Migraine headache

* Introduction Fortunately, management of migraine headache pain has improved dramatically in the last decade. If you’ve seen a doctor in the past and had no success, it’s time to make another appointment. Although there’s still no cure, medications can help reduce the frequency of migraine headaches and stop the pain once it has started. The right medicines combined with self-help remedies and changes in lifestyle may make a tremendous difference for you.

Signs and symptoms
A typical migraine headache attack produces some or all of these signs and symptoms:

* Moderate to severe pain — many migraine headache sufferers feel pain on only one side of their head, while some experience pain on both sides
* Head pain with a pulsating or throbbing quality
* Pain that worsens with physical activity
* Pain that hinders your regular daily activities
* Nausea with or without vomiting
* Sensitivity to light and sound

When left untreated, a migraine headache typically lasts from four to 72 hours, but the frequency with which they occur can vary from person to person. You may have migraines several times a month or just once or twice a year.

Not all migraine headaches are the same. Most people suffer from migraines without auras, which were previously called common migraines. Some have migraines with auras, which were previously called classic migraines. If you’re in the second group, you’ll likely have auras about 15 to 30 minutes before your headache begins. They may continue after your headache starts or even occur after your headache begins. These may include:

* Sparkling flashes of light
* Dazzling zigzag lines in your field of vision
* Slowly spreading blind spots in your vision
* Tingling, pins-and-needles sensations in one arm or leg
* Rarely, weakness or language and speech problems

Whether or not you have auras, you may have one or more sensations of premonition (prodrome) several hours or a day or so before your headache actually strikes, including:

* Feelings of elation or intense energy
* Cravings for sweets
* Thirst
* Drowsiness
* Irritability or depression

Migraine headache symptoms in children
Migraines typically begin in childhood, adolescence or early adulthood and may become less frequent and intense as you grow older. Children as young as age 1 can have these headaches. In addition to physical suffering, severe headaches often mean missed school days and trips to the emergency room, as well as lost work time for anxious parents.

Children’s migraines tend to last for a shorter time. But the pain can be disabling and can be accompanied by nausea, vomiting, lightheadedness and increased sensitivity to light. A migraine headache tends to occur on both sides of the head in children, and visual auras are rare. However, children often have premonition signs and symptoms, such as:

* Yawning
* Sleepiness or listlessness
* A craving for foods such as chocolate, hot dogs, sugary snacks, yogurt and bananas

Children may also have all of the signs and symptoms of a migraine headache — nausea, vomiting, increased sensitivity to light and sound — but no head pain. These “abdominal migraines” can be especially difficult to diagnose.

The good news is that some of the same medications that are effective for adults also work for children. Your child doesn’t have to suffer the pain and disruption of migraines. If your child has headaches, talk to your pediatrician. He or she may want to refer your child to a pediatric neurologist.

Although much about headaches still isn’t understood, some researchers think migraines may be caused by functional changes in the trigeminal nerve system, a major pain pathway in your nervous system, and by imbalances in brain chemicals, including serotonin, which regulates pain messages going through this pathway.

During a headache, serotonin levels drop. Researchers believe this causes the trigeminal nerve to release substances called neuropeptides, which travel to your brain’s outer covering. There they cause blood vessels to become dilated and inflamed. The result is headache pain.

Because levels of magnesium, a mineral involved in nerve cell function, also drop right before or during a migraine headache, it’s possible that low amounts of magnesium may cause nerve cells in the brain to misfire.

Migraine headache triggers
Whatever the exact mechanism of headaches, a number of things may trigger them. Common migraine headache triggers include:

* Hormonal changes. Although the exact relationship between hormones and headaches isn’t clear, fluctuations in estrogen and progesterone seem to trigger headaches in many women with migraine headaches. Women with a history of migraines often have reported headaches immediately before or during their periods. Others report more migraines during pregnancy or menopause. Hormonal medications, such as contraceptives and hormone replacement therapy, also may worsen migraines.
* Foods. Certain foods appear to trigger headaches in some people. Common offenders include alcohol, especially beer and red wine; aged cheeses; chocolate; fermented, pickled or marinated foods; aspartame; caffeine; monosodium glutamate — a key ingredient in some Asian foods; certain seasonings; and many canned and processed foods. Skipping meals or fasting also can trigger migraines.
* Stress. A period of hard work followed by relaxation may lead to a weekend migraine headache. Stress at work or home also can instigate migraines.
* Sensory stimulus. Bright lights and sun glare can produce head pain. So can unusual smells — including pleasant scents, such as perfume and flowers, and unpleasant odors, such as paint thinner and secondhand smoke.
* Physical factors. Intense physical exertion, including sexual activity, may provoke migraines. Changes in sleep patterns — including too much or too little sleep — also can initiate a migraine headache.
* Changes in the environment. A change of weather, season, altitude level, barometric pressure or time zone can prompt a migraine headache.
* Medications. Certain medications can aggravate migraines.

Risk factors

Many people with migraines have a family history of migraine. If both your parents have migraines, there’s a good chance you will too. Even if only one of your parents has migraines, you’re still at increased risk of developing migraines.

You also have a relatively higher risk of migraines if you’re young and female. In fact, women are three times as likely to have migraines as men are. Headaches tend to affect boys and girls equally during childhood but increase in girls after puberty.

If you’re a woman with migraines, you may find that your headaches worsen during menstruation. They may also change during pregnancy or menopause. Many women report improvement in their migraines later in pregnancy, but others report that their migraines worsened during the first trimester. If pregnancy or menstruation affects your migraines, your headaches are also likely to worsen if you take birth control pills or hormone replacement therapy (HRT).

When to seek medical advice

Migraines are a chronic disorder, but they’re often undiagnosed and untreated. If you experience signs and symptoms of migraine, track and record your attacks and how you treated them. Then make an appointment with your doctor to discuss your migraines and decide on a treatment plan.

If you don’t have a treatment plan when a migraine headache strikes, try over-the-counter (OTC) medications such as ibuprofen (Advil, Motrin, others), naproxen sodium (Aleve) or aspirin, or other self-care measures for a day or two. If you don’t get relief, see your doctor. Don’t give aspirin to children under 16 because of the risk of Reye’s syndrome, a rare but potentially fatal disease.

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 another, more serious medical problem such as a concussion:

* An abrupt, severe headache like a thunderclap
* A new severe headache that isn’t just on one side of your head
* Headache with fever, stiff neck, rash, mental confusion, seizures, double vision, weakness, numbness or trouble speaking
* Headache after a recent sore throat or respiratory infection
* Headache after a head injury, especially if the 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 55

It’s likely your headaches don’t signal a serious medical condition. But in a small number of cases, headaches may be a symptom of a blood clot or brain tumor. They may also signal temporal arteritis — a rare, headache-related condition that usually affects people older than 55 and, if not treated, may lead to blindness or stroke.

Screening and diagnosis

If you have typical migraine headaches or a family history of migraines, your doctor will likely diagnose the condition on the basis of your medical history and a physical exam. But if your headaches are unusual, severe or sudden, your doctor may recommend certain tests to rule out other possible causes for your pain.

You may have vision tests, a computerized tomography (CT) head scan or magnetic resonance imaging (MRI) — a diagnostic imaging procedure that combines a strong magnetic field, radio waves and computer technology to produce clear images of your internal organs, including your brain. During an MRI, you lie on a special table while detectors take measurements of your head from multiple angles. A computer processes the collected data to produce a three-dimensional representation of your head.

If your doctor suspects that an underlying medical condition, such as meningitis or subarachnoid hemorrhage, is the cause of your headaches, he or she may recommend a spinal tap (lumbar puncture). In this procedure, a thin needle is inserted between two vertebrae in your lower back to extract a sample of cerebrospinal fluid (CSF) for laboratory analysis. The procedure takes about 30 minutes. You may feel pressure while the fluid is extracted and have a headache afterward because of a drop in CSF pressure. Lumbar puncture isn’t without other risks, including a small risk of causing infection.


Sometimes your efforts to control your pain cause problems. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others) and aspirin, may cause side effects such as abdominal pain, bleeding and ulcers, especially if taken in large doses or for a long period of time.

In addition, if you take over-the-counter (OTC) or prescription headache medications more than two or three times a week or in excessive amounts, you may be setting yourself up for a serious complication known as rebound headaches. Although these drugs can give you temporary relief, they not only stop relieving pain, but actually begin to cause headaches. You then use more pain medication, which traps you in a vicious cycle. If you’re caught in the rebound headache trap, talk to your doctor.


At one time, aspirin was almost the only available treatment for headaches. Now there are drugs specifically designed to treat migraines. Several drugs commonly used to treat other conditions also may help relieve migraines in some people. All of these medications fall into two classes:

* Pain-relieving medications. These stop pain once it has started.
* Preventive medications. These reduce or prevent a migraine headache.

Choosing a preventive strategy or a pain-relieving strategy depends on the frequency and severity of your headaches, the degree of disability your headaches cause and other medical conditions you may have. You may be a candidate for preventive therapy if you have two or more debilitating attacks a month, if you use pain-relieving medications more than twice a week, if pain-relieving medications aren’t helping or if you have uncommon migraines.

Some medications aren’t recommended if you’re pregnant or breast-feeding. Some aren’t used for children. Your doctor can help find the right medication for you.

Pain-relieving medications
For best results, take pain-relieving drugs as soon as you experience signs or symptoms of a migraine headache. It may help if you rest or sleep in a dark room after taking them:

* Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibuprofen (Advil, Motrin, others) or aspirin, may help relieve mild migraines. Drugs marketed specifically for migraine, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraines, but aren’t effective alone for severe migraines. If over-the-counter medications don’t help, your doctor may suggest a stronger, prescription-only version of the same drug. If taken too often or for long periods of time, NSAIDs can lead to ulcers, gastrointestinal bleeding and rebound headaches.
* Triptans. Sumatriptan (Imitrex) was the first drug specifically developed to treat migraines. It mimics the action of serotonin by binding to serotonin receptors and causing blood vessels to constrict. Sumatriptan is available in oral, nasal and injection form. Injected sumatriptan works faster than any other migraine-specific medication — in as little as 15 minutes — and is effective in most cases. But injections may be inconvenient and painful.

Since the introduction of sumatriptan, a number of similar drugs have become available, including rizatriptan (Maxalt), naratriptan (Amerge), zolmitriptan (Zomig), almotriptan (Axert), frovatriptan (Frova) and eletriptan (Relpax). These newer agents provide pain relief within two hours for most people, have fewer side effects and cause fewer recurring headaches. Side effects of triptans include nausea, dizziness, and muscle weakness and, rarely, stroke and heart attack.
* Ergots. Drugs such as ergotamine (Ergomar) and dihydroergotamine (D.H.E. 45) and dihydroergotamine nasal spray (Migranal) help relieve pain. These drugs may have more side effects than do triptans.
* Medications for nausea. Metoclopramide (Reglan) is useful for relieving the nausea and vomiting associated with migraines, not the migraine pain itself. It also improves gastric emptying, which leads to better absorption and more rapid action of many oral drugs. It’s most effective when taken early in the course of your migraine or even during the aura before your headache begins. The drugs prochlorperazine (Compazine), chlorpromazine (Thorazine), promethazine (Phenergan) and hydroxyzine (Vistaril) also may relieve nausea, but don’t affect gastric emptying.

Preventive medications
Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of pain-relieving medicines used during migraine attacks. In most cases, preventive medications don’t eliminate headaches completely, and some can have serious side effects. For best results, take these medications as your doctor recommends:

* Cardiovascular drugs. Beta blockers — which are commonly used to treat high blood pressure and coronary artery disease — can reduce the frequency and severity of migraines. These drugs are considered among first-line treatment agents. Calcium channel blockers, another class of cardiovascular drugs, especially verapamil (Calan, Isoptin), also may be helpful. In addition, the antihypertensive medications lisinopril (Prinivil, Zestril) and candesartan (Atacand) are useful migraine prevention medications. Researchers don’t understand exactly why all of these cardiovascular drugs prevent migraines. Side effects can include dizziness, drowsiness or lightheadedness.
* Antidepressants. Certain antidepressants are good at helping prevent all types of headaches, including migraines. Most effective are tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and protriptyline (Vivactil). These medications are considered among first-line treatment agents and may reduce migraines by affecting the level of serotonin and other brain chemicals. Newer antidepressants, however, generally aren’t as effective for migraine prevention. You don’t have to have depression to benefit from these drugs.
* Nonsteroidal anti-inflammatory drugs (NSAIDs). Regularly taking over-the-counter NSAIDs such as ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve) may reduce the frequency of migraines. If these medications don’t help, your doctor may suggest a stronger, prescription-only version of the same drug. However, NSAIDs may increase your risk of cardiovascular events, such as heart attack and stroke. In addition, long-term use of these medications can lead to ulcers and other gastrointestinal problems, such as stomach bleeding. Talk to your doctor before taking these medications regularly — even the nonprescription varieties.
* Anti-seizure drugs. Although the reason is unclear, some anti-seizure drugs, such as divalproex sodium (Depakote), valproic acid (Depakene) and topiramate (Topamax), which are used to treat epilepsy and bipolar disease, seem to prevent migraines. Gabapentin (Neurontin), another anti-seizure medication, is considered a second-line treatment agent. Taken in high doses, however, these anti-seizure drugs, depending on which one you take, may cause side effects such as nausea and vomiting, diarrhea, cramps, hair loss and dizziness.
* Cyproheptadine. This antihistamine specifically affects serotonin activity. Doctors sometimes give it to children as a preventive measure.
* Botulinum toxin type A (Botox). Some people receiving Botox injections for their facial wrinkles have noted improvement of their headaches. However, it’s unclear what effect Botox actually has on headaches. It may cause changes in your nervous system that modify your tendency to develop migraines. Additional research is necessary.


Whether or not you take preventive medications, you may benefit from lifestyle changes that can help reduce the number and severity of migraines. One or more of these suggestions may be helpful for you:

* Avoid triggers. If certain foods seem to have triggered your headaches in the past, eat something else. If certain scents are a problem, try to avoid them. In general, try to establish a daily routine with regular sleep patterns and regular meals.
* Exercise regularly. Regular aerobic exercise reduces tension and can help prevent migraines. If your doctor agrees, choose any aerobic exercise you enjoy, including walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches.
* Reduce the effects of estrogen. If you’re a woman with migraines and estrogen seems to trigger or make your headaches worse, or if you have a family history of stroke or high blood pressure, you may want to avoid or reduce the amount of medications you take that contain estrogen. These medications include birth control pills and hormone replacement therapy. Talk with your doctor about the best alternatives or dosages for you.
* Quit smoking. If you smoke, talk to your doctor about quitting. Smoking can trigger headaches or make headaches worse.


Self-care measures can help ease the pain of a migraine headache. Try these headache helpers:

* Keep a diary. A diary can help you determine what triggers your migraines. Note when your headaches start, how long they last and what, if anything, provides relief. Be sure to record your response to any headache medications you take. Also pay special attention to foods you ate in the 24 hours preceding attacks, any unusual stress, and how you feel and what you’re doing when headaches strike. If you’re under stress, tell your doctor.
* Try muscle relaxation exercises. Progressive muscle relaxation, meditation and yoga don’t require any equipment. You can learn them in classes or at home using books or tapes. Or spend at least a half-hour each day doing something you find relaxing — listening to music, gardening, taking a hot bath or reading.
* Get enough sleep, but don’t oversleep. The average adult needs seven to nine hours of sleep a night.
* Rest and relax. If possible, rest in a dark, quiet room when you feel a headache coming on. Place an ice pack wrapped in a cloth on the back of your neck and apply gentle pressure to painful areas on your scalp.

Coping skills

Living with migraines is a daily challenge. Headaches can be both incapacitating and unpredictable and may interfere with your job, your relationships with family and friends, and your overall quality of life. Although new treatments offer more options for pain management, you may still get disabling headaches. You may also occasionally feel anxious or depressed. These options may help you cope:

* Counseling. A counselor or therapist can teach you techniques for managing stress and coping with pain. Family therapy may help the people in your life understand more about migraines.
* Support groups. Like many people with migraines, you may find that these groups are a good source of useful information as well as support. Group members often know about the latest medical treatments and self-care or complementary remedies. Your doctor may put you in touch with a group in your area. The American Council for Headache Education Web site also provides referrals to support groups nationwide.
* Balance. Try to balance the use of medications with regular exercise, relaxation techniques, nutritious meals and adequate rest. Allow yourself at least a half-hour every day for relaxation.

Complementary and alternative medicine

Nontraditional therapies may be helpful if you have chronic headache pain:

* Acupuncture. Among other benefits, acupuncture may be helpful for headache pain. This treatment uses very thin, disposable needles that generally cause little or no pain or discomfort.
* Biofeedback. Biofeedback appears to be especially effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses, such as muscle tension.
* Massage. Although massage is a wonderful way to reduce stress and relieve tension, its value in treating headaches hasn’t been fully determined. For people who have tight, tender muscles in the back of the head, neck and shoulders, massage may help relieve headache pain.
* Herbs, vitamins and minerals. There is some evidence that the herbs feverfew (Tanacet, Tenliv) and butterbur (DoloMed, Petadolex, Petadolor) may prevent migraines or reduce their severity. A high dose of riboflavin (vitamin B-2) also may prevent migraines by correcting tiny deficiencies in the brain cells. Oral magnesium sulfate supplements may reduce the frequency of headaches in some people, although studies don’t all agree on this issue. In addition, infusions of magnesium sulfate seem to help some people during an acute headache, and they seem to relieve migraine pain in people with magnesium deficiencies. Ask your doctor if these treatments are right for you. Don’t use feverfew or butterbur if you’re pregnant.
* Cervical manipulation. There are no scientifically valid studies that prove that chiropractic or other spine-manipulation treatments are effective in the treatment of migraine.


© 1998-2007 Mayo Foundation for Medical Education and Research

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