Migraine symptoms, causes and treatment

A migraine is a common health condition that often begins in adolescence but is commonly found in people aged 30 to 40. The prevalence of migraines has been reported in 22% of women and 7% of men and 15% of the general population. A migraine is a moderate to severe throbbing or pulsating sensation usually felt on one side of the head but can be felt on both. Migraines can be disabling and are usually accompanied by other symptoms such as nausea, vomiting and sensitivity to light, sound and smell.

A migraine can last a few hours to a few days, usually between 4 to 72 hours. For some, migraines can occur several times a week and for others, they can happen as infrequently as once a year.

The exact cause of migraine is unknown, although you may have inherited migraine from your parents. There may not be one specific cause for your migraine if you are experiencing them daily. There may be triggers in your lifestyle such as stress and diet.

You can tell if you are experiencing a migraine headache if you feel moderate to severe throbbing on one side of your head. This pain is usually located in front of the head or behind the eyes or ears. However, migraines can affect any part of the head. Symptoms of migraines are different for different people, however, they can be accompanied by other symptoms such as:

• Nausea
• Vomiting
• Sensitivity to light, sounds and smells
• Poor concentration
• Diarrhoea
• Stomach pains
• Scalp tenderness

Migraines may affect people in different ways, depending on what kind of migraine they may be experiencing. However, there are a few symptoms that indicate your migraine is about to begin:

• Fatigue or feeling tired
• The need to pee more often
• Craving certain sweet foods more than usual, like chocolate
• Changes in mood
• Constipation or diarrhoea
• Sensitivity to light and sound
• Changes in vision

A migraine can progress through stages such as the prodrome, headache and postdrome phases, however, not everyone will experience each stage. The stages of a migraine:

Prodrome

In the prodrome stage, you may feel the warning symptoms. This can occur for a few hours or up to 2 days before the migraine. In this stage, you may feel symptoms such as:

• A change in mood from euphoria to irritability or sadness
• Muscle tension
• Fatigue
• Constipation
• Food cravings
• Increased thirst and urination

Aura

A third of migraine patients experience aura. The aura stage can occur just before the migraine headache starts or when you are experiencing a migraine. Visual aura is most common. These include:

• Blind spots
• Geometric patterns such as zig zag lines
• Flashing lights
• Hemianopia (loss of vision on one side)
• Slurred speech

Headache

This is moderate to severe, throbbing or pulsating on one side of the head or across the forehead but can be anywhere in the head. You may experience nausea, vomiting, sensitivity to light sound or smell and the headache worsens with physical activity. If untreated the headache may last between 4 to 72 hours.

Headache termination

Your migraine headache may go away when you sleep or after taking pain relievers.

Postdrome

This is a period of time following a migraine in which you may not feel well. You may feel unwell after the migraine and you can experience fatigue and problems with thinking. This period may take up to 48 hours to improve or feel better.

Migraines can be caused by problems with the nerves and blood vessels in the brain. The exact cause of migraines is unknown. Some researchers from the International Headache Genetics Consortium have located genes which may indicate a risk of suffering from migraines. Migraines typically tend to run in families, however, this does not mean everyone will experience them.

Some researchers argue that everyone has a threshold of experiencing headache to provoking factors or triggers. Those with migraine have a low threshold and hence experience headache much more easily than those with a high threshold. For example, hangover headaches are experienced by more or less everyone as the trigger is very strong.

Migraines are usually associated with triggers. These triggers are factors that can set off migraines. They include lifestyle factors such as stress, meal and sleeping patterns, and certain dietary factors. These triggers may be different for different people.

There are some physical factors that can increase your chances of experiencing a migraine. Some of these triggers include:

• Tiredness
• Lack of sleep
• Irregular sleep patterns
• Poor posture
• Tension in the neck and shoulders
• Strenuous exercises
• Dental problems (teeth grinding or a toothache)
• Low blood sugar (hypoglycemia)
• Changes in hormones (menstrual cycles)
• Jet lag
• Eyestrain
• Changes in routine (worse at weekends if routine is broken)

Some factors that trigger migraines are changes to your mood or mental wellbeing. Some emotional triggers include:

• Anxiety
• Stress
• Anger
• Worry
• Excitement
• Shock

There are lifestyle factors that can increase your chance of getting migraines. These lifestyle factors include the types of foods you eat. Some dietary triggers of migraine headaches are:

• Alcohol (especially red wine and beer)
• Caffeine
• Lack of food or irregular meals
• Dehydration
• Chocolate
• Aged cheese
• Cured meats
• Smoked fish
• Yeast extract
• Artificial sweeteners (aspartame)
• Monosodium glutamate (MSG)
• Tyramine and nitrates

Some researchers argue that migraine patients may have cravings for certain foods in the prodromal stage of their migraine such as cheese and chocolate, and these may not be the actual trigger.

Migraine with aura is a type of migraine headache in which visual and/or sensorimotor or speech symptoms occur before or during a migraine headache. The most common aura symptom is visual changes that include blind spots, dizziness, flashing lights and seeing zig-zag lines in the field of vision. Other symptoms may include experiencing pins and needles or weakness in one or both arms and legs. These symptoms are warning signs that a migraine headache is about to start. There are some specific types of migraine associated with aura that include:

• Migraine with aura—with a headache or without a headache
• Migraine with brainstem aura
• Hemiplegic migraine
• Retinal migraine

A migraine without aura was previously termed as a “common migraine”. This type of migraine does not include aura symptoms prior to headaches. Nearly two third of migraines are of this type.

People who experience migraines without aura may feel severe pain on one or both sides of the head as well as other common symptoms of a migraine such as nausea, vomiting and sensitivity to light and sound. Migraines without aura may in some cases be accompanied by anxiety, depression and fatigue several hours prior to the headache.

The common migraine symptoms are normally:

Headache lasting 4-72 hours (untreated or unsuccessfully treated). The onset of the headache is usually gradual, peaking after 2-12 hours, then gradually subsiding. Attacks often begin in the morning, possibly waking the person from sleep, but may begin at any time of day or night.

Headache has at least two of the following characteristics:

• Unilateral location (one side of the head). It is usually one sided but may be bilateral (on both sides of the head) at the onset, or may start unilaterally and become generalised.
• Usually frontotemporal (at the front of the head or around the sides).
• Pulsating quality (usually in the temples).
• Moderate or severe pain intensity.
• Aggravated by, or causing avoidance of, routine physical activity.

During the headache at least one of the following is present:

• Nausea and/or vomiting
• Sensitivity to light and noise

Frequency of attacks is extremely variable. Some people may have several attacks a week, others may go for several months to years between attacks.

Other features that may occur during an attack include:

• Loss of appetite
• Blurred vision
• Impaired concentration
• Nasal stuffiness
• Hunger
• Bowel discomfort
• Diarrhoea
• Abdominal pain
• Passing large volumes of urine and sweating

These are a spectrum of symptoms experienced by a third of migraine sufferers that occur just before or during migraine headache. The exact cause of aura remains unknown, although certain changes in the posterior part of the brain (occipital lobe) may result in generating a wave (spreading depression) that moves forward like a rippling water wave and causes symptoms that resemble stroke. To know if you are experiencing migraine with aura, there are a few symptoms you can look out for. The most common are visual although there may be other symptoms that can signify aura:

Visual symptoms can include flickering lights, spots or lines, or loss of vision. These can come on and then disappear entirely in a short time, often between 5-60 minutes. Visual symptoms may include:

• Blind spots, called scotomas
• Coloured spots
• Zigzag lines
• Tunnel vision
• Flashes of light
• Stars or sparkles of light
• Temporary vision loss
• Shimmerings or specks of light

Sensory symptoms (e.g. tingling sensation or numbness) which start gradually and disappear slowly. These include:

• Paraesthesia (tingling)
• Numbness that often starts in the hand
• Pins and needles in the arms and legs
• Dizziness
• Vertigo (spinning dizziness)

Speech or language symptoms may include:

• Dysphasia (the loss of ability to speak)
• Difficulty communicating (mumbled or slurred speech)

Other rare symptoms of a migraine aura include:

• Memory changes
• Feelings of fear
• Confusion
• Partial paralysis or fainting (rare)

Migraine aura symptoms usually appear over a 5–20 minute period and can last for up to 60 minutes or more.

The methods of treating migraine with aura are similar to those used to treat a common migraine. These methods can include medication, the use of medical devices, lifestyle changes and home remedies.

If you are experiencing a migraine with aura, you should book a GP appointment as soon as possible to consult with your doctor on your symptoms. You should see a doctor immediately if your symptoms:

• Start abruptly
• Last longer than one hour or do not resolve completely
• Only affect one eye
• Are different from previously established aura symptoms (change in characteristics of aura)
• Symptoms do not completely resolve with time

A migraine without head pain is also known as a silent or acephalgic migraine. With this type of migraine, you may not experience head pain, however, you may experience an aura, visual disturbances, nausea and other symptoms associated with a migraine. People who experience these migraines are likely to experience other types of migraines and they are set off by common migraine triggers.

It is a rare type of migraine that can feel similar to a stroke. It often runs in families. With this type of migraine, you may experience temporary weakness or paralysis on one side of the body. It may accompany other symptoms such as visual disturbances, the sensation of “pins and needles” and a loss of sensation in one side of the body. This type of migraine may not always include serious head pain. Hemiplegic migraine can be disabling but usually resolves within 24 hours.

A retinal migraine is another rare type of migraine aura with or without headache. Retinal migraine affects vision in one eye. It can cause you to lose vision temporarily or see flickering lights in one eye. This type of aura usually accompanies a migraine headache but usually lasts less than an hour. It typically affects women during their childbearing years and most people who experience this are under 40. It may also run in families.

If you are experiencing a retinal migraine, you should book a doctor’s appointment as soon as possible as this can be an indication of a serious issue.

You may be suffering from a chronic migraine if you experience migraine for over half each month for three months in a row. The migraines may be with or without aura. The intensity and severity of the head pain you experience throughout this time can vary. You may also mistake the migraine headache for a sinus or tension headache.

Formerly known as basilar-type migraine, brainstem aura is a rare type of aura with symptoms on both arms or legs and symptoms related to your brainstem i.e., vertigo, slurred speech, tinnitus, double vision (diplopia).

A vestibular migraine is a type of migraine caused by problems associated with the balance system. With this type of migraine, you may not always experience a headache but it can cause repeated dizziness (or vertigo). It is more common in females. Other symptoms of vestibular migraines include:

• Sensitivity to sound
• Nausea and vomiting
• Balance problems and feeling unsteady
• Disorientation or confusion
• Extreme motion sensitivity

Abdominal migraine is a type of migraine seen most commonly in children aged 5 to 9 years old but it can occur in adults as well. The main symptom of abdominal migraine is abdominal pain. This can occur in the middle of the abdomen. Other symptoms of this migraine include loss of appetite, nausea, vomiting and pallor. This type of migraine usually lasts anywhere from 2 to 72 hours. Children experiencing these migraines may grow out of it and start experiencing migraine headaches later in life.

If you or your child are experiencing abdominal pains, it is important to see a doctor as soon as possible as this can be the result of underlying gastrointestinal, urogenital or metabolic conditions.

Many people who experience migraine headaches find that over-the-counter painkillers can relieve their symptoms. However, if you choose to use painkillers it is important:

• Not to overuse them as they can cause medication-overuse headaches, and possibly ulcers and bleeding in the gastrointestinal tract. We commonly advise not to exceed painkiller intake to more than two days a week.
• Ensure that the painkiller does not have codeine or other opiate analgesic as they increase the risk of medication overuse headaches.

Some painkillers you can try include:

• Ibuprofen (Advil, Motrin IB, others)
• Paracetamol
• Aspirin

Triptans are specific remedies for the treatment of acute migraine headache and some of them are available over the counter. Your GP may be able to prescribe triptans if the simple painkillers, given above, are not adequately working. These are available as pills, injections or nasal sprays. They work by narrowing blood vessels around the brain as the widening of blood vessels is believed to be part of the migraine process. Taking too many triptans can also lead to medication overuse headaches. Some triptans include:

• Sumatriptan (Imitrex, Tosymra)
• Rizatriptan (Maxalt)
• Naratriptan (Naramig)
• Zolmitriptan (Zomig)

Acute medication should be taken early while pain is mild. If you have aura, triptans should be taken at the start of the headache and not at the start of the aura (unless the aura and headache start simultaneously).

Anti-sickness medicines are also known as antiemetics and they can be used by those who experience nausea and vomiting with migraine headaches. They should be taken as soon as your migraine symptoms start. Your GP may prescribe these to you and advise you to take them alongside painkillers or triptans. These medicines can come with some side effects such as drowsiness and diarrhoea.

It may be useful to take combination medicines which act as painkillers and anti-sickness medicines. You are able to purchase these medicines at your local pharmacy without needing a prescription from your doctor. However, these combination medicines may not have a high enough dose of painkillers or anti-sickness medicine to relieve your symptoms effectively. In this instance, you may want to take both medications separately.

There are some medical devices that may reduce the symptoms of migraines by affecting the brain in different ways. These medical devices include a Cefaly device and a single-pulse transcranial magnetic stimulation (sTMS).

A Cefaly is a device that can be worn as a headband around the head for 20 minutes a day. This device was designed for migraine prevention and some research has shown it to be promising in reducing migraine symptoms in some individuals.

A sTMS is a device that can be placed on the head which uses pulses of magnetic energy to reduce the severity and frequency of migraines. However, these can only be used under prescription and are not appropriate for everyone.

You may be referred to a specialist if adequate treatment, as above, is not controlling your symptoms or the attacks are so frequent that they are seriously affecting the quality of your life. At times, a GP may be unsure about the diagnosis and may choose to refer you much earlier before offering you any treatment. The specialist can further investigate your symptoms and recommend treatment that is right for you.

Some individuals have found acupuncture to be an effective remedy for migraines when medications are not working to ease their symptoms. For this treatment, you may have to pay for it privately as most GP surgeries do not offer acupuncture treatment for migraines.

Your food choices may have an effect on the severity and frequency of your migraine. Fasting, skipping meals and not drinking enough water can trigger migraines. There are certain foods that can also contribute to migraines that you can avoid. Many patients have a combination of various triggers but certain patients can indicate precipitation of their migraine with foods, such as:

• Chocolate
• Alcohol (especially red wine and champagne)
• Processed meats
• Sweeteners
• Cheese
• Caffeine

There are several preventative medications you can take to help you have fewer migraines and reduce the severity of your migraine headaches. However, these medications can include side effects which you can talk to your GP about. Some preventative medications include:

• Anti-seizure drugs can work to calm nerve cells in the brain.
• Beta-blockers may work to prevent migraine headaches. They act to reduce the frequency and duration of migraine. These drugs are usually used to treat high blood pressure and heart disease. Some beta-blockers include Metoprolol (Lopressor, Toprol XL), Propranolol (Inderal, Innopran XL) and Timolol (Blocadren).
• Antidepressants can affect the level of the brain chemical serotonin, which may be linked to migraines. Some antidepressants include amitriptyline and venlafaxine.
• Candesartan is a blood pressure medication with anti-migraine effects and is often used when the first line medicines do not work.
• Botox injections are often used as the preventive therapy in patients with chronic migraine after failure of three first line drugs. These are given as intramuscular injections every three months by a trained clinician with experience in headaches.
• Ajovy (Fremanezumab) has recently been approved for the prevention of chronic migraine in patients in whom other medication has not worked.
• Triptans are used to treat migraines when they’re occurring, but one type, frovatriptan (Frova Migard), may help prevent migraines that women get because of their menstrual cycle.

Strenuous exercise like lifting heavy weights can cause migraines. However, there are some exercises that promote stress relief and reduce the occurrence of migraine headaches. Some of these exercises include yoga, light aerobics, or tai chi. Migraines can also occur after stressful situations. In order to prevent migraines happening, you can try different methods of relaxation such as meditation, yoga, and biofeedback.

Migraine triggers are variable for different people. Some experience more migraine in hot weather while others complain more during cold temperatures. For some overcast conditions bring on migraine, while others get more migraines during bright sunshine.

A change in your surroundings may be what is needed to ease your migraines. While the environmental factors cannot always be changed, you can sometimes avoid those triggers. For example, if bright sunshine triggers migraine one can stay indoors during hot sunny weather.

Other environmental factors that can trigger your migraines are flashing or flickering lights, loud noises and strange smells. There are some steps you can take to avoid situations with a lot of sensory stimulation. You can avoid:

• Driving at night
• Being in movie theatres
• Attending clubs or crowded venues
• The glare from the sun
• Staring at TV or computer screens without breaks

To prevent migraines, you should be aware of your migraine triggers and try to avoid them. Keep a headache diary close by and make a note of what happens prior to your migraine. You can make a note of:

• The weather
• What foods you eat or drink
• Your exercise routine
• Any strong feelings and emotions you may be having
• What medications you may have taken
• The frequency and severity of migraine symptoms

Migraines during pregnancy can be the result of many factors related to pregnancy changes, such as:

• Hormonal changes
• Fatigue
• Tension
• Blood sugar drops
• Physical or emotional stress
• Nasal congestion
• Overheating
• Lack of sleep
• Change in eating patterns
• Dehydration

New-onset severe migraines are rare in pregnant women, and pre-existing migraine can often improve. Always make sure your GP or midwife checks your blood pressure and performs a urine test in addition to a nerve examination if you experience new onset headaches in pregnancy. This is to rule out development of issues such as pre-eclampsia and cerebral venous thrombosis (blood clots).

You may be concerned about which drugs are safe to take when you are pregnant and experiencing a migraine. Generally, paracetamol and triptans are safe and effective when taken in a limited way. However, please check with your GP before using any other medication. Typically, nausea medications prescribed to women are safe to use if you are pregnant and experiencing migraine symptoms. Please avoid NSAID and aspirin. Sometimes codeine may be given if the headaches are extremely severe but only if your doctor feels it is really required.appropriate.

Please speak to your GP for further information on what medications are safe to take during pregnancy.

There are some pregnancy-safe treatments for the onset of migraines:

• Lie down in a dark and quiet room and place a cold or warm compress on your neck or forehead for two or three hours. This can help you relax and ease your migraine headache.
• Talk to your doctor about alternative methods and relaxation exercises that are safe during pregnancy. Tension in your back, neck, and head can cause pressure leading to a migraine.

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Dr Abby Hyams grew up in Manchester and did her medical training in Bristol. She has been a GP for over ten years, many of them as a partner in an NHS practice in Hemel Hempstead. Dr Hyams loves being a GP because of the wide spectrum of people she encounters every day.

Professor Fayyaz Ahmed is a Consultant Neurologist and Professor (Hon) in Clinical Neurology at Hull University Teaching Hospitals NHS Trust and Hull York Medical School. Professor Ahmed graduated from Dow Medical College Karachi, Pakistan in 1986. He moved on to the UK after his residency and received his neurology training at St James’s University Hospital, Leeds and Imperial College London.

He did his research on cerebral blood flow in migraine and clinical training in headache at the Princess Margaret Migraine Clinic, Charing Cross Hospital, London. He was appointed as Consultant Neurologist in Hull in 1996 where he established a dedicated headache clinic.

He did his MBA in Public Sector Management from University of Hull in 2010 and is currently the Educational Officer of the British Association for the Study of Headache (BASH) having served as a Secretary (2005-2008), Vice Chair (2009-2010) and Chair (2011-2013). He was Chair of Headache UK and Director of the European Headache and Migraine Trust International Congress (EHMTIC) and now serves as Trustee of the International Headache Society and Director of Migraine Trust International Symposium. He advises the Association of British Neurologist through advisory group membership and has co-authored the recent BASH guidelines for headache disorders.

Dr Saloni Kapoor is an enthusiastic and dynamic GP with a varied portfolio. She studied at University College London Medical School and trained as a GP in London. She has a multitude of special interests to include cancer medicine, genitourinary medicine, women’s health, integrative medicine and medical education. Saloni strongly believes in the transformative power of technology and innovation to solve the health challenges of the future and for telemedicine to ensure universal, safe and high-quality access to care for all.

This article is for general information only and should not be used for the diagnosis or treatment of medical conditions. Medic Spot Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. In the event of an emergency, please call 999 for immediate assistance.