Everything You Need to Know About Migraine

Author: J. Flowers Health Staff

What is a Migraine?

A migraine is a common disabling primary headache disorder characterized by attacks of throbbing, unilateral headache which are exacerbated by physical activity and associated with photophobia, phonophobia, nausea, and vomiting (and sometimes cutaneous allodynia – pain provoked by non-noxious tactile stimuli).¹

Although there are several migraine sub-types, only two are major: migraines with aura and migraines without aura.²

What is Aura?

Aura is a manifestation of focal cerebral dysfunction. It is neurally driven – likely due to a mechanism called cortical spreading depression of Leão – with visual, sensory, or motor symptoms most common.³

The distinction between migraine with aura and migraine without aura is best explained using the diagnostic criteria set forth by the International Headache Society (HIS) in the International Classification of Headache Disorders, 3rd edition (ICHD-3), published in 2018.

Migraines With Aura (Previously Termed ‘Complicated Migraine’

Migraines with aura are primarily characterized by transient focal neurological symptoms that usually precede or sometimes accompany the headache. About one-third of people with migraines have migraines with aura. Migraines with aura diagnostic criteria include:

At least two attacks fulfilling criteria B and C
At least one of the following fully reversible aura symptoms:
- Visual
- Sensory
- Speech and/or language
- Motor
- Brainstem
- Retinal
At least three of the following six characteristics:
- At least one aura symptom spreads gradually over five minutes
- At least two symptoms occur in succession
- Each aura symptom lasts five to sixty minutes
- At least one aura symptom is unilateral
- At least one is positive
- Aura accompanied or followed, in less than sixty minutes, by headache
Not better accounted for by another ICHD-3 diagnosis

Migraines Without Aura (Previously Termed ‘Common Migraine’)

Migraines without aura are a clinical syndrome and neurobiological disorder characterized by headaches with specific features and associated symptoms. Migraines without aura diagnostic criteria include:

At least five attacks fulfilling criteria B-D
Headache attacks lasting four to seventy-four hours (untreated or successfully treated)
Headache has at least two of the following characteristics:
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by or causing avoidance of routine physical activity (e.g. walking, climbing stairs)
During headache at least of the following occur:
- Nausea and/or vomiting
- Photophobia and phonophobia
Not better accounted for by another ICHD-3 diagnosis

What Does a Migraine Feel Like?

The pain experienced in migraines is pulsating, defined below along with other types of headache pain.

Pulsating: characterized by rhythmic intensification in time with the heartbeat
Throbbing: synonym for pulsating
Pressing/tightening: the pain of a constant quality (like a tight band around the head)
Stabbing: sudden pain lasting a minute or less (usually a second or less)

Migraine vs. Headache

Migraine is a type of headache disorder.

A headache is one of the best-classified neurological diseases. As previously mentioned, the ICHD-3 hierarchically organizes and provides diagnostic criteria for all headache disorders. The ICHD-3 consists of fourteen sub-groups organized into three parts – the primary headaches, the secondary headaches, and painful cranial neuropathies, other facial pain, and other headaches.

The primary headaches include migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders.

The Principles of Migraines

What Causes a Migraine?

The pathophysiology of migraines is based on the anatomy and physiology of pain-producing structures of the cranium as well as knowledge of central nervous system modulation of these pathways.4 More than one mechanism (e.g., blood flow, chemicals, electrical signals) and multiple locations are involved, and the abnormal brain activity that occurs during a migraine can be triggered by a variety of factors, but the exact basis for the initiation and cessation of migraine attacks is not known.⁵

Types of Migraines

Many types of migraines can be found in part one of the ICHD-3. The last two types in this section, menstrual and vestibular, are found in the Appendix of the ICDH-3, indicating that more research is needed before the entity can be included in the main body of classification.

Migraine With Brainstem Aura (Previously Termed ‘Basilar Migraine’)

Migraines with brainstem aura are migraines with aura symptoms originating from the brainstem, but no motor weakness. Migraines with brainstem diagnostic criteria include:

Attacks fulfilling criteria for migraine with aura and criterion B below
Aura with both of the following:
- At least two of the following fully reversible brainstem symptoms:
  - Dysarthria
  - Vertigo
  - Tinnitus
  - Hypoacusis
  - Diplopia
  - Ataxia not attributable to sensory deficit
  - Decreased level of consciousness
- No motor or retinal symptoms

Hemiplegic

A hemiplegic migraine is a migraine with aura including motor weakness (not paralysis, even though plegic means paralysis in most languages). Hemiplegic migraine diagnostic criteria include:

Attacks fulfilling criteria for migraines with aura and criterion B below
Aura consisting of both of the following:
- Fully reversible motor weakness
- Fully reversible visual, sensory, and/or speech/language symptoms

Chronic

Chronic migraine is a headache occurring fifteen or more days per month for more than three months which has features of migraine headache on at least eight days per month. Chronic migraine diagnostic criteria include:

Headache (migraine-like or tension-type-like) on at least fifteen days/month for more than three months, and fulfilling criteria B and C
Occurring in a patient who has had at least five attacks fulfilling criteria B-D for migraine without aura and/or criteria B and C for migraine with aura
On at least eight days/month for more than months, fulfilling any of the following:
- Criteria C and D for migraine without aura
- Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
Not better accounted for by another ICHD-3 diagnosis

The last criterion for almost every headache disorder in the ICHD-3 is ‘Not better accounted for by another ICHD-3 diagnosis.’ It’s a routine part of the clinical diagnostic process to consider other possible diagnoses. For example, medication overuse is the most common cause of symptoms suggestive of chronic migraine. Around 50% of patients that appear to have chronic migraines revert to an episodic migraine-type after drug withdrawal.

Abdominal

At least five attacks of abdominal pain, fulfilling criteria B-D
Pain has at least two of the following three characteristics:
- Midline location, periumbilical or poorly localized
- Dull or ‘just sore’ quality
- Moderate or severe intensity
At least two of the following four associated symptoms or signs:
- Anorexia
- Nausea
- Vomiting
- Pallor
Attacks last two to seventy-two hours when untreated or unsuccessfully treated
Complete freedom from symptoms between attacks
Not attributed to another disorder

Menstrual

Less than 10% of women have attacks of migraines in association with most of their menstrual cycles. Of these attacks, most are without aura. Attacks during menstruation tend to be longer and come with more severe nausea than attacks outside the menstrual cycle. More research is needed to determine the role hormones play in the mechanism of migraine during the menstrual cycle.

Vestibular (Previously Termed ‘Migraine-associated Vertigo/Dizziness’)

Vestibular migraine diagnostic criteria:

At least five episodes fulfilling criteria C and D
A current or past history of migraine without aura or migraine with aura
Vestibular symptoms of moderate or severe intensity, lasting between five minutes and seventy-two hours
At least half of episodes are associated with at least one of the following three migrainous features:
- Headache with at least two of the following four characteristics:
  - Unilateral location
  - Pulsating quality
  - Moderate or severe intensity
  - Aggravation by routine physical activity
- Photophobia and phonophobia
- Visual aura
Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder.

Phases of migraine

Typical migraines progress through four phases: prodrome, aura, headache, and postdrome.

The Principles of Migraines

Migraine Symptoms

Prodrome Symptoms

Prodrome is a symptomatic phase, lasting up to forty-eight hours, occurring before the onset of pain in migraine without aura or before the aura in migraine with aura. Common prodromal symptoms include:

Fatigue

Difficulty in concentrating

Neck stiffness

Sensitivity to light and/or sound

Nausea

Blurred vision

Yawning

Pallor

Elated or depressed mood

Unusual hunger

Cravings for certain foods

Aura Symptoms

Aura symptoms typically last between five and sixty minutes and are classified as visual, sensory, speech and/or language, motor, brainstem, or retinal. Aura symptoms may be positive or negative. Positive phenomena are caused by active release from central nervous system neurons, while negative phenomena indicate a lack or loss of function.⁶

Examples of each type of aura are given below:

Visual

A zigzag figure appearing near the point of fixation, which may spread gradually sideways and/or take on a “laterally convex” shape with a scintillating (sparkling/shining) edge (also known as “fortification spectrum” due to its resemblance to the wall of a medieval fortress)
Scotoma

Sensory

Pins and needles moving slowly from point of origin and affecting a greater or smaller part of one side of the body, face, and/or tongue
Numbness

Speech and/or Language

Aphasia (loss of ability to understand or express speech)

Motor

Weakness

Brainstem

Dysarthria (distinct from aphasia)
Vertigo
Tinnitus
Hypacusis
Diplopia
Ataxia
Decreased level of consciousness

Retinal

Monocular (in one eye):
- Scintillations
- Scotomata
- Blindness

Headache Symptoms

The most frequent accompanying symptoms (occurring with, rather than before or following) of migraines are:

Nausea
Vomiting
Photophobia (hypersensitivity to light, even at normal levels, usually causing avoidance)
Phonophobia (hypersensitivity to sound, even at normal levels, usually causing avoidance).

Postdrome Symptoms

Postdrome is a symptomatic phase, lasting up to forty-eight hours, following the resolution (complete remission) of pain in migraine attacks with or without aura. Common postdrome symptoms include:

Feeling tired or weary
Difficulty with concentration
Neck stiffness

Triggers of a Migraine

A migraine trigger is any factor that on exposure or withdrawal leads to the development of a migraine headache. The most common triggers are stress, sleep disturbances, fasting, caffeine consumption, and visual stimuli. The table below illustrates the vast number of possible trigger factors.⁷

Behavioral	Dietary
Fasting	Caffeinated beverages
Emotions	Alcoholic beverages
Sleep disturbances	Aged cheeses
Stress	Chocolate
Exercise	Ice cream
Environmental	Chemical
Bright light/visual stimuli	Monosodium glutamate (MSG)
Odors	Tyramine
Weather changes	Nitrates
Cigarette smoke	Aspartame
Infectious	Hormonal
Upper respiratory infections	Menstruation

Triggers are defined by how frequently they are associated with a change in headache pattern and as such are classified as either:⁸

Definite: associated more than 50% of the time
Possible: associated 25-50% of the time
Unlikely: associated less than 25% of the time

Sensitivity

It can be difficult to determine whether sensory stimuli (e.g., visual, auditory, or olfactory) are actual triggers or people with migraines are just more sensitive to stimuli during the prodrome. Examples are included below.

Smell: Perfumes, paints, gasoline, bleach, rancid smells, smoke, exhaust fumes
Noise: Loud or high-pitched sounds
Visual: Sunlight, striped patterns, bright or flashing lights

Caffeine

Migraines can be triggered by caffeine withdrawal. One study found that caffeine discontinuation improved responsiveness to migraine treatment.

Hormones

Hormone changes during menstruation, ovulation, and pregnancy can result in migraines.

Barometric pressure changes

Low barometric pressures alone are probably unlikely to trigger a migraine unless accompanied by other factors such as hypoxia at high altitudes or Saharan dust.

Painkillers

Painkillers can be a trigger of medication overuse headache, which is not explicitly migrainous, but the symptoms of medication overuse headaches can mimic those of chronic migraines.

An Overview of Migraine Triggers

Diagnosis of a Migraine

Diagnosis of migraines is based on patient history, physical examination, and fulfillment of diagnostic criteria. In practice, if a patient has a type of headache that fulfills two different sets of ICHD-3 diagnostic criteria, other information – such as headache history (how/when did headache start), family history, the effect of drugs, menstrual relationship, age, and gender – is used to decide which diagnosis is correct or more likely.

Migraine Journal

Determining what triggers a migraine is key to determining how to prevent it. However, the subjective nature of migraine headaches means that physicians rely heavily on patient reporting (e.g., of pain, frequency of attacks, etc.). In addition, depending on the trigger, it can take twenty-four hours after exposure to a trigger factor to cause a migraine.

For these reasons, some people keep a migraine journal as a way to track and identify their trigger factors. Once identified, it may be possible to modify such triggers. Thus, keeping a migraine journal may be particularly beneficial to those who experience chronic migraines or those whose migraine headaches cannot be managed with abortive medication.

Severity of Headaches

Status migrainosus is a debilitating migraine attack lasting more than seventy-two hours. ICHD-3 diagnostic criteria state that the attack in this sub-type is typical of previous attacks (as of migraine with or without aura) except for its duration and severity. Medication overuse can cause symptoms of status migrainosus.

What Are the Risk Factors of a Migraine?

Genetics

Many people with migraines have first-degree relatives who also suffer from this issue.

Gender

Women have migraines around three times more frequently than men. For women, menstrual changes may be the most common trigger. Estrogen withdrawal before menses is likely the cause of menstrual migraines.⁸

Stress

Stress can contribute to migraines, but not directly – one study found that a migraine is more likely to occur immediately after periods of reduced stress, suggesting that “let-down” headache is probably more common than acute stress-related migraines.⁸

Smoking

Smoking is an unproven factor of migraines. It can cause a headache, but not necessarily a migraine.⁹

Medication for Migraine

The pain and associated migraine symptoms can be addressed with acute and preventative treatments. According to the American Headache Society, all patients with a confirmed diagnosis of migraines should be offered a trial of acute pharmacological and/or nonpharmacologic treatment.

However, preventative treatments – pharmacologic, interventional, biobehavioral, neurostimulation, nutraceuticals, and lifestyle modification – are underused. It is believed that while only 3-13% of migraine patients use preventative treatment, nearly 40% of those with migraine with or without aura, and almost all of those with chronic migraine, would benefit.

Acute Treatment

The goals of acute treatment of migraines are:

Rapid and consistent freedom from pain and associated symptoms without recurrence
Restored ability to function
Minimal need for repeat dosing
Optimal self-care

The principles of acute treatment include using evidence-based treatments, choosing nonoral agents for patients with severe nausea or vomiting, accounting for tolerability and safety issues, considering self-administered rescue, and avoiding medication overuse. Medication used as an acute treatment for migraines should be limited to an average of two headaches per week.

Migraine-specific agents are prescribed for treatment of moderate to severe migraine attacks and mild to moderate attacks that respond poorly to nonspecific therapy:

Triptans
- Sumatriptan
Ergotamine derivatives
Gepants (small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists)
- Ubrogepant
- Rimegepant
Ditans (selective serotonin receptor agonist)
- Lasmiditan

Celecoxib oral solution (Elyxyb), a nonspecific medication, is also used.

Over-the-Counter Medication

Over-the-counter (OTC) medication is medicine that you can buy without a prescription. Nonspecific, OTC medication is used for the treatment of mild to moderate migraine attacks, including:

Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Aspirin (Bayer)
- Diclofenac
- Ibuprofen (Advil, Motrin)
- Naproxen (Aleve)
Nonopioid analgesics
Acetaminophen (Tylenol)
Caffeinated analgesic combinations (e.g., aspirin plus acetaminophen plus caffeine)

Preventative Treatment

The goals of migraine prevention are to:

Reduce attack frequency, severity, duration, and disability

Improve responsiveness to and avoid escalation in the use of acute treatment

Reduce overall cost associated with migraine treatment

Improve health-related quality of life

The principles of preventative treatment include using evidence-based treatments, titrating until clinical benefits are achieved, giving each treatment a trial of at least two to three months, and avoiding overuse of acute treatments. The decision to initiate preventative treatment is based on the frequency of migraine attacks, the average number of days with migraine or moderate/severe headache, degree of disability, and failure of acute treatment.

Medications used as preventative treatment are administered orally or parenterally (injection, e.g. subcutaneous or intravenous).

Oral	Parenteral
Candesartan	CGRP mAbs (monoclonal antibodies)
Divalproex solution	Eptinezumab
Frovatriptan	Erenumab
Metoprolol	Fremanezumab
Propranolol	Galcanezumab
Timolol	OnabotulinumtoxinA
Topiramate
Valproate sodium

Treating Migraines

Types of Treatment

Neuromodulation is considered a “dual-use” therapy because it provides meaningful benefits as an acute and preventative treatment. Neuromodulator devices are used in patients with tolerability and/or safety issues with pharmacotherapy. All four of the following FDA-approved neuromodulator devices modulate pain mechanisms involved in headaches by stimulating the nervous system centrally or peripherally with an electric current or magnetic field:

Electrical trigeminal nerve stimulation (eTNS)
Noninvasive vagus nerve stimulation (nVNS)
Remote electrical neuromodulation (REN)
Single-pulse transcranial magnetic stimulation (sTMS)

Novel Migraine Therapies

The FDA has recently approved or cleared celecoxib, Lasmiditan, REN, Rimegepant, and ubrogepant as therapies for the acute treatment of migraine and eptinezumab for preventative treatment.

Home Remedies For Migraine Headaches

Proper nutrition
Regular exercise
Adequate hydration
Proper sleep
Stress management
Identification and minimization of exposure to migraine triggers