other drugs to form an analgesic compound (e.g., Midrin, Fioricet).

    Side effects caused by aspirin and ibuprofen (e.g., Advil, Motrin) include gastrointestinal upset and bleeding. These drugs should be taken with food and used only as directed. Ibuprofen is available in suppository form, which can be useful if the migraine is accompanied by severe nausea and vomiting.

  • Serotonin receptors (e.g., Imitrex, Treximet [sumatriptan/naproxen sodium], Amerge, Axert, Zomig), are fast-acting, usually well- tolerated medications commonly used to treat migraines. They are available in oral, injectable, and nasal spray forms and can be taken any time during the headache. Side effects of these medications include dizziness, drowsiness, flushing, discomfort, tingling, and nausea. Overuse also may lead to headache exacerbation—daily headaches or more frequent migraine attacks requiring detoxification.
  • In January 2013, the U.S. Food and Drug Administration (FDA) approved Zecuity—the first transdermal delivery system (patch) to treat migraines. This battery-powered patch delivers sumatriptan (Imitrex) through an 8-inch long, 4-inch wide patch that wraps around the arm or thigh like an elastic bandage.The dosage is regulated by a small battery and a computer chip and is administered over the course of 4 hours. A weak electrical current moves the medication through the skin.

    The migraine patch provides an additional option for patients who, for example, have difficulty swallowing oral medication or don’t like the unpleasant aftertaste of nasal spray. Side effects include a painful sensation and redness at the site of application.

  • Ergots (e.g., Cafergot, Mioranal) may be administered orally, intranasally, or as a suppository and is often combined with antinausea drugs, such as prochlorperazine (Compazine). This medication should be taken at the first sign of a migraine and may not be effective if the headache has moved into the throbbing stage.Side effects include gastrointestinal upset, dizziness, stroke, and high blood pressure (hypertension). Ergots should not be taken by patients with heart, vascular, liver or kidney disease.

Approved Medical Devices to Treat Migraines

Adults with migraines who do not tolerate drug treatments well, or for whom medications are ineffective, may be treated using the Cerena transcranial magnetic stimulator or the Cefaly transcutaneous electrical nerve stimulation device—prescription medical devices approved by the U.S. Food and Drug Administration (FDA) to treat migraines. These devices, which have been shown in studies to be effective, pose few risks/side effects.

Cerena is approved for adults who experience migraine with aura and should be used at the start of a migraine headache. The device emits a short magnetic pulse at the back of the head to stimulate a part of the brain called the occipital cortex. Cephaly can be used daily to help prevent migraines. Worn across the forehead for 20 minutes, electrical current from the device stimulates the trigeminal nerve.

Side effects of these devices include pain, discomfort, and irritation at the application site; dizziness; and sleepiness. Safety of Cerena and Cefaly has not been established in children, women who are pregnant, and people with pacemakers.