MIGRAINE HEADACHE OVERVIEW

Headaches can be quite debilitating, although the vast majority are not due to life-threatening disorders. Approximately 90 percent of headaches are caused by one of three syndromes (table 1):

 

• 
  Migraine headache


• 
  Tension-type headaches


• 
  Cluster headaches

 

This article discusses migraine headaches in adults. Other types of headaches are discussed separately. (See "Patient information: Headache causes and diagnosis in adults (Beyond the Basics)" and "Patient information: Headache treatment in adults (Beyond the Basics)".)

MIGRAINE HEADACHE SYMPTOMS

Between 12 and 16 percent of people in the United States experience migraine headaches, making it the second most common type of headache.

Pain — The pain of a migraine headache usually begins gradually, intensifies over minutes to one or more hours, and resolves gradually at the end of the attack. The headache is typically dull, deep, and steady when mild to moderate in severity; it becomes throbbing or pulsatile when severe.

Migraine headaches are worsened by light, sneezing, straining, constant motion, moving the head rapidly, or physical activity. Many migraine sufferers try to get relief by lying down in a darkened, quiet room. In 60 to 70 percent of people, the pain occurs on only one side of the head. In adults, a migraine headache usually lasts a few hours, although it can last from four to 72 hours.

Other symptoms — Migraine headaches are often accompanied by nausea and vomiting, as well as sensitivity to light and noise. Between 10 and 20 percent of people with migraines also experience nasal stuffiness and runny nose, or teary eyes.

The symptoms of a migraine attack may be severe and alarming, but in most cases there are no lasting health effects when the attack ends.

Aura — About 20 percent of people with migraines experience symptoms before the headache; this is called an aura. The aura may include flashing lights or bright spots, zigzag lines, changes in vision, or numbness or tingling in the fingers of one hand, lips, tongue, or lower face. You may have one or more of these aura symptoms.

Auras may also involve other senses and can occasionally cause temporary muscle weakness or changes in speech; these symptoms can be frightening.

Aura symptoms typically last five to 20 minutes and rarely last more than 60 minutes. The headache occurs soon after the aura stops. Muscle-related auras may last longer.

MIGRAINE HEADACHE TRIGGERS

Migraines can be triggered by stress, worry, menstrual periods, birth control pills, physical exertion, fatigue, lack of sleep, hunger, head trauma, and certain foods or drinks that contain chemicals such as nitrites, glutamate, aspartate, tyramine. A partial list of potential triggers appears in the table (table 2).

Certain medications and chemicals can also trigger a migraine, including nitroglycerin (used to treat chest pain), estrogens, hydralazine (used to treat high blood pressure), perfumes, smoke, and organic solvents with a strong odor.

Headache diary — People who have frequent or severe headaches may benefit from keeping a headache diary over the course of one month. This can be used to determine what triggers the migraines and what makes them better. A sample diary is included here (figure 1).

MIGRAINE HEADACHE TREATMENT TYPES

Migraine headache treatment depends upon the frequency, severity, and symptoms of your headache.

 

• 
  Acute treatment refers to medicines you can take when you have a headache to relieve the pain immediately.


• 
  Preventive treatment refers to medicines you can take on a regular (usually daily) basis to prevent headaches in the future.

 

Acute treatment — The pain of migraines can be tough to get rid of. Treatment is most likely to work if you take it at the first sign of an attack (eg, at the first sign of aura if one occurs, or when pain begins).

In some people, an aura occurs before the migraine (see 'Aura' above). Therefore, an aura can serve as a reliable warning that a migraine headache is on the way, and should be the signal to take migraine medication. (See "Acute treatment of migraine in adults".)

Pain relievers — Mild migraine attacks may respond to pain relievers, some of which are available without a prescription. These drugs include:

 

• 
  Aspirin


• 
  Acetaminophen (sold as Tylenol®)


• 
  Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (sold as Motrin® or Advil®), indomethacin, or naproxen (sold as Naprosyn® or Aleve®).


• 
  Indomethacin is a prescription medicine that comes in a rectal suppository, which may be useful for people who have nausea during their headaches.

 

Pain relievers are also available in combination with caffeine, which enhances their antimigraine effect. As an example, some pain relievers contain a combination of acetaminophen, aspirin, and caffeine.

Pain relievers are often recommended first for mild to moderate migraine attacks. However, they should not be used too often because overuse can lead to medication-overuse headaches or chronic daily headaches. If you respond to a pain reliever, continue taking it with each attack, as long as you do not take it more than once or twice per week.

People with gastritis (inflammation of the stomach), ulcers, kidney disease, and bleeding conditions should not take products containing aspirin or NSAIDs.

Anti-nausea medications — If you have nausea and vomiting with a migraine, you can take an anti-nausea medicine by injection or rectal suppository. In some cases, antimigraine drugs can be taken in combination with drugs that alleviate nausea and vomiting, such as metoclopramide or prochlorperazine. Anti-nausea medications given by mouth are usually used in combination with other medications to treat acute migraine. However, anti-nausea medications can be given alone in the hospital by intravenous and intramuscular administration to treat acute migraine headache.

Triptans — If a pain reliever does not control your migraine pain, most healthcare providers will recommend a treatment that is migraine-specific. This includes a class of medications called triptans. Examples of triptans are sumatriptan (also sold as Imitrex®), zolmitriptan (sold as Zomig®), naratriptan (sold as Amerge®), rizatriptan (sold as Maxalt®), almotriptan (sold as Axert®), eletriptan (sold as Relpax®) and frovatriptan (sold as Frova®).

Triptans can be used at home or work/school, and are all available in an oral (pill) form. Sumatriptan and zolmitriptan are available as nasal sprays, and sumatriptan is available as an injection.

People with familial hemiplegic migraine, basilar migraine, uncontrolled high blood pressure, vascular disease (including ischemic stroke and coronary artery disease), Prinzmetal's angina, pregnancy, and severe kidney or liver disease should not take triptans in most cases.

 

• 
  Sumatriptan — Sumatriptan is available in many different formulas, including a tablet, nasal spray, and injection. Over 70 percent of people get pain relief within one hour of injecting sumatriptan; by two hours, 90 percent of people notice improvement. Your healthcare provider can help to decide which formula (pill, nasal spray, or shot) is best for you.

 

Common side effects of injectable sumatriptan include pain at the injection site, dizziness, a feeling of warmth, and tingling in the arms or legs. Most of these reactions occur soon after the injection and resolve within 30 minutes. These drugs are safe for most patients.

Sumatriptan nasal spray begins to work faster than the pill form and has fewer side effects than the injection. The most common side effect of the nasal spray is an unpleasant taste.

A tablet that contains a combination of sumatriptan-naproxen (sold as Treximet®) appears to be more effective than each medication taken alone. It is not known if taking the two medications separately would be as effective as the combination tablet.

Ergots — Ergotamine is an older, migraine-specific drug. It is often combined with caffeine. Ergots are not usually as effective as triptans and are more likely to cause side effects. Ergots are sometimes recommended for people with migraines of a long duration (greater than 48 hours) or that frequently recur. People with high blood pressure, coronary artery disease, or kidney or liver disease should not use ergotamines.

Dihydroergotamine is related to ergotamine, and can be taken by nasal spray for mild or moderate migraine attacks. It can also be given by injection for severe attacks.

Other medications — Other medications for migraine are not as well studied or are less effective. A small percentage of people with migraine headaches do not respond to routine acute treatments and may require additional treatment for pain.

Dexamethasone is a glucocorticoid (steroid) medication that can be given by injection, along with another acute migraine treatment, to reduce the risk of a migraine coming back. Dexamethasone injections may be given in an emergency department or clinic.

Preventive treatment — Preventive treatment effectively controls migraine headaches in most people, although the benefits of this treatment may not be evident for three to four weeks. In some cases, both acute treatment and preventive treatment are necessary to adequately control migraines. (See "Preventive treatment of migraine in adults".)

Beta blockers — Beta blockers were originally developed to treat high blood pressure. In addition, beta blockers reduce the frequency of migraine attacks in 60 to 80 percent of people. Commonly used beta blockers include propranolol, nadolol, atenolol, and metoprolol. Beta blockers may cause depression in some people or impotence in some men.

Antidepressant medications — Tricyclic antidepressants (TCAs) and certain other antidepressant medications are often recommended for migraine prevention. These include amitriptyline, nortriptyline, and doxepin. Of these, amitriptyline has proven benefit for migraine prevention, while there is less data for the other tricyclics.

Side effects are common with tricyclic antidepressants. Most of these drugs cause drowsiness, particularly amitriptyline and doxepin. Therefore, these drugs are usually taken at bedtime and started at a low dose. Additional side effects of tricyclics can include dry mouth, constipation, palpitations, weight gain, blurred vision, and urinary retention. Confusion can occur, particularly in older adults.

Anti-seizure medications — The anti-seizure medications valproate (also called divalproex or Depakote®), gabapentin, and topiramate (sold as Topamax®) are sometimes used to prevent migraines.

 

• 
  Valproate is an anti-seizure drug that seems to work as well as beta blockers for preventing migraine, and may be better tolerated. However, valproate can cause weight gain and hair loss. Women who are pregnant or sexually active and not using birth control (pills, condoms, etc) should not take valproate.


• 
  Gabapentin was effective for reducing migraine headache frequency in a small clinical trial. Potential side effects include lightheadedness, drowsiness, dizziness, and balance problems.


• 
  Topiramate is an anti-seizure drug that can help to prevent migraine. It can cause mild to moderate side effects that may include abnormal sensations (often tingling), fatigue, nausea, changes in taste, loss of appetite, diarrhea, and weight loss. More severe side effects can occur, including difficulty with thinking and concentration.

 

Calcium channel blockers — Calcium channel blockers were developed to treat high blood pressure. Calcium channel blockers are widely used for migraine prevention. Examples of calcium channel blockers include verapamil and nifedipine extended-release. Verapamil is frequently used as a first choice for preventive migraine therapy because it is easy to use and has few side effects.

Calcium channel blockers may lose their effectiveness over time, but this can sometimes be remedied by taking a higher dose of the drug or switching to a similar drug.

Herbal therapies — Herbal therapies have been evaluated for the treatment of migraine headache, including feverfew and butterbur. Of these, feverfew has been the most widely studied. Some studies have found it to be effective for migraine prevention, although most experts agree that the benefits are still unproven. Neither treatment is recommended.

Avoiding medication overuse — It is essential to use antimigraine medications according to the prescription and clinician's instructions. Overuse of certain medications for migraine, including over-the-counter drugs such as acetaminophen and nonsteroidal antiinflammatory drugs, or prescription drugs such as triptans, can lead to medication-overuse headaches (also called rebound headaches) and to a pattern of daily headaches that require increasing quantities of drugs for relief.

A vicious cycle occurs when frequent headaches cause you to take medications, which then cause rebound headaches as the medications wear off, causing you to take more medication, and so on. (See "Patient information: Headache treatment in adults (Beyond the Basics)".)

Speak with a healthcare provider if your migraine treatment does not relieve your headaches or if you are having unpleasant medication side effects. Switching to another drug or switching from acute treatment to preventive treatment may be helpful.

MENSTRUAL MIGRAINES

Migraines occur about three times more commonly in women than in men. Estrogen has a variable effect on the frequency and severity of a woman's migraines; some women who take birth control pills (which contain estrogen) or hormone replacement therapy experience worsening headaches, while others improve. Similarly, some women have more frequent or severe headaches during pregnancy while others have improvement. (See "Estrogen-associated migraine".)

Menstrual migraines are migraine headaches that occur around the beginning of a woman's menstrual period (usually two days before to three days after the period begins). Women with menstrual migraine may also have migraines at other times during the month. Most often, there is no migraine aura associated with menstrual migraines, even if the woman usually has aura at other times.

Menstrual migraines are thought to be triggered by the normal decrease in estrogen levels that occurs before the menstrual period begins. Menstrual migraines tend to be longer lasting, more severe, and more resistant to treatment than other types of migraine.

Treatment — Initial treatment of acute menstrual migraine is the same as treatment for migraine occurring at any other time. (See 'Acute treatment' above.)

Preventive therapies for menstrual migraine can be either nonspecific (those that do not address the hormonal trigger) or specific (hormone-based treatments). (See "Estrogen-associated migraine", section on 'Preventive therapies'.)

With nonspecific strategies, success requires accurate anticipation of menses for scheduling interventions; therefore, women with irregular cycles are not good candidates for these options. Coexisting problems, such as dysmenorrhea, menorrhagia, endometriosis, as well as contraception needs may influence choice of preventive therapy.

A preventive treatment may be useful for women who have menstrual migraines on a predictable schedule. This treatment strategy is called "mini-prophylaxis".

 

• 
  Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen or naproxen are one option for mini-prophylaxis of menstrual migraine.


• 
  Triptans such as frovatriptan, sumatriptan, or naratriptan are another option. Typically, long-acting triptans are dosed twice daily beginning two days before anticipated menses and continued for five days.

 

Hormonal treatments may be recommended to prevent menstrual migraines. One approach is to use estrogen-progestin contraceptive pills in an extended cycle; another choice is menstrually-targeted supplemental estrogen. These treatments work by preventing a rapid decline in the level of estrogen in the body before the menstrual period, which is believed to trigger the migraine. However, some experts avoid treatment with estrogen-progestin contraceptives for women who have a menstrual migraine with aura. Others consider the use of such treatment only for healthy women younger than age 35 who do not have focal neurologic signs and who do not smoke.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Headache (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Headache causes and diagnosis in adults (Beyond the Basics)

Patient information: Headache treatment in adults (Beyond the Basics)

 

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Acute treatment of migraine in adults

Basilar-type migraine

Chronic migraine

Estrogen-associated migraine

Evaluation of headache in adults

Headache syndromes other than migraine

Headache, migraine, and stroke

Preventive treatment of migraine in adults



The following organizations also provide reliable health information.

 

• 
  National Library of Medicine

 

(www.nlm.nih.gov/medlineplus/migraine.html, available in Spanish)

 

• 
  National Institute of Neurological Disorders and Stroke

 

(www.ninds.nih.gov/disorders/migraine/migraine.htm)

 

• 
  American Headache Society

 

(www.achenet.org/resources/information_for_patients/)

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