Migraine Headaches

Topic Overview

What are migraine headaches?

Migraines are painful, throbbing headaches that last from 4 to 72 hours. When you have a migraine, it may be so painful that you are not able to follow your normal routine or do your usual activities. But even though they make you feel bad, migraines do not cause long-term damage.

Migraines are a disease. You cannot just "will them away." Talk to your doctor about your migraines. There are treatments that can help you manage them.

What causes migraines?

Experts are not sure what causes migraines.

Migraines run in families, but it is not clear why some people get migraines and others do not.

What are the symptoms?

The main symptom of a migraine is a throbbing headache on one side of your head. You may also feel sick to your stomach and vomit. Activity, light, noise, or odors may make the migraine worse. The pain may move from one side of your head to the other, or you may feel it on both sides at the same time. Different people have different symptoms.

Some people have an aura before the migraine begins. When you have an aura, you may first see spots, wavy lines, or flashing lights. Your hands, arms, or face may tingle or feel numb. The aura usually starts about 30 minutes before the headache. But most people do not have auras.

How are migraines diagnosed?

A doctor can usually tell if you have a migraine by asking about your symptoms and examining you. You probably will not need lab tests, but your doctor may order some if he or she thinks your symptoms are caused by another disease.

How are they treated?

You can usually manage your migraines. First try an over-the-counter pain medicine, such as ibuprofen or naproxen. Brand names include Advil, Motrin, and Aleve.

If over-the-counter medicine does not work, your doctor can prescribe stronger medicine that stops the migraine as it is starting. You may not be able to use some medicines if you are pregnant or have other health problems, such as heart problems or high blood pressure.

When you feel a migraine coming on:

  • Stop what you are doing, and take your medicine. Do not wait for the migraine to get worse. Take your medicine exactly as your doctor told you to.
  • Take it easy. Rest in a quiet, dark room. Close your eyes, and try to relax or go to sleep. Do not watch TV or read. Put a cold pack or cool cloth on the painful area.

If the first treatment you try does not work, ask your doctor if you can try something else. It may take time to find what works best for you.

Some people also use other kinds of treatments, such as acupuncture. These may help reduce the pain or the number of migraines you have.

Be careful when you use your migraine medicines. Taking them too often can cause you to get another headache when you stop taking the medicine. This is called a rebound headache. If you are taking headache medicine more than 2 days a week, or if you get more than 3 headaches a month, talk to your doctor.

Can you reduce how often you have migraines?

You may be able to reduce how often you have migraines by staying away from things that cause them. These are called "triggers." Common triggers include chocolate, red wine, cheese, MSG, strong odors, not eating, and poor sleep habits. It may be helpful for you to track and write down your triggers. You may be able to avoid the trigger and more migraines.

If you have migraines often, your doctor may prescribe medicine that helps prevent them.

Frequently Asked Questions

Learning about migraine headaches:

Being diagnosed:

Getting treatment:

Living with migraines:

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Decision Points focus on key medical care decisions that are important to many health problems. Decision Points focus on key medical care decisions that are important to many health problems.
  Headaches: Should I take medicine to prevent migraines?

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  Headaches: Managing a headache
  Migraines: Identifying and avoiding triggers

Cause

Migraines run in families, and a genetic link has been identified. But it is not entirely clear why some people get migraines and others do not.

Experts are not sure what causes migraines.

Symptoms

Migraine headache symptoms vary and may occur with or without a warning sign called an aura. People who get an aura, which usually begins within 30 minutes before the headache starts, may see spots, wavy lines, or flashing lights. Some people have numbness or a "pins-and-needles" sensation in their hands, arms, or face during the aura. But most people do not have an aura before they get a migraine headache.

Common symptoms of migraine include:

  • Throbbing or pulsating headache on one side of your head.
  • Moderate to severe headache intensity.
  • Headache that gets worse with routine physical activity.
  • Nausea, vomiting, or both.
  • Sensitivity to light and noise, and sometimes smells.

There are several types of migraine headaches, each with unique features. For example, some women get migraines before, during, or shortly after their menstrual periods.

It can be difficult to tell the difference between a migraine headache and another kind of headache (such as a tension or sinus headache). You may think your headaches are sinus headaches, but it is more likely they are migraine headaches if they happen often and interfere with your daily life. Unlike other headaches, migraines usually occur on one side of your head, although the side that is affected can shift with each new attack. Migraines are also often accompanied by sensitivity to light and noise.

Migraines may occur along with many other conditions, such as asthma or depression. More serious conditions, such as tumors or infections, can also cause migraine-like symptoms. Headaches that are caused by more serious health problems are rare.

What Happens

Symptoms before the migraine begins (prodromal)

In the day or two before a migraine starts, you may experience symptoms such as fatigue, excessive yawning, food cravings (such as for chocolate), irritability, or restlessness.

Aura

Some people (about 1 out of 5) experience a warning sign called an aura within 30 minutes before a migraine headache develops. Symptoms of an aura usually develop gradually over 5 to 20 minutes. During an aura, you may see wavy lines, flashes, sparks of light, blind spots, or distortions. You may also feel tingling or a "pins-and-needles" sensation in your hands, arms, or face.

Less commonly, you may temporarily be unable to put words in proper order or have difficulty finding the right words. You may also experience short-term weakness on one side of your body. If you have these symptoms and have not had them before, call your doctor immediately so he or she can rule out a transient ischemic attack (TIA), stroke, or other serious condition.

Onset of headache and accompanying symptoms

A migraine usually starts with throbbing pain on one side of the head. But it’s not uncommon to have pain on both sides of the head. Or you may experience the throbbing pain behind your eye.

Without treatment, a migraine headache lasts from 4 to 72 hours. The pain from the headache may be moderate to severe and can be disabling. Other symptoms that commonly occur with the headache include:

  • Extreme sensitivity to light, noise, and smells.
  • Nausea and vomiting.
  • Symptoms that get worse with physical activity.

Less commonly, problems with speech; tingling in the face, arms, and shoulders; or temporary weakness on one side of the body can occur.

Symptoms after the headache (postdromal)

After the headache eases, you may experience symptoms such as muscle aches, fatigue, or even a brief period of elation. These symptoms may last up to 24 hours after your migraine headache ends.

What Increases Your Risk

You may be more likely to get migraines if you:

  • Have a family history of migraines.
  • Are female. Women are three times more likely to develop migraines than men.
  • Are a teenager or young adult. Migraines commonly begin during these years.
  • Have depression, anxiety disorder, asthma, or epilepsy.

When To Call a Doctor

If you have a headache or have been diagnosed with migraine headaches, use the following information to help you decide when to call your doctor.

Call 911 or other emergency services if:

  • You have a very sudden, severe, "thunderclap" headache that seems to come on instantly and is unlike any headache you have had before.
  • You have symptoms of a stroke, such as:
    • Sudden numbness, paralysis, or weakness in your face, arm, or leg, especially on only one side of your body.
    • New problems with walking or balance.
    • Sudden vision changes.
    • New problems speaking or understanding simple statements, or feeling confused.
    • Drooling, or slurred speech.
    • A sudden, severe headache that is different from past headaches.

Call your doctor now or go to the emergency room if:

  • You develop fever and a stiff neck.
  • You have new nausea and vomiting, or you cannot keep food or liquids down.

Watch closely for changes in your health, and be sure to contact your doctor if:

  • Your headache does not get better within 24 hours.
  • Your headache wakes you up at night.
  • Your headaches get worse or happen more often.
  • You develop new symptoms.
  • You have any problems with your medicine, or your medicine isn't helping your headaches.
  • You are older than 50 and have new or more frequent headaches.
  • Your headaches occur after physical exercise, sexual activity, coughing, or sneezing.
  • Your life is disrupted by your headaches (for example, you miss work or school regularly).

Watchful Waiting

Watchful waiting is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment. Watchful waiting may be appropriate if you have recently been diagnosed with migraines and are taking medicine to reduce the pain or frequency of the migraines.

Who To See

Health professionals who may diagnose and treat your migraines include:

It may be helpful to see a doctor who has considerable experience treating migraines, especially if your migraines do not respond to drugs. If your child has migraines, it may be helpful for you to locate a doctor who has experience treating migraines in children. Research on the safety of migraine drugs for children is limited.

If you think your headaches might be linked to depression or anxiety, you may want to seek additional treatment from a psychiatrist, psychologist, or licensed mental health counselor.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Your doctor will diagnose a migraine by asking you questions about your health and lifestyle and by examining you. There are no lab tests that can confirm a diagnosis. Migraines can be difficult to diagnose because symptoms resemble those of other headache conditions. For example, many people have been diagnosed with sinus headaches when they actually have migraines. As a result, migraines are underdiagnosed and undertreated. You are likely having migraine headaches if they happen often and interfere with your daily life.

Your doctor may use the International Headache Society's criteria to diagnose migraines. You may be diagnosed if you experience 5 or more headache attacks without an aura (or 2 attacks with an aura) that last from 4 to 72 hours without treatment and are accompanied by symptoms of nausea, vomiting, or sensitivity to light or noise.

Your doctor will check your symptoms and decide whether you need to have tests to rule out other conditions that might be causing your headaches. Tests may include:

  • MRI or CT scan, which may be used to rule out tumors or bleeding in the brain.
  • Lumbar puncture (also called a spinal tap), which may be done if your doctor thinks that you might have another condition such as meningitis or bleeding in the brain.
  • Sedimentation rate (a blood test), which may help determine whether another condition is causing inflammation related to your headaches.

Treatment Overview

Although there is no cure for migraines, you can often reduce and possibly prevent some migraines. Drugs are available to prevent or treat migraines.

You may also reduce the number of migraines you have by identifying and avoiding triggers that lead to migraines, such as drinking red wine or getting too much or too little sleep.

For more information, see:

Click here to view an Actionset. Migraines: Identifying and avoiding triggers.

Initial and ongoing treatment

At first you may use pain relievers that you can buy without a prescription, such as acetaminophen (for example, Tylenol), and nonsteroidal anti-inflammatory drugs (NSAIDs)) such as aspirin, ibuprofen, or naproxen, to reduce migraine symptoms. Some over-the-counter medicines combine acetaminophen, aspirin, and caffeine (for example, Excedrin). Most doctors recommend that you first try an NSAID to see whether it reduces pain before trying abortive or preventive drugs, which may have more side effects.

Initial treatment depends on how severe your migraine attacks are and how often they occur, but usually includes drugs to stop a headache (abortive) or drugs to prevent a headache (preventive), along with treatments that may reduce stress.

The most commonly used abortive drugs are:

  • Acetaminophen or NSAIDs, such as aspirin, some of which you can buy without a prescription.
  • Triptans (serotonin receptor agonists). These are usually the first type of prescription medicines tried to quickly stop a migraine attack.
  • Ergotamine derivatives, such as Cafergot.
  • Midrin, which is a combination of the drugs isometheptene, acetaminophen, and dichloralphenazone.

Your doctor may recommend that you take a combination of medicines to stop a headache. For example, he or she may have you take a nonprescription medicine (such as acetaminophen or naproxen) with a prescription medicine (such as a triptan).

Antinausea drugs (such as prochlorperazine or metoclopramide) are sometimes prescribed along with abortive drugs to relieve symptoms of nausea and vomiting.

The most commonly used preventive drugs—used to avoid or reduce the frequency of migraine attacks—include:

For more information on preventive medicines, see:

Click here to view a Decision Point. Should I take medicine to prevent migraines?

Complementary therapies may be added to drug treatment to reduce or prevent migraine symptoms. Be sure to ask your doctor before you try these therapies, to make sure they are safe for you. These therapies include:

  • Acupuncture, which involves putting very thin needles into the skin at certain points on the body. Current evidence suggests that acupuncture can help prevent some headaches.1
  • Biofeedback, a relaxation method for learning to control a body function that is not normally under conscious control, such as muscle tension.
  • Butterbur, which is an herb that has been shown to help prevent migraines in some people.2
  • Feverfew, which is an herb that has been studied a lot for migraine prevention. Some small studies show that it may help prevent migraines in some people. But most experts think the benefits are still unproven.3
  • Magnesium, which some doctors recommend to help prevent migraines. Studies have found that some people with migraines have low levels of magnesium in the brain.4
  • Relaxation techniques to reduce stress and tension.
  • Riboflavin (vitamin B2) and coenzyme Q10, which in small studies have both been shown to help prevent migraines.5

Treatment if the condition gets worse

If you continue to have migraines while receiving treatment, you and your doctor may want to change your abortive or preventive headache drugs or try a different type of migraine drug. If you have already tried several different types of migraine drugs, your doctor may seek additional testing (such as MRI or CT scan) to rule out other causes for your recurring headaches.

It is possible you have been misdiagnosed with migraines when you really have another type of headache. It can be difficult to distinguish migraines from other types of headaches such as sinus, tension, or cluster headaches, as symptoms can be similar or overlap. Different types of headaches require different treatment.

What To Think About

Even with treatment, you may continue to have migraines. The goal of treatment is to reduce the frequency of attacks and relieve your symptoms as quickly as possible with the fewest drug side effects. For mild to moderate migraines, you may first want to try a nonprescription pain reliever that has fewer side effects and is less expensive than other drugs. But if this treatment is not effective or if you have frequent or severe headaches, prescription drugs may be needed.

Finding an effective medicine may require some time and patience.

Overuse of abortive headache drugs or pain relievers can cause rebound headaches. Rebound headaches are different from migraine headaches. They are usually triggered after pain medicine has worn off, prompting you to take another dose. Eventually you get a headache whenever you stop taking the drug. Be sure to take your migraine medicine only as prescribed by your doctor.

If you think your recurring headaches could be associated with depression or anxiety, be sure to let your doctor know. You may be able to eliminate or reduce some headaches with proper treatment of these conditions.

Prevention

You may be able to reduce frequent migraines by avoiding triggers, such as certain foods, stress, and changes in your daily routine, although it is not clear how or why these events lead to migraines. Some common triggers of migraines include:

  • Consuming certain substances such as chocolate, monosodium glutamate (MSG), red wine, and caffeine.
  • Getting too much or not enough sleep.
  • Fasting or skipping meals.
  • Changes in the weather or barometric pressure.
  • Stress or intense emotions.
  • Strong odors or cigarette smoke.
  • Bright lights or reflected sunlight.

For more information, see:

Click here to view an Actionset. Migraines: Identifying and avoiding triggers.

Your doctor may also prescribe drugs to help prevent migraine headaches.

Home Treatment

There are many steps you can take at home to reduce the frequency of migraine attacks and treat the symptoms, such as reducing stress, taking prescription drugs, and identifying and avoiding migraine triggers.

  • Find healthy ways to deal with stress. Migraine headaches seem to be more common during stressful times or right after you have "let down" after a stressful time.
  • Practice relaxation techniques to reduce muscle tension and stress.
  • Take preventive drugs as prescribed by your doctor.
  • To help identify triggers of your headaches and determine if your headaches are becoming more severe or more frequent, keep a headache diary(What is a PDF document?) .
  • Seek help if you think that your migraines may be linked to depression or anxiety. Proper treatment of these conditions may reduce the frequency of your migraines.

For more information, see:

Click here to view an Actionset. Migraines: Identifying and avoiding triggers.
Click here to view an Actionset. Headaches: Managing headaches.

Often children's headaches are related to stress about school, such as tests, athletic or social events, or peer pressure. They may also be related to lack of sleep. If your child has headaches, follow the treatment your doctor recommends. If your child has trouble managing his or her headaches with home treatment and your doctor's advice, keep a diary of the headaches and talk with your doctor.

Medications

Drugs are used to treat migraine symptoms after they have started (abortive drugs) as well as to prevent future attacks (preventive drugs). You may have to try several different drugs or types of drugs before you find the one that is right for you. Good communication with your doctor is important in this process.

Usually, your doctor will first prescribe a drug that causes the fewest side effects. Drugs may be prescribed based on the type of migraine that you experience. If your migraines are mild to moderate, you may need only a nonprescription drug to relieve your symptoms. But if your migraines are moderate to severe and disabling, you may need a prescription migraine drug to treat your symptoms. If you experience frequent migraine attacks, your doctor may suggest a preventive drug.

Medication Choices

Abortive drugs—used to stop a migraine attack—include:

  • Acetaminophen (Tylenol, for example) and NSAIDs, such as aspirin or ibuprofen, which may be tried first to reduce migraine symptoms.
  • Triptans (serotonin receptor agonists). These are usually the first type of prescription medicine tried to quickly stop acute migraine attacks.
  • Ergotamine derivatives, such as Cafergot.
  • Midrin, which is a combination of the drugs isometheptene, acetaminophen, and dichloralphenazone.

Your doctor may recommend that you take a combination of medicines to stop a headache. For example, he or she may have you take a nonprescription medicine (such as acetaminophen or naproxen) with a prescription medicine (such as a triptan).

Preventive drugs—used to avoid or reduce the frequency of migraine attacks—include:

For more information, see:

Click here to view a Decision Point. Should I take medicine to prevent migraines?

What To Think About

It may take several attempts with different drugs before the right one or combination of drugs is found. It is a good idea to try a nonsteroidal anti-inflammatory drug (NSAID), such as aspirin or ibuprofen, to reduce headache pain before trying a prescription migraine drug, which may have more side effects than an NSAID.

Your doctor may recommend that you take a combination of medicines to stop a headache. For example, he or she may have you take a nonprescription medicine (such as acetaminophen or naproxen) with a prescription medicine (such as a triptan).

Because many people who have migraines also have depression, taking prescription medicines for both problems is common. In very rare cases, when a triptan such as sumatriptan (Imitrex) for migraines is taken with an SSRI (selective serotonin reuptake inhibitor) or SNRI (selective serotonin/norepinephrine reuptake inhibitor) such as fluoxetine (Prozac) or duloxetine (Cymbalta) for depression, these medicines can cause a very rare but serious condition called serotonin syndrome. But most people take these two types of medicines together and have no problems. If you are worried about serotonin syndrome, talk to your doctor.

If you experience increased nausea or vomiting as a side effect of a migraine drug, your doctor may also prescribe an antinausea drug to reduce these symptoms.

Overuse of migraine drugs or pain relievers can cause rebound headaches. Rebound headaches are different from migraine headaches. They are usually triggered after pain medicine has worn off, prompting you to take another dose. Eventually you get a headache whenever you stop taking the drug. Be sure to take your migraine medicine only as prescribed by your doctor.

Surgery

There is no surgical treatment for migraine headaches.

Other Treatment

Although drugs are usually the primary treatment for migraines, adding complementary therapies may help reduce symptoms and the frequency of your migraine attacks. You may want to try these therapies after discussing them with your doctor. Therapies include:

  • Acupuncture, which involves putting very thin needles into the skin at certain points on the body. Current evidence suggests that acupuncture can help prevent some headaches.1
  • Biofeedback, a relaxation method for learning to control a body function that is not normally under conscious control, such as muscle tension.
  • Butterbur, which is an herb that has been shown to help prevent migraines in some people.2
  • Feverfew, which is an herb that has been studied a lot for migraine prevention. Some small studies show that it may help prevent migraines in some people. But most experts think the benefits are still unproven.3
  • Magnesium, which some doctors recommend to help prevent migraines. Studies have found that some people with migraines have low levels of magnesium in the brain.4
  • Relaxation techniques to reduce stress and tension.
  • Riboflavin (vitamin B2) and coenzyme Q10, which in small studies have both been shown to help prevent migraines.5

Other Places To Get Help

Organizations

National Institute of Neurological Disorders and Stroke
P.O. Box 5801
Bethesda, MD  20824
Phone: 1-800-352-9424
(301) 496-5751
TDD: (301) 468-5981
Web Address: www.ninds.nih.gov
 

The National Institute of Neurological Disorders and Stroke (NINDS), a part of the National Institutes of Health, is the leading U.S. federal government agency supporting research on brain and nervous system disorders. It provides the public with educational materials and information about these disorders.


American College of Physicians
90 North Independence Mall West
Philadelphia, PA  19106-1572
Phone: 1-800-523-1546
(215) 351-2600
Web Address: www.acponline.org/patients_families
 

The American College of Physicians (ACP) is a national organization of internists. Doctors of internal medicine focus on adult medicine and have had special study and training focusing on the prevention and treatment of adult diseases. The ACP provides information for patients and families on the organization's Web site, including information on diseases and conditions, end-of-life care, women's issues, and immunizations. The site also offers video news stories, health tips, special reports, and a link to the ACP diabetes Web page.


American Headache Society Committee for Headache Education (ACHE)
19 Mantua Road
Mount Royal, NJ  08061
Phone: 1-800-255-2243
Fax: (856) 423-0082
E-mail: achehq@talley.com
Web Address: www.achenet.org
 

The American Headache Society Committee for Headache Education (ACHE) is a nonprofit partnership between health professionals and headache sufferers. ACHE provides resources and tools to health care professionals to help them help their headache patients. This Web site has many different educational resources for doctors, patients, families, schools, and employers. Resources include newsletters, articles on headaches, tools for both patients and doctors, and lists of certified headache doctors.


National Headache Foundation (NHF)
820 North Orleans
Suite 217
Chicago, IL  60610
Phone: 1-888-643-5552
(312) 274-2650
E-mail: info@headaches.org
Web Address: www.headaches.org
 

The National Headache Foundation is a nonprofit organization dedicated to three major goals: educating the public that headaches are serious disorders and that sufferers need understanding and continuity of care; promoting research into potential headache causes and treatments; and serving as an information resource for sufferers, their families, and doctors who treat them. The NHF can provide lists of local doctors specializing in headache treatment. It also has a monthly newsletter and many pamphlets on a variety of topics related to the different headache syndromes.


References

Citations

  1. Linde K, et al. (2009). Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews (1).
  2. Lipton RB, et al. (2004). Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology, 63(12): 2240–2244.
  3. Pittler MH, Ernst E (2004). Feverfew for preventing migraine. Cochrane Database of Systematic Reviews (1).
  4. Evans RW, Taylor FR (2006). "Natural" or alternative medications for migraine prevention. Headache, 46(6): 1012–1018.
  5. Sándor PS, et al. (2005). Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial. Neurology, 64(4): 713–715.

Other Works Consulted

  • Landy S, et al. (2004). Efficacy and tolerability of sumatriptan tablets administered during the mild-pain phase of menstrually associated migraine. International Journal of Clinical Practice, 10: 913–919.
  • Loder E, et al. (2004). Efficacy and tolerability of oral zolmitriptan in menstrually associated migraine: A randomized, prospective, parallel-group, double-blind, placebo-controlled study. Headache, 44: 120–130.

Credits

Author Monica Rhodes
Editor Kathleen M. Ariss, MS
Associate Editor Michele Cronen
Associate Editor Terrina Vail
Primary Medical Reviewer Martin Gabica, MD - Family Medicine
Primary Medical Reviewer Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer Colin Chalk, MD, CM, FRCPC - Neurology
Last Updated June 30, 2009

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