Migraine Headaches

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Migraine headaches are a common medical problem and a frequent cause of disability.  In fact of adults over the age of 18, migraines are one of the top 20 causes of disability worldwide.1Severe migraine attacks are actually classified by the WHO as one of the most disabling diseases. 2 In the 2011 National Health Interview survey, 16.6% of adults over the age of 18 reported having migraines or other severe headaches in the previous 3 months.  It was found to be the 5th leading cause of ED visits and represented 1.2 % of outpatient visits.3 A survey of neurologists found that one-third of all their patients consulted them because of migraines.4 It has been estimated that 50% of migraine patients remain undiagnosed and undertreated.5


What Causes Migraine Headaches?


Although the exact cause of migraine headaches is unknown, genetics and environmental factors appear to play a role. Researchers have noted a drop in serotonin levels (a chemical in the brain) during migraine attacks. The role of serotonin is being studied.6 There is also recent evidence that the process of the migraine and what makes people susceptible to certain triggers lies within the brain stem.7 More recently, genetic factors have been investigated. Migraines have been found to be an inheritable disorder. A team of scientists discovered a genetic mutation that may make people more susceptible to developing migraines.8 It appears then, the etiology of migraines has many contributing factors and more research is being done to learn the exact mechanism by which people develop this illness.


The Prevention of Migraines is Based on Identifying Triggers!

There have been noted to be many triggers in migraine sufferers of what brings about an acute attack.

Hormonal changes Changes in estrogen level seem to trigger migraines in women with migraines. It can be worse immediately before or during their periods. Also, may be increased during pregnancy and menopause. Birth control pills and hormone replacement therapy may also trigger headaches.
Foods Aged cheeses, salty foods and processed foods may also trigger migraine headaches.
Food additives The sweetener aspartame and MSG may also trigger attacks.
Drinks Alcohol, especially wine and caffeinated beverages may also trigger attacks.
Stress Can worse migraines
Sensory stimuli Bright lights, sun glare, loud sounds, unusual smells can trigger migraines
Too much or too little sleep Can trigger migraines. Also, jet lag.
Physical factors Intense physical exertion, including sexual activity
Environmental changes Change in weather or barometric pressure
Medications Many meds may trigger migraines.




The Patient’s History and Exam is Often Enough to Make a Diagnosis of Migraines.


Migraine headaches are largely diagnosed based on patient symptoms.  About 75% of all patients with migraines are women. During childhood, boys and girl are equally affected. After puberty, it is more common on girls. It typically occurs in women between the ages of 20-45. Many children will stop having migraines when they reach adulthood or will have their headaches change to less severe tension type headaches. 10

Common symptoms include a headache on one side of the head which is throbbing in nature. It can cause moderate to severe disability. It can be associated with nausea, vomiting, sensitivity to light and sound and the pain can be increased with physical exertion. In children, the duration is generally shorter than in adults. Usually, children have less noticeable associated symptoms and may present as cyclic vomiting, abdominal symptoms, or vertigo. It is important to know that no single characteristic is needed to make the diagnosis.  The 3 most predictive symptoms are disability, nausea, sensitivity to light. Less than a third of patients will also have local neurologic signs just before or during headaches. These are also called auras. They are most commonly visual and less often sensory or motor in nature. Migraines can also present with nasal congestion and runny nose, making it often confused with sinus headaches. And they are very often confused with tension headaches as many migraine patients often have neck pain right before or during an attack.11


Acute Migraine Attacks Can Come in Types and Phases


Migraines can come in four symptom phases, although they do not occur in every patient or every attack.  Patients may have a prodromal phase, a group of unclear symptoms before an attack, the attack, and the postdrome phase. In the prodromal phase, patients may experience sensitivity to light or sound, changes in appetite, thirst, fatigue and drowsiness, and mood changes, including depression, irritability and restlessness. 12

There are many types of migraine headaches. Here we shall focus on the two most common types: migraines with aura (classic migraines) and migraines without aura. The International Headaches Society Diagnosis Criteria is used to classify migraines. The second edition replaced the previous in 2004.


Migraine headaches without aura are diagnosed when a patient has at least 5 attacks with 2-4 of the following:

    •  Headache attacks that last 4-72 hours (untreated or unsuccessfully treated)
    •  The headache has at least two of the following four characteristics:
      – unilateral location
      – pulsating quality
      – moderate or severe intensity which interferes with daily activities
      – worsened routine physical activity
    •  During the  headache at least one of the two following symptoms occur:
      – nausea and/or vomiting
      – photophobia (sensitivity to light)  and phonophobia (sensitivity to sound)
    •  At least one of the following three characteristics is present:
      – history and physical do not suggest another disorder
      – if another disorder is suspected, it has been ruled out by diagnostic tests
      – another disorder is present, but the migraine does not occur within a certain time of that other disorder


  • Migraines with aura are diagnosed when:
    •  At least two attacks fulfilling 2 of the following
  • Headache has at least three of the following four characteristics:
    – one or more fully reversible aura symptoms –
  • at least one aura -symptom develops gradually over more than 4 minutes, or two or more symptoms occur in succession
    – no aura symptom lasts more than 60 minutes; if more than one aura symptom is present, accepted duration is increased in relationship to this.
    – headache follows aura with a free interval of less than 60 minutes (it may also begin before or simultaneously with the aura).
  • At least one of the following three characteristics is present:
    – history and physical examinations do not suggest another disorder
    – history and physical examinations do suggest such a disorder, but it is ruled out by appropriate investigations
    – such a disorder is present, but migraine attacks do not occur for the first time in close relation to the disorder. 13

What are auras?

Aura symptoms can further be defined into positive or negative auras. Positive auras include bright or shimmering lights or shapes at the edge of the field of vision, which are called scintillating scotoma. Other positives are zigzag lines or stars. Negative auras are dark holes, blind spots or tunnel vision (inability to see to the side). Patients may have mixed positive and negative auras. Other neurologic symptoms may also occur, including speech disturbance, tingling/numbness or weakness in an arm or leg, perceptual disturbances such as space or size disturbance or confusion. These are less common.14

When Does a Headache Require Further Testing?

Most migraine headaches can be diagnosed based just on the history and physical examination. The only time a diagnostic test would be done is when a secondary cause of headache is suspected.  The following are reasons that physicians would consider doing neuroimaging studies:

-The worst headache of a person’s life

-headaches with increasing frequency or severity

-a progressive headache

-chronic daily headaches

-headaches that are not responding to treatment

-new onset headaches in patients who have cancer or who have HIV infection

-new onset headache after the age of 50

-patients who have headaches and seizures

-headaches with other signs and symptoms, such as fever, stiff neck, nausea and vomiting

-headaches that are associated with papilledema (swelling of the optic nerve seen on exam of the retina), cognitive impairment or personality change

An MRI study of the brain is the preferred diagnostic test. A Ct scan can be done in patients who have a contraindication for having an MRI. Blood tests are not helpful.15

When Should I be Concerned that my Migraine May be Something Else?

There are also times when neuroimaging should be considered in patients who already have the diagnosis of migraine headaches. Reasons would include:

-unusual, persistent, or prolonged aura

-increasing severity, or change in clinical features

-first or worst migraine



-aura without headache


Treatment of Migraines Focuses on Relieving the Acute Attack and Preventing Further Ones.

The treatment of migraine headaches involves two approaches: treating acute attacks and preventing them. There are studies that show 38% of patients who suffer migraine headaches need preventive treatment, but only 3-13% actually uses it.17

There are many effective treatments for migraine headaches available. The main types of medicine for treating an acute attack are: OTC pain relievers such as Tylenol or ibuprofen, Ergotamines, Triptans, and other prescription pain meds. It is recommended to start with over-the-counter meds first for mild to moderate attacks. If the headache is severe, a prescription NSAID (non-steroidal anti-inflammatory) can be used. The next step is usually a Triptan (which will be discussed in more detail). In some patients, Ergotamines may help. Also, medications to treat the nausea and vomiting may be prescribed.18

The goals of treating an acute attack are as follows:

-treating the attack quickly and consistently with little recurrence

-getting the patient functional

-reduce the use of back up medication

-it is easily administered by the patients themselves

-be cost effective

– have minimal side effects19


What Medications are Available for Treating Acute Migraine attacks? 

Triptans were the first medications developed specifically for the treatment of migraine headaches and remain the most important treatment option. They work by helping maintain serotonin levels in the brain, which is a chemical found naturally in the brain. They are recommended when NSAID’s fail in patients with moderate to severe migraine headaches. They work for most patients and do not have sedative side effects. The oldest one is Sumatriptan (Imitrex).  It can be used as a rapid dissolving pill, nasal spray or injection. Side effects include tingling and numbness in the toes, warm sensations, pain in the ears, nose & throat, nausea, dizziness, muscle weakness, chest heaviness, and rapid heart rate. They should be avoided in patients with heart disease or risks for heart disease. Additionally, they should not be used in patients taking a certain class of anti-depressants called SSRI’s. When combined, it can lead to a potentially life threatening condition that starts suddenly with the most significant features of increased heart rate, shaking, shivering and sweating. This condition will not occur if the SSRI is discontinued prior to starting the triptan or replacing it with another class of medication.20

Ergotamines have been used for the treatment of acute attacks for over 50 years. Its use has not been shown to be conclusively beneficial. It is only beneficial in a limited number of patients, usually those have infrequent or headaches of longer duration and are more likely to follow dosing restrictions.  Side effects include muscle weakness and pain, numbness and tingling in the fingers and toes, local edema, itching, and bradycardia. They should not be used in women who are or may become pregnant. They should also not be used in patients with any kind of vascular disease, or patients with any decreased functioning of their kidneys and liver.21


       I am Getting Frequent Migraine Attacks. How Can I prevent Them?

Preventing migraine headaches include both the use of medication and behavioral therapies. Patients who should be started on preventive modalities include those who are not helped by acute treatment meds, those who have attacks more than once per week, and those having side effects or contraindications to taking them.  The main medications used for prevention are Beta-blocker drugs (usually propranolol or timolol), anti-seizure medications (divalproex, valproate, gabapentin or toprimate), tricyclic anti-depressants (amitriptyline) or the dual inhibitor amitriptyline (venlafaxine) and the triptan frovatriptan (for menstrual migraines). Botox injection has also been recently approved for the prevention of migraines. A preventive medication usually starts at a low dose and is gradually increased as needed.  It may take a few months for it to be effective.22

Other preventive medications studied include ACE inhibitors, Calcium channel blockers and SSRI’s.  ACE inhibitors were found to be possibly effective but no clear guidelines on their use exist. Calcium channel blockers were found to be probably effective and the evidence on their use to prevent migraines appears to be insufficient.  The medications that have shown evidence of preventing migraines are Divalproex, sodium valproate, Toprimate, Metoprolol, Propranolol, Timolol, Frovatriptan. SSRI’s have been shown to be probably effective.23

Beta-blockers such as Propranolol and Timolol which are generally used for the treatment of high blood pressure have also been approved for the treatment of migraine prevention. Metoprolol is also recommended and atenolol and Naldolol may be considered. Side effects include, fatigue, vivid dreams, depression, memory loss, dizziness which may be worse upon standing, decreased exercise capacity, cold feet or hands, asthma worsening, decreased heart function, gastrointestinal problems, and sexual dysfunction. These medications should not be stopped suddenly. Anti-seizure medications can cause nausea and vomiting, diarrhea, cramps, tingling in arms or legs, hair loss, dizziness, fatigue, blurred vision, weight changes, Divalproex, valproic acid and toprimate are the only anti-seizure medications approved for preventing migraine headaches. They can also cause birth defects and should not be taken by women pregnant or who might become pregnant. Additionally, the anti-seizure medications can increase suicidal thoughts and behavior. 24

Tricyclic antidepressants were first used effectively to treat migraine headaches in 1964. They have become a mainstay of the treatment of migraines. The effect of the improvement of migraine headaches improves over time of using the medication.  Side effects include dry mouth, drowsiness, and gastrointestinal distress.25 These medications are effective in preventing migraines, and the response is usually more rapid (within 4 weeks) than with β-blockers.26   Amitriptyline hydrochloride is the first-line medication among the tricyclic antidepressants for the use of preventing migraines.27

Botox has recently become approved by the FDA for the treatment of chronic migraine headaches. They have shown it effective in preventing migraines. It is usually given approximately every 12 weeks as a series of injections in the head and neck. The FDA has placed a “boxed warning” on Botox. The warning says the effects of botox may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism.

These symptoms can include swallowing and problems breathing. The FDA has not confirmed any cases of the spread of the toxin effect when Botox has been used at the recommended dose to treat chronic migraines. The drug also can cause muscle weakness, blurred vision, drooping eyelids, loss of bladder control, and hoarseness.28



 What Can I do to Prevent Migraine Attacks if I Don’t Want to take Medications?

Nonpharmacologic treatment of migraine is often used by patients. Avoiding of trigger factors can help. Behavioral approaches, such as relaxation techniques, biofeedback, and cognitive-behavioral therapy, are supported by some older evidence. The same is true for hypnosis. Aerobic exercise can also be effective. There is no good evidence for the use of spinal manipulation. Hyperbaric oxygen may be an effective. The evidence pertaining to the efficacy of acupuncture is controversial. Nutritional supplements acting on mitochondrial metabolism, such as magnesium, riboflavin, and coenzyme Q10 was shown in some small studies to be helpful. More studies are needed to be done on these non-pharmacologic management.29


                A very helpful tool can be keeping a headache diary and trying to determine triggering events. The following is a sample that can be used. It is obvious by looking at it how it can be helpful in making this determination:


Time Headache Began

Time headache Ended

Warning Signs (aura)

Location of Pain

Type of Pain (pressing, throbbing, piercing, etc.)

Intensity of Pain* (circle one number to the right)1 2 3 4 5 6 7 8 9 10

Other Symptoms (nausea, vomiting)

Medication Taken/ Other Treatment

Effect of Treatment

How Headache Affected My Normal Routine

Hours of Sleep the Night Before the Headache

What I Ate Before the Headache

Activities Before Headache Occurred

Important or Stressful Events That Occurred Today


  Complications of Migraines Can be Serious. 

Complications of migraine headaches include the following: chronic migraines which are unrelieved with medications, seizures, stroke, and persistent auras.  Risk factors for patients with migraines developing strokes include having migraines with auras, being a woman, smoking, and the use of estrogen.30

Migraines progresses to chronic at the rate of 2.5% per year. To classify migraines as chronic, an arbitrary definition of 15 or more headaches per month has been set. Risk factors for migraine turning chronic include: obesity, depression, and medication overuse. These risk factors can be changed by lifestyle changes, treating depression, and avoiding overusing pain meds. Caffeine has also been suggesting as a risk factor but more study is needed to prove this. Chronic migraines can be very disabling so identifying this complication is very important. Additionally, there are some modifiable risk factors that can ease the suffering of this disease.31

A migraine triggered seizure is defined as one occurring during or within 1 hour of a migraine aura. They are more common in children. It is often misdiagnosed as epilepsy. More study is needed in this complication.32

There are many studies exploring the risk of migraine headaches in stroke.  It most commonly occurs in women over the age of 45 who have migraines with auras.  It is further increased by smoking and the use of estrogen. The mechanism is not exactly known. Migraines appear to be less of a risk factor after the age of 50.33

My approach is to start by identifying triggering factors. I ask patients to keep a diary and try to identify things that may be triggering attacks. I point out common migraine triggers as listed above and ask them to look for these things. If any triggers are found, lifestyles changes are recommended. I start with abortive (medication for the acute attack to stop it) meds. I typically start with NSAID’s as mentioned above. I then move to triptans when these do not work. The exact medication I choose is often based on the patient’s insurance coverage. If the patient continues to get persistent migraines, usually more than 1-2 per week, I recommend prophylaxis (preventive) medication. I typically start with anti-depressants or anti-seizure medications. This is tailored to the individual patient depending on coexisting medical problems and other factors. If the patient fails prophylaxis or develops complications, I will then refer the patient to a neurologist. I order diagnostic tests as per the guidelines addressed above.



Migraine headaches are one of the biggest causes of disabilities and time missed from work. There is a lot still not known about migraines.

  • There are many triggers that cause migraine attacks. The most common cause include hormones, certain foods/food additives, alcohol, stress, too much or too little sleep, physical exertion, environmental factors, and certain medications.
  • Typical symptoms of migraines include throbbing on one side of the head, nausea, vomiting, and sensitivity to light and sound.
  • There are three symptom phases: prodromal (before the attack, the attack, and postdrome (after the arrack). These phases may not occur in every patient or even every attack.
  • The two most common types of migraines are: migraines with aura and migraines without aura.
  • Most of the time migraines can be diagnosed based just on the history and physical examination.
  • Patients only need neuroimaging studies (i.e. MRI or CT scan) in cases where there might be a secondary cause of the headache.
  • In those cases, MRI as it is the preferred diagnostic test.
  • Some cases of extreme or prolonged symptoms of patients already diagnosed with migraines will also need neuroimaging.
  • There are two approaches to the treatment of migraine headaches: treating acute attacks and preventing them. However, many people do not use the preventative treatment.
  • The first line of treatment for migraine is OTC (over the counter) pain medications, which is also the recommended starting treatment.
  • If the starting treatment does not achieve its goal then a prescription NSAID (non-steroidal- anti-inflammatory) can be used.
  • If another step is needed then a Triptan can be used.
  • Triptans, which are the most important treatment option, were the first medications developed specifically for the treatment of migraines
  • Preventing migraines includes a combination of medication and behavioral therapy
  • Non pharmacologic treatments for migraines include: avoiding trigger factors, relaxation techniques, biofeedback, and cognitive behavioral therapy.
  • Avoiding trigger factors is a very essential component.


There are many theories regarding the cause of migraine headaches, including vascular abnormalities, genetics, environmental factors, nerve dysfunction and chemical imbalances in the brain. It seems most likely the true etiology lies in a combination of these causes. Further research is needed to determine the exact cause of migraines so more targeted medications can be developed to treat migraines. Additionally, many patients would clearly prevent from preventive medicine. Yet, the vast majority of patients do not take preventive medications. More patient education is needed so patients know this option is available. And more clinicians need to offer these medications to patients.



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Authored by Linda Girgis, MD

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