What is a Migraine?
Migraine is a headache typically characterized by its unilateral onset, pounding character, and association with nausea and sometimes vomiting. A headache typically lasts for a few hours. Many patients have an aura prior to the onset of a migraine, which is usually described as a flashing appearance peripherally of the visual field. Migraine headache pain can be severe and debilitating. It often worsens with light and sound and patients frequently go into a quiet, dark room during their headache.
What Causes a Migraine?
Experts believe that a migraine headache is related to changes in the blood vessels in the brain. Some medications that lead to blood vessel dilation (e.g. nitrates) can provoke migraine headaches. There is also a strong genetic component as first-degree family members tend to be affected as well. Migraines affect women more often than men, and can be seen as early as adolescence throughout adulthood.
Certain things may trigger a migraine headache such as:
- Tobacco use
- Alcohol use or withdrawal
- Lack of sleep
- Elevated blood pressure
- Flu or sinus infections
- Depression or anxiety
- Certain medications (e.g. nitrates, albuterol inhalers, SSRIs)
- Head trauma
How Common is a Migraine?
Migraine headaches are a common condition that is frequently evaluated in the primary care clinic and the emergency department. This disease frequently requires referral to a neurology specialist.
The prevalence in the United States is approximately 4-9% in men and 11- 25% in women. Among women, about 20% of Caucasians, 16% of African Americans, and 9% of Asian Americans have a diagnosis of migraine headaches. About 7.7% of children and adolescents also experience migraines.
Signs and Symptoms
The most common symptoms of migraine include:
- Unilateral headache
- Nausea & vomiting
- Photophobia (sensitivity to light)
- Phonophobia (sensitivity to sound)
- Aura – may precede or occur during migraine – unilateral flashing lights in the peripheral field
- Temporary sensory loss or weakness – this can also occur with stroke or seizure
Your doctor will often perform a detailed neurologic and eye examination evaluating for:
- Visual acuity and visual fields
- Pupillary reflexes
- Facial expression and weakness
- Weakness or numbness in the limbs
- Knee and ankle jerk reflexes
- Balance & Coordination
- Cerebellar function
A migraine is diagnosed based on symptoms and physical examination. If it is your first migraine or you have a change in the quality of your prior migraine, your doctor may order blood tests such as a CMP (comprehensive metabolic panel), CBC (complete blood cell count), thyroid function (TSH, free T4), inflammatory markers (ESR/CRP), and coagulation studies (PT/INR, PTT). They may also obtain a pregnancy test if you are a woman of childbearing age.
Your doctor may consider evaluating for other important causes of headache besides primary migraine, including:
- Brain tumor
- Brain infection (e.g. meningitis, encephalitis)
- Temporal arteritis
- Trigeminal neuralgia
- Pseudotumor cerebri
- Intracranial hemorrhage – subdural hematoma, epidural hematoma, parenchymal hemorrhage
If the diagnosis of migraine is unclear, your doctor may obtain a CT scan of the head or MRI of the brain to rule out any structural abnormalities (e.g. tumor, infection, hemorrhage).
If they suspect infection (e.g. meningitis, encephalitis), they may recommend a spinal tap. During this procedure, they inject a needle into the fluid-filled pouch surrounding the spine – they then drain this fluid and analyze it for protein, blood, glucose, cell counts, and bacteria. They will often send the fluid for bacterial culture.
If you have worrisome symptoms such as the worse headache in your life, or headache associated neurologic deficits such as weakness, numbness, confusion, or visual loss/double vision, this can suggest an intracranial hemorrhage or stroke, which warrants a visit to the hospital. Also, if you have persistent nausea and vomiting and cannot hold anything down you may have to go to emergency department or call 911.
Other concerning features of headache include recent head trauma, headache worsening at nighttime/early morning, and increasing headache during episodes of bearing down (e.g. coughing, straining). The latter suggest that you have a space-occupying lesion in the brain that is causing increased intracranial pressure during Valsalva maneuvers.
Migraine Medication and Treatment
Patients with migraine headache often benefit from going into a quiet and dark room. Proper fluid hydration is important as dehydration can provoke migraine or make it worse especially in the setting of nausea and vomiting. Patients with a mild migraine headache can often achieve improvement in symptoms with the following medications:
- Tylenol (acetaminophen)
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Advil (ibuprofen)
- Naprosyn (naproxen)
There are some oral preparations such as Excedrin that contain the combination of acetaminophen, aspirin, and caffeine. Those with more severe migraine headaches unresponsive to acetaminophen or NSAIDs may require the use of opiate analgesics. This can include medications such as:
These are often found in formulations combined with acetaminophen such as Vicodin (hydrocodone-acetaminophen) and Percocet (oxycodone-acetaminophen).
Opiates are generally avoided due to their abuse potential and ability to cause dependence. If used, they should be taken at the lowest dose possible and for the shortest duration of time.
Migraine headaches often respond to a class of medications called Triptans - these are very effective in decreasing the severity of acute migraine:
Most Triptans are administered orally and sublingually, but some come in nasal spray preparations. The sublingual and nasal spray formulations are particularly useful in patients who are nauseated or vomiting. These medications are generally taken prior to the onset of headache. Taking them after the migraine starts can be less effective in improving symptoms.
If your headache is very severe and you decide to get evaluated in the emergency department, you may receive anti-nausea and antihistamine preparations to reduce your symptoms. These often include Reglan (metoclopramide) and Benadryl (diphenhydramine) given intravenously at the same time.
- Gilmore B, Michael M. Treatment of Acute Migraine Headache. Am Fam Physician. 2011 Feb 1;83(3):271-280. - https://www.aafp.org/afp/2018/0215/p243.html
- Negro A, Rocchietti-March M, Fiorillo M. Chronic migraine: current concepts and ongoing treatments. Eur Rev Med Pharmacol Sci. 2011 Dec;15(12):1401-20. - https://www.ncbi.nlm.nih.gov/pubmed/22288302
- Lionetto L, Negro A, Palmisani S,Emerging treatment for chronic migraine and refractory chronic migraine. Expert Opin Emerg Drugs. 2012 Sep;17(3):393-406. - https://europepmc.org/article/med/21459461
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.