Migraine

Causes

• Genetics: Migraines, especially those with aura, often run in families, suggesting a strong genetic component.
• Brain Chemistry: Changes in brain chemicals, particularly serotonin, which helps regulate pain, can play a role. A drop in serotonin levels may trigger migraine symptoms.
• Brain Regions Involved: Areas like the trigeminal nerve and the brainstem are thought to be involved in the pain pathways.
• Triggers (often individual-specific):
  • Hormonal Changes in Women: Fluctuations in estrogen (before or during menstrual periods, during pregnancy, or around menopause) are common triggers.
  • Stress: High stress or even the "let-down" period after stress can trigger migraines.
  • Certain Foods and Drinks: Aged cheeses, processed meats, chocolate, caffeine withdrawal, alcohol (especially red wine), and artificial sweeteners.
  • Skipping Meals: Can lead to low blood sugar, a migraine trigger.
  • Sensory Stimuli: Bright or flickering lights, loud noises, strong smells (perfume, smoke, certain foods).
  • Changes in Sleep Pattern: Both too little and too much sleep can trigger migraines.
  • Physical Exertion: Intense exercise or prolonged physical activity can sometimes trigger an attack.
  • Weather Changes: Barometric pressure changes, strong winds, or storms.
  • Medication Overuse: Overuse of pain relievers can lead to medication overuse headaches, which can mimic or worsen migraines.

Symptoms

• Prodrome (Warning Stage - 1 to 2 days before):
  • Constipation.
  • Mood changes (from depression to euphoria).
  • Food cravings.
  • Neck stiffness.
  • Increased urination.
  • Frequent yawning.
• Aura (Occurs in 20-30% of people, just before or during the headache):
  • Visual Aura: Flashing lights, zig-zag lines, blind spots, shimmering lights (most common).
  • Sensory Aura: Numbness or tingling in an arm or leg, or on one side of the face.
  • Verbal/Language Aura: Difficulty speaking or finding words.
  • Motor Aura: Weakness on one side of the body (rare, indicates hemiplegic migraine).
• Attack (Headache Phase - 4 to 72 hours without treatment):
  • Moderate to Severe Pain: Often throbbing or pulsing.
  • Unilateral Pain: Usually on one side of the head, but can be bilateral.
  • Nausea and Vomiting.
  • Photophobia: Increased sensitivity to light.
  • Phonophobia: Increased sensitivity to sound.
  • Osmophobia: Increased sensitivity to smells.
  • Worsened by physical activity.
• Postdrome (After the Attack - lasts 24-48 hours):
  • Fatigue, drained feeling.
  • Confusion.
  • Mood changes.
  • Muscle weakness.
  • Head pain may recur with sudden head movement.

Diagnosis

• Medical History:
  • The doctor will ask detailed questions about your headaches, including frequency, severity, location, type of pain, accompanying symptoms (nausea, sensitivity), and any triggers.
  • Family history of migraines.
  • Impact on daily life.
• Physical and Neurological Exam: To rule out other conditions that could cause similar symptoms (e.g., tumors, strokes, or other neurological disorders). This involves checking reflexes, sensation, vision, and coordination.
• Imaging Tests (not for routine diagnosis of migraine, but to rule out other conditions):
  • CT Scan (Computed Tomography) or MRI (Magnetic Resonance Imaging): May be performed if symptoms are unusual, severe, or suggest other neurological problems, such as a tumor, stroke, or bleeding in the brain.
• Keeping a Headache Diary: Can be very helpful for both diagnosis and identifying triggers. Patients record details of each headache episode.

Treatment

• Acute (Abortive) Treatments (taken at the first sign of a migraine):
  • Over-the-Counter Pain Relievers: (e.g., ibuprofen, naproxen, acetaminophen, aspirin). Effective for mild to moderate migraines.
  • Triptans: (e.g., sumatriptan - Imitrex, zolmitriptan - Zomig). Specific migraine drugs that constrict blood vessels and block pain pathways in the brain. Highly effective for many.
  • CGRP Receptor Antagonists (Gepants): (e.g., ubrogepant - Ubrelvy, rimegepant - Nurtec ODT). Newer oral medications that block the CGRP protein, involved in migraine pain.
  • Ditans: (e.g., lasmiditan - Reyvow). Targets serotonin receptors different from triptans; does not cause vasoconstriction.
  • Ergots: (e.g., ergotamine with caffeine - Cafergot). Older class of drugs, less commonly used due to side effects.
  • Anti-Nausea Medications: (e.g., prochlorperazine, metoclopramide) To relieve nausea and vomiting.
• Preventive (Prophylactic) Treatments (taken regularly to reduce frequency/severity):
  • Beta-Blockers: (e.g., propranolol, metoprolol). Commonly used for high blood pressure or heart conditions, but also effective for migraine prevention.
  • Antidepressants: (e.g., amitriptyline, venlafaxine). Tricyclic antidepressants and SNRIs can help prevent migraines.
  • Anticonvulsants: (e.g., topiramate - Topamax, valproic acid). Used for epilepsy but also effective for migraine prevention.
  • CGRP Inhibitors (Monoclonal Antibodies): (e.g., erenumab - Aimovig, fremanezumab - Ajovy, galcanezumab - Emgality, eptinezumab - Vyepti). Newer injectable medications that target CGRP or its receptor to prevent migraines.
  • Botulinum Toxin (Botox) Injections: For chronic migraine (15 or more headache days per month), injections into specific head and neck muscles can help prevent attacks.
  • Blood Pressure Medications (e.g., candesartan): Can be used for prevention.
• Lifestyle Management:
  • Identify and Avoid Triggers: Keeping a headache diary is crucial.
  • Stress Management: Relaxation techniques, yoga, meditation.
  • Regular Sleep Schedule: Consistent bedtime and wake-up times.
  • Regular Meals: Avoid skipping meals.
  • Regular Exercise: Moderate, consistent physical activity.
  • Biofeedback: Learning to control certain body responses to reduce tension.

Getting Ahead of Migraine

Migraine is managed well or badly on a few habits: treating attacks early, not treating them too often, and starting prevention when the frequency warrants it. Each of those has a threshold that is worth knowing precisely.

Treat early, and treat with enough

Acute medication works best taken at the first sign of pain rather than once the attack is established. A triptan such as sumatriptan combined with an NSAID outperforms either alone for moderate to severe attacks. When triptans fail or cannot be used, as in coronary artery disease, the newer gepants such as rimegepant and ubrogepant are effective without constricting blood vessels. An anti-nausea medication taken alongside improves absorption of everything else.

The medication overuse trap

Taking triptans, opioids, or combination analgesics on 10 or more days a month, or simple pain relievers on 15 or more, converts episodic migraine into a daily headache that no acute medication will fix. It is the most common reason migraine becomes chronic, and the only treatment is to stop the overused drug and start prevention, which is uncomfortable for a few weeks and then works.

When prevention is warranted

Four or more migraine days a month, or fewer that are severely disabling, justifies daily preventive treatment. Topiramate, a beta-blocker such as propranolol or metoprolol, amitriptyline, and candesartan are established first choices, each given a fair trial of two to three months at an adequate dose. Monoclonal antibodies against CGRP such as erenumab, and gepants used preventively, are now well established when older options fail or are not tolerated, and our CGRP migraine prevention article compares them.

The triggers you can change

Irregular sleep, skipped meals, dehydration, and inconsistent caffeine are the modifiable triggers with the best evidence, and in Florida the summer heat and the barometric swings before storms add two more. Trigger diaries help most when they identify patterns rather than a list of foods to fear, since restrictive diets rarely reduce attacks and often add stress that does the opposite.

Aura, hormones, and stroke risk

Migraine with aura modestly raises stroke risk, and the practical consequence is that estrogen-containing contraception is not used in women who have it, and smoking matters more than usual. Attacks tied to the menstrual cycle respond to short courses of prevention timed around the period. Sudden, worst-ever headache, headache with fever and a stiff neck, a new pattern after 50, or a neurologic symptom that does not resolve with the attack are emergencies rather than migraine. Our neurology team manages prevention and difficult cases. The NINDS and the American Migraine Foundation publish patient guidance on treatment and prevention.

If you have migraine on four or more days a month, or are taking pain medication most weeks, schedule a visit to discuss prevention.