Migraine

Overview

A migraine is a headache that can cause intense throbbing pain or a pulsing feeling, usually on one side of the head. It often happens with nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so bad that it interferes with your daily activities.

For some people, a warning symptom known as an aura occurs before or with a migraine. An aura can include visual changes, such as flashes of light or blind spots. The aura also can cause tingling on one side of the face or in an arm or leg and trouble speaking.

Medicines can help prevent some migraines and make them less painful. Combining medicines with self-help remedies and lifestyle changes also might help.

Causes

Though migraine causes aren't fully understood, genetics and environmental factors appear to play a role.

Changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway, might be involved. Imbalances in brain chemicals also might be involved — including serotonin, which helps regulate pain in your nervous system. Researchers are studying the role of serotonin in migraines.

Other chemical messengers play a role in migraine pain, including calcitonin gene-related peptide, also known as CGRP.

Migraine triggers

There are a number of things that can bring on a migraine, including:

• Hormonal changes. Fluctuation in estrogen levels seems to trigger headaches in many people. This can happen before or during menstrual periods or during pregnancy and menopause. Hormonal medicines, such as oral contraceptives, also can worsen migraines. Some people, however, find that their migraines occur less often when taking hormonal contraceptives.
• Alcohol and caffeine. Alcohol, especially wine, and too much caffeine, such as in coffee, can trigger a migraine.
• Stress. Stress at work or home can cause migraines.
• Sensory stimuli. Bright or flashing lights can induce migraines, as can loud sounds. Strong smells can trigger migraines in some people. These smells can include perfume, paint thinner, secondhand smoke and other triggers.
• Sleep changes. Missing sleep or getting too much sleep can trigger migraines in some people.
• Physical strain. Intense physical exertion, including sexual activity, might provoke migraines.
• Weather changes. A change of weather or barometric pressure can prompt a migraine.
• Medicines. Oral contraceptives and vasodilators, such as nitroglycerin (Nitrostat, Nitro-Dur, others), can aggravate migraines.
• Foods. Aged cheeses and salty and processed foods might trigger migraines. Skipping meals also can bring on a migraine.
• Food additives. These include the sweetener aspartame and the preservative monosodium glutamate, also called MSG. These additives are found in many foods.

Complications

A complication for some people with migraines is medication overuse headaches. Taking painkillers too often can trigger these headaches. Medication overuse headaches may occur if you take aspirin or ibuprofen (Advil, Motrin IB, others) for more than 14 days a month. Or they can occur if you take medicines known as triptans for more than nine days a month. The risk seems to be highest with medicines that combine aspirin, acetaminophen and caffeine.

Medication overuse headaches can lead to a painful cycle. If medicines stop relieving pain and begin to cause headaches, you might then try taking more pain medicine to find relief.

Treatment

Migraine treatment is aimed at stopping symptoms and preventing future attacks.

Medicines

Many medicines have been designed to treat migraines. They fall into two broad categories:

• Pain-relieving medicines. Also known as acute or abortive treatments, these medicines are taken during migraine attacks and are designed to stop symptoms.
• Preventive medicines. These medicines are taken regularly, often daily, to reduce migraine symptoms.

Your treatment choices depend on how often you have headaches and how painful they are. Your treatment also depends on whether you have nausea and vomiting, whether your headaches are disabling, and whether you have other medical conditions.

Pain-relieving medicines

Medicines used to relieve migraine pain work best when taken as soon as symptoms begin. These medicines include:

• Pain relievers. Pain relievers that you can get with or without a prescription include aspirin and ibuprofen (Advil, Motrin IB, others). Medicines that combine caffeine, aspirin and acetaminophen (Excedrin Migraine) may be helpful, but usually only against mild migraine pain. But be sure to talk with your healthcare professional about how often it's safe to take these medicines. When taken too long, they can cause medication overuse headaches and possibly ulcers and bleeding in the gastrointestinal tract.
• Triptans. These prescription medicines can relieve many symptoms of migraine by blocking pain pathways in the brain. Triptans are taken as pills, shots, nasal sprays, nasal powders and disintegrating tablets. They include sumatriptan (Imitrex, Tosymra, others), rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan, almotriptan, eletriptan (Relpax) and frovatriptan (Frova). They might not be safe to take if you're at risk of a stroke or heart attack.
• Dihydroergotamine (Migranal, Trudhesa). Available as a nasal spray, this medicine is most effective when taken shortly after the start of symptoms for migraines that tend to last longer than 24 hours. Side effects can include worsening of migraine-related vomiting and nausea. People with coronary artery disease, high blood pressure, or kidney or liver disease should avoid dihydroergotamine.
• Lasmiditan (Reyvow). This is an oral medicine approved for the treatment of migraines with or without aura. In studies, lasmiditan significantly improved headache pain. Lasmiditan can make you sleepy and cause dizziness, so don't drive or operate machinery for at least eight hours after taking it.
• Oral calcitonin gene-related peptides antagonists, also known as gepants. Ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) are oral gepants approved for the treatment of migraines in adults. In clinical trials, medicines from this class were more effective than placebo at relieving pain two hours after taking them. They also were effective at treating migraine symptoms such as nausea and sensitivity to light and sound. Common side effects include dry mouth, nausea and too much sleepiness. Ubrogepant and rimegepant should not be taken with strong CYP3A4 inhibitor medicines such as some medicines used to treat cancer.
• Intranasal zavegepant (Zavzpret). This nasal spray is a gepant that can relieve migraine pain within two hours and for up to 48 hours. It also can improve other symptoms, such as nausea and sensitivity to light and sound. Side effects of zavegepant include a change in your sense of taste, nasal discomfort and throat irritation.
• Antinausea medicines. These are usually taken with pain medicines and can help if you have nausea and vomiting with your migraines. Medicines include chlorpromazine, metoclopramide (Gimoti, Reglan) and prochlorperazine (Compro).
• Opioid and barbiturate medicines. Opioids or barbiturates may help if you can't take other migraine medicines. However, they're usually avoided due to better and more effective options. Because they can be highly addictive, these medicines are used only if no other treatments are effective.

Some migraine medicines are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medicines without first talking with your healthcare professional.

Preventive medicines

Medicines can help prevent frequent migraines. Your healthcare professional might recommend these medicines if you have long-lasting, very bad headaches that happen often and don't respond well to treatment.

Preventive medicine can reduce how often you get a migraine, how painful the attacks are and how long they last. Options include:

• Blood pressure-lowering medicines. These include beta blockers such as propranolol (Inderal LA, InnoPran XL) and metoprolol (Lopressor, Toprol-XL). Calcium channel blockers such as verapamil (Verelan) can be helpful in preventing migraines with aura.
• Antidepressants. Tricyclic antidepressants, such as amitriptyline and nortriptyline, are the most commonly used medicines to prevent migraine. These medicines have side effects that include dry mouth and sleepiness, and they may interact with other medicines. For these reasons, another antidepressant with fewer side effects or interactions, such as venlafaxine (Effexor XR), might be prescribed instead.
• Antiseizure medicines. Valproate and topiramate (Topamax, Qudexy XR, others) might help if you have less frequent migraines. These medicines can cause side effects such as dizziness, weight changes, nausea and others. They're also not recommended in people who are pregnant or who are trying to get pregnant.
• Botox injections. Shots of onabotulinumtoxinA (Botox) about every 12 weeks help prevent migraines in some adults.
• Calcitonin gene-related peptide, also called CGRP, monoclonal antibodies. These medicines help prevent migraines by blocking the chemical messenger CGRP. Medicines include erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), galcanezumab-gnlm (Emgality) and eptinezumab-jjmr (Vyepti). They're given monthly or once every three months by injection. The most common side effect is a reaction at the injection site.
• Atogepant (Qulipta). This medicine is a gepant that helps prevent migraines. It's a tablet taken by mouth daily. Potential side effects of the medicine include nausea, constipation and fatigue.
• Rimegepant (Nurtec ODT). This medicine is unique in that it's a gepant that helps prevent migraines in addition to treating migraines after they begin.

Ask your healthcare professional if these medicines are right for you. Some are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medicines without first talking with your healthcare professional.

Neuromodulation therapy

Devices that stimulate nerves, known as neuromodulation devices, can reduce the number of migraines you have or make them less painful. The devices are noninvasive and work by stimulating a peripheral or cranial nerve to change the brain's response to pain. Therapies include transcutaneous supraorbital nerve stimulation, external vagal nerve stimulation and distal transcutaneous electrical stimulation. Combined occipital and trigeminal neurostimulation is another option.

Another therapy called single-pulse transcranial magnetic stimulation treats the brain to relieve migraine pain. For this therapy, you place the device on the back of your head.

Alternative medicine

Nontraditional therapies might help with chronic migraine pain.

• Acupuncture. Clinical trials have found that acupuncture may be helpful for headache pain. In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin at defined points.
• Biofeedback. Biofeedback appears to be effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses related to stress, such as muscle tension.
• Cognitive behavioral therapy. Cognitive behavioral therapy may benefit some people with migraines. This type of psychotherapy teaches you how behaviors and thoughts affect how you perceive pain.
• Meditation and yoga. Meditation may relieve stress, which is a known trigger of migraines. Done on a regular basis, yoga may reduce the number of migraines you have or how long they last.

• Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur might prevent migraines or reduce their severity, though study results are mixed. Butterbur isn't recommended because of safety concerns.

  A high dose of riboflavin, also called vitamin B-2, may reduce the number of migraines you have and how painful they are. Coenzyme Q10 supplements might decrease the frequency of migraines, but larger studies are needed.

  Magnesium supplements have been used to treat migraines, but with mixed results.

Ask your healthcare professional if these treatments are right for you. If you're pregnant, talk with your healthcare professional before trying any of these treatments.