What is a migraine

A migraine is usually a moderate or severe headache felt as a throbbing pain or a pulsing sensation lasting from four to 72 hours, usually migraine headache on just one side of the head usually frontotemporal. Many people also have symptoms such as nausea, vomiting and increased sensitivity to light [photophobia] or sound [phonophobia] ¹. A subset of otherwise typical patients have facial location of pain, which is called ‘facial migraine’ in the literature ¹; there is no evidence that these patients form a separate subgroup of migraine patients.

Migraine attacks can cause significant pain for hours to days and can be so severe that the pain is disabling.

Migraine is a common health condition, affecting around one in every five women and around one in every 15 men. They usually begin in early adulthood.

Migraine headache in children and adolescents (aged under 18 years) is more often bilateral than is the case in adults; unilateral pain usually emerges in late adolescence or early adult life.

Epidemiological studies have consistently shown that migraine is a common disorder with a one-year prevalence of around 10% to 12% and a lifetime prevalence of between 15% and 20% ². In Europe, the economic cost of migraine is estimated at EUR 27 billion per year ³. Migraine is subclassified into the more frequent episodic migraine (fewer than 15 days with migrainous headaches per month) and the less frequent chronic migraine (more than 15 days per month).

There are several types of migraine, including ¹:

• Migraine with aura – where there are specific warning signs just before the migraine begins, such as seeing flashing lights
• Migraine without aura – the most common type, where the migraine occurs without the specific warning signs
• Migraine aura without headache, also known as silent migraine – where an aura or other migraine symptoms are experienced, but a headache doesn’t develop

Warning symptoms known as aura may occur before or with the headache. These can include flashes of light, blind spots, or tingling on one side of the face or in your arm or leg.

Some people have migraines frequently, up to several times a week. Other people only have a migraine occasionally. It’s possible for years to pass between migraine attacks.

Medications can help prevent some migraines and make them less painful. Talk to your doctor about different migraine treatment options if you can’t find relief.

Most people with migraine can be adequately managed by treating of acute headaches alone, but a relevant minority need prophylactic interventions, as their attacks are either very frequent or are insufficiently controlled by acute therapy. Several drugs, such as propranolol, metoprolol, flunarizine, valproic acid and topiramate, have been shown to reduce attack frequency in some people ⁴, however, all these drugs are associated with adverse effects. Dropout rates in most clinical trials are high, suggesting that the drugs are not well accepted by patients. There is some evidence that behavioural interventions such as relaxation or biofeedback are beneficial ⁵. The right medicines, combined with self-help remedies and lifestyle changes, may help.

Migraine vs headache

The term ‘headache’ covers any pain around the head, face or neck area. Headache is the most common form of pain and almost everyone has had a headache.

There are two main types of headache:

1. Primary – which often “just happen” and are not caused by another injury or illness
2. Secondary – which are caused by some underlying health condition.

Primary headaches

Primary headaches are the most common. They include tension headaches, migraine, cluster headaches and sinus headaches.

The most common type of headache is a tension headache. Tension headaches are due to tight muscles in your shoulders, neck, scalp and jaw. They are often related to stress, depression or anxiety. You are more likely to get tension headaches if you work too much, don’t get enough sleep, miss meals, or use alcohol.

Other common types of headaches include migraines, cluster headaches, and sinus headaches. Most people can feel much better by making lifestyle changes, learning ways to relax and taking pain relievers.

Not all headaches require a doctor’s attention. But sometimes headaches warn of a more serious disorder. Let your health care provider know if you have sudden, severe headaches. Get medical help right away if you have a headache after a blow to your head, or if you have a headache along with a stiff neck, fever, confusion, loss of consciousness, or pain in the eye or ear.

Most headaches are not serious. But seek medical attention if:

• you have a very bad, blinding headache that appears suddenly and gets worse
• you have had a severe head injury
• you get a sudden headache when you cough, laugh, sneeze or move
• you have other symptoms like slurred speech, confusion, weakness, drowsiness, memory loss, or trouble walking
• you have a fever, stiff neck, rash, pain in the jaw when you chew, vision problems, a sore scalp or bad pain in an eye.

Primary headaches can be caused by a number of things including:

• stress
• eye strain or squinting
• poor posture
• dehydration
• drinking too much alcohol or eating certain foods
• lack of sleep
• poor posture
• skipping a meal.

Sometimes there is no obvious cause.

Secondary headaches

Secondary headaches have a separate cause, such as illness. They include headaches caused by drinking too much alcohol or a head injury or concussion.

Headaches in women may be caused by hormones, and some women notice a link between headaches and their periods. Hormonal changes due to taking the Pill, menopause and pregnancy can also be triggers for headaches.

Some headaches can even occur as a side effect of medication, such as painkillers. People sometimes get headaches when they’re unwell. For example, you may get a headache when you have a cold, sinusitis, flu or an allergic reaction.

There are a lot of illnesses that can cause headaches. See your doctor if you are getting more headaches than usual, they are worse or don’t improve with over the counter medicines, or they are stopping you from working or sleeping.

Dehydration

Lack of fluids can cause dehydration and is a common cause of headaches. Fluids are needed for the body to function correctly and may be lost through:

• illness such as vomiting or diarrhea
• vigorous exercise
• excessive sweating
• alcohol
• having large amounts of drinks containing caffeine such as coffee, tea or cola, which cause you to urinate frequently
• working in hot weather or high-temperature environments.

If you are getting a lot of headaches or concerned talk to your doctor.

Hemiplegic migraine

Hemiplegic migraine is a rare form of migraine headache.

Hemiplegic Migraine Diagnostic criteria ¹:

1. At least two attacks fulfilling criteria:
   1. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) ²
      
   2. Headache has at least two of the following four characteristics:
      1. unilateral location
      2. pulsating quality
      3. moderate or severe pain intensity
      4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
2. Aura consisting of both of the following:
   1. fully reversible motor weakness
   2. fully reversible visual, sensory and/or speech/language symptoms
3. At least two of the following four characteristics:
   1. at least one aura symptom spreads gradually over ≥5 minutes, and/or two or more symptoms occur in succession
   2. each individual non-motor aura symptom lasts 5–60 minutes, and motor symptoms last <72 hours²
      
   3. at least one aura symptom is unilateral ³
      
   4. the aura is accompanied, or followed within 60 minutes, by headache
4. Transient ischemic attack and stroke have been excluded.

Notes:

1. The term plegic means paralysis in most languages, but most attacks are characterized by motor weakness.
2. In some patients, motor weakness may last weeks.
3. Aphasia is always regarded as a unilateral symptom; dysarthria may or may not be. Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write. Dysarthria is a condition in which the muscles you use for speech are weak or you have difficulty controlling them. Dysarthria often is characterized by slurred or slow speech that can be difficult to understand.

There is some evidence suggesting that epilepsy and hemiplegic migraine have a close genetic relationship ⁶. This relationship provides a foundation for a new strategic direction for research and treatment. Epilepsy and hemiplegic migraine are disorders associated with abnormal neuronal excitability; they have overlapping regions of genetic inheritance. However, epilepsy occurs from the synchronous discharge of excited neurons, and abnormal neuronal excitability is transformed into cortical spreading depression ⁷ in migraine patients. Future studies should investigate this relationship and the different phenotypes of the two disorders.

There are two types of hemiplegic migraine ⁶:

• Familial hemiplegic migraine (FHM) and
• Sporadic hemiplegic migraine (SHM).

Each headache may last from a few hours to a few days. Mutations in three different genes, two ion-channel genes and one encoding an ATP exchanger, calcium voltage-gated channel subunit alpha1 A (CACNA1A), ATPase Na+/K+ transporting subunit alpha 2 (ATP1A2), Sodium channel protein type 1 subunit alpha (SCN1A) are all responsible for the hemiplegic migraine phenotype, thus indicating a genetic heterogeneity for this disorder ⁸, ⁹. Recently, also proline rich transmembrane protein 2 (PRRT2) has been associated to hemiplegic migraine ⁹. ATP1A2 is located on 1q23 (Familial hemiplegic migraine2, MIM #182340) ¹⁰ and more than 60 mutations have been identified in association to the familial hemiplegic migraine phenotype. This gene, ATP1A2, encodes the alpha-2 catalytic subunit of a sodium-potassium-ATPases ¹⁰. Mutations in ATP1A2 are mainly missense; few deletions have been described ¹⁰ but so far no duplications in ATP1A2 have been discovered ⁸.

Familial Hemiplegic Migraine

Familial hemiplegic migraine is a form of migraine headache that runs in families ¹¹. Migraines usually cause intense, throbbing pain in one area of the head, often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. These recurrent headaches typically begin in childhood or adolescence and can be triggered by certain foods, emotional stress, and minor head trauma. Each headache may last from a few hours to a few days.

The worldwide prevalence of familial hemiplegic migraine is unknown. Studies suggest that in Denmark about 1 in 10,000 people have hemiplegic migraine and that the condition occurs equally in families with multiple affected individuals (familial hemiplegic migraine) and in individuals with no family history of the condition (sporadic hemiplegic migraine). Like other forms of migraine, familial hemiplegic migraine affects females more often than males.

In some types of migraine, including familial hemiplegic migraine, a pattern of neurological symptoms called an aura precedes the headache. The most common symptoms associated with an aura are temporary visual changes such as blind spots (scotomas), flashing lights, zig-zagging lines, and double vision. In people with familial hemiplegic migraine, auras are also characterized by temporary numbness or weakness, often affecting one side of the body (hemiparesis). Additional features of an aura can include difficulty with speech, confusion, and drowsiness. An aura typically develops gradually over a few minutes and lasts about an hour.

Unusually severe migraine episodes have been reported in some people with familial hemiplegic migraine. These episodes have included fever, seizures, prolonged weakness, coma, and, rarely, death. Although most people with familial hemiplegic migraine recover completely between episodes, neurological symptoms such as memory loss and problems with attention can last for weeks or months. About 20 percent of people with this condition develop mild but permanent difficulty coordinating movements (ataxia), which may worsen with time, and rapid, involuntary eye movements called nystagmus.

Familial Hemiplegic Migraine Genetic Changes

Mutations in the CACNA1A, ATP1A2, SCN1A, and PRRT2 genes have been found to cause familial hemiplegic migraine. The first three genes provide instructions for making proteins that are involved in the transport of charged atoms (ions) across cell membranes. The movement of these ions is critical for normal signaling between nerve cells (neurons) in the brain and other parts of the nervous system. The function of the protein produced from the PRRT2 gene is unknown, although studies suggest it interacts with a protein that helps control signaling between neurons.

Communication between neurons depends on chemicals called neurotransmitters, which are released from one neuron and taken up by neighboring neurons. Researchers believe that mutations in the CACNA1A, ATP1A2, and SCN1A genes can upset the balance of ions in neurons, which disrupts the normal release and uptake of certain neurotransmitters in the brain. Although the mechanism is unknown, researchers speculate that mutations in the PRRT2 gene, which reduce the amount of PRRT2 protein, also disrupt normal control of neurotransmitter release. The resulting changes in signaling between neurons lead people with familial hemiplegic migraine to develop these severe headaches.

There is little evidence that mutations in the CACNA1A, ATP1A2, SCN1A, and PRRT2 genes play a role in common migraines, which affect millions of people each year. Researchers are searching for additional genetic changes that may underlie rare types of migraine, such as familial hemiplegic migraine, as well as the more common forms of migraine.

Inheritance Pattern

This condition is inherited in an autosomal dominant pattern, which means one copy of the altered gene in each cell is sufficient to cause the disorder. In most cases, affected individuals have one affected parent. However, some people who inherit an altered gene never develop features of familial hemiplegic migraine. (This situation is known as reduced penetrance.) A related condition, sporadic hemiplegic migraine, has identical signs and symptoms but occurs in individuals with no history of the disorder in their family.

Chronic migraines

Chronic migraine is a debilitating neurobiological disorder that affects about 1.4–2.2% of the population worldwide ¹². According to the International Classification of Headache Disorders, third edition (beta version), chronic migraine is defined as headache occurring on “headache occurring on 15 or more days per month for more than 3 months, which has the features of migraine headache on at least 8 days per month” which include at least two of the following four qualities: unilateral location, pulsatile quality, moderate or severe pain intensity and aggravation by physical activity, as well as at least one of the following: nausea, vomiting, photophobia and phonophobia ¹³.

Diagnostic criteria:

1. Headache (tension-type-like and/or migraine-like) on ≥15 days per month for >3 months² and fulfilling criteria 1 and 2:
   1. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) ³
      
   2. Headache has at least two of the following four characteristics:
      1. unilateral location
      2. pulsating quality
      3. moderate or severe pain intensity
      4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)

Notes:

1. The diagnosis of chronic migraine excludes the diagnosis of Tension-type headache or its subtypes because tension-type-like headache.
2. The reason for singling out chronic from episodic migraine is that it is impossible to distinguish the individual episodes of headache in patients with such frequent or continuous headaches. In fact, the characteristics of the headache may change not only from day to day but even within the same day. It is extremely difficult to keep such patients medication-free in order to observe the natural history of the headache. In this situation, attacks with or without aura are both counted, as well as tension-type-like headaches. The most common cause of symptoms suggestive of chronic migraine is medication overuse, as defined under medication-overuse headache. Around 50% of patients apparently with Chronic migraine revert to an episodic migraine subtype after drug withdrawal; such patients are in a sense wrongly diagnosed as Chronic migraine. Equally, many patients apparently overusing medication do not improve after drug withdrawal, and the diagnosis of Medication-overuse headache may in a sense be inappropriate (assuming that chronicity induced by drug overuse is always reversible). For these reasons, and because of the general rule, patients meeting criteria for Chronic migraine and for Medication-overuse headache should be given both diagnoses. After drug withdrawal, migraine will either revert to the episodic subtype or remain chronic, and be re-diagnosed accordingly; in the latter case, the diagnosis of Medication-overuse headache may be rescinded. In some countries, it is usual practice to diagnose Medication-overuse headache only on discharge.
3. Characterization of frequently recurring headache generally requires a headache diary to record information on pain and associated symptoms day-by-day for at least 1 month.

Studies from different parts of the world have shown that patients with chronic migraine have a higher degree of disability and burden, a greater chance of missing family activities, reduced productivity and greater healthcare resource utilization than those who have episodic migraine ¹⁴. Patients with chronic migraine suffer from a lower health-related quality of life and higher levels of anxiety and depression, and are less likely to be able to work ¹⁵. Moreover, chronic migraine is a critical factor for perceived stress that affects the quality of life of migraine patients ¹⁶.

Despite the high prevalence of chronic migraine, many patients do not receive the appropriate diagnosis and even fewer patients receive appropriate treatment. In the Chronic Migraine Epidemiology and Outcomes ¹⁷ study, a large population-based epidemiology study in the United States, 1254 of the participants met the diagnostic criteria for chronic migraine. Of those patients, only 512 (41%) reported discussing headache with a healthcare provider. Of the 512, only 126 (25%) received an accurate diagnosis, and of the 126, only 56 (44%) received both acute and preventive treatment. To help care providers worldwide decrease the burden of chronic migraine, evidence-based discussions of the clinical trials and patient care experiences are crucial.

An adequate treatment plan for chronic migraine includes both acute and preventive medications. Acute medications are those given to alleviate the acute head pain and discomfort of a migraine attack and include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, triptans, combination analgesics, or less ideally, butalbital and opioid medications. The European Federation of Neurological Societies guideline recommends NSAIDs and triptans for the acute treatment of migraine attacks (level A recommendation – a strong recommendation that the clinicians provide the intervention to eligible patients. Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.) ¹⁸. The guideline also recommends the use of metoclopramide and domperidone before the intake of an NSAID or triptan (level B recommendation – a recommendation that clinicians provide (the service) to eligible patients. A least fair evidence was found that the intervention improves health outcomes and concludes that benefit outweigh harm.) ¹⁸. The acute medications should only be used on an as-needed basis, and patients should be advised not to take the medications for more than 10 to 15 days per month, according to the type of acute medication, to avoid developing a medication-overuse headache. Preventive medications are those taken daily to decrease the frequency, duration, and severity of migraine headaches. Preventive medications should be considered when patients are having three or more headache episodes per month or when headache substantially interferes with daily activities. These medications can also be used when acute medications are ineffective, contraindicated, or overused ¹⁹. Preventive medications should be initiated for patients with chronic migraine, and evidence-based prophylactic medications for episodic migraine are often used for the treatment of chronic migraine. Oral medications that are commonly used include antiepileptics, such as topiramate; antihypertensives, such as beta blockers; and antidepressants, such as tricyclic antidepressants ²⁰, ²¹. Flunarizine is also considered a drug of first choice for the prophylaxis of migraine in Europe ¹⁸. Among these medications, topiramate has been shown to be effective in large, randomized placebo-controlled trials of patients with chronic migraine.

Vestibular migraine

Vestibular migraine is a migraine-associated vertigo/dizziness; migraine-related vestibulopathy; migrainous vertigo ²².

Many studies have demonstrated a significant overlap between symptoms of Meniere’s disease and vestibular migraine ²³. Both diseases have distinct proposed pathophysiologic mechanisms. In the case of vestibular migraine, vasospasm of the internal auditory artery was one of the first proposed explanations ²⁴, followed by the implication of the trigemino-vascular system ²⁵. Also, based on a review of several imaging studies done on vestibular migraine patients, Espinosa-Sanchez et al ²⁶ hypothesize that vestibular migraine may be due to a defect in sensory functioning at the levels of the vestibular system, thalamus and cortex.

In vestibular migraine, studies have shown a familial occurrence with an autosomal dominant pattern with moderate to high penetrance ²⁷. However, Sanger sequencing ²⁷ and other methods ²⁸ have been used to try and identify a genomic region responsible for this inheritance pattern. These measures were unsuccessful. This indicates the possibility of a polygenic inheritance in vestibular migraine patients. Bahmad et al ²⁹ also demonstrated an autosomal dominant inheritance pattern when studying 10 family members suffering from vestibular migraine. A location in chromosome 5q35 between rs244895 and D5S2073 markers was discovered when using genome-wide linkage analysis and subsequent fine mapping. In another study, a genome-wide scan identified, on chromosome 6q at marker D6S1556, a suggestive linkage in four families suffering from migraine and vestibular pathology ³⁰.

Vestibular migraine diagnostic criteria ²²:

1. At least five episodes fulfilling criteria 3 and 4
2. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura¹
3. Vestibular symptoms² of moderate or severe intensity,³ lasting between 5 minutes and 72 hours⁴
4. At least 50% of episodes are associated with at least one of the following three migrainous features⁵:
   1. headache with at least two of the following four characteristics:
      1. unilateral location
      2. pulsating quality
      3. moderate or severe intensity
      4. aggravation by routine physical activity
   2. photophobia and phonophobia⁶
   3. visual aura⁷
5. Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder⁸.

Notes:

1. Code also for the underlying migraine diagnosis.
2. Vestibular symptoms, as defined by the Bárány Society’s Classification of Vestibular Symptoms and qualifying for a diagnosis of Vestibular migraine, include:
   1. spontaneous vertigo:
      1. internal vertigo (a false sensation of self-motion);
      2. external vertigo (a false sensation that the visual surround is spinning or flowing);
   2. positional vertigo, occurring after a change of head position;
   3. visually induced vertigo, triggered by a complex or large moving visual stimulus;
   4. head motion-induced vertigo, occurring during head motion;
   5. head motion-induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine).
3. Vestibular symptoms are rated moderate when they interfere with but do not prevent daily activities and severe when daily activities cannot be continued.
4. Duration of episodes is highly variable. About 30% of patients have episodes lasting minutes, 30% have attacks for hours and another 30% have attacks over several days. The remaining 10% have attacks lasting seconds only, which tend to occur repeatedly during head motion, visual stimulation or after changes of head position. In these patients, episode duration is defined as the total period during which short attacks recur. At the other end of the spectrum, there are patients who may take 4 weeks to recover fully from an episode. However, the core episode rarely exceeds 72 hours.
5. One symptom is sufficient during a single episode. Different symptoms may occur during different episodes. Associated symptoms may occur before, during or after the vestibular symptoms.
6. Phonophobia is defined as sound-induced discomfort. It is a transient and bilateral phenomenon that must be differentiated from recruitment, which is often unilateral and persistent. Recruitment leads to an enhanced perception and often distortion of loud sounds in an ear with decreased hearing.
7. Visual auras are characterized by bright scintillating lights or zigzag lines, often with a scotoma that interferes with reading. Visual auras typically expand over 5–20 minutes and last for less than 60 minutes. They are often, but not always restricted to one hemifield. Other types of migraine aura, for example somatosensory or dysphasic aura, are not included as diagnostic criteria because their phenomenology is less specific and most patients also have visual auras.
8. History and physical examinations do not suggest another vestibular disorder or such a disorder has been considered but ruled out by appropriate investigations or such a disorder is present as a comorbid or independent condition, but episodes can be clearly differentiated. Migraine attacks may be induced by vestibular stimulation. Therefore, the differential diagnosis should include other vestibular disorders complicated by superimposed migraine attacks.

Abdominal migraine

There can be a link. Nausea and vomiting are often associated with migraine attacks.

In young children, several syndromes that cause gastrointestinal symptoms are also associated with migraines. These syndromes can cause episodes of vomiting (cyclical vomiting), abdominal pain (abdominal migraine) and dizziness (benign paroxysmal vertigo) and are often referred to as childhood periodic syndromes.

Although these syndromes usually aren’t accompanied by migraine headache, they’re considered a form of migraine. In many cases, childhood periodic syndromes evolve into migraines later in life.

Research has shown that people who regularly experience gastrointestinal symptoms — such as reflux, diarrhea, constipation and nausea — have a higher prevalence of headaches than those who don’t have gastrointestinal symptoms.

There is emerging research evidence for the gastrointestinal system playing an important role in the pathophysiology of migraine ³¹, ³². A possible connection was initially prompted by the observation that gastrointestinal symptoms such as nausea, vomiting, and gastroparesis constitute clinical hallmarks of migraine ³³. Moreover, abdominal migraine, a condition that presents with both migrainous and abdominal symptoms, suggests that a common mechanism underlies both affected systems ³⁴. Furthermore, migraines can often coexist with GI disorders such as inflammatory bowel disease (IBD), celiac disease (CD), irritable bowel syndrome (IBS), and Helicobacter pylori (H. pylori) infection ³⁵. Moreover, gastrointestinal tract (GIT) microbiota have been implicated in the pathogenesis of more than 25 diseases with central nervous system effects, for which multiple mechanisms have been discussed, such as bacterial translocation secondary to an impaired intestinal barrier, migration of stimulated immune cells, and the systemic diffusion of microbial products or metabolites ³⁶. This complex interplay between the brain and gastrointestinal tract (GIT) is referred to in the literature as the gut-brain axis, which involves immune, neuroendocrine, and metabolic pathways, although the precise pathophysiology linking the different gastrointestinal entities with migraine remains unclear ³¹.

These studies suggest that people who get frequent headaches may be predisposed to gastrointestinal problems. Digestive conditions, such as irritable bowel syndrome and celiac disease, also may be linked to migraines. However, more research is needed to understand these connections.

If you experience nausea, vomiting or diarrhea with your headaches, talk to your doctor about treatment options. Treating the headache usually relieves gastrointestinal symptoms.

However, in some cases, an anti-nausea or anti-diarrheal medication or use of a nonoral pain medication may be recommended. Keep in mind that some pain medications such as aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) may increase nausea.

Ocular migraine

The term “ocular migraine” can be confusing. It generally means a headache that’s accompanied by changes in vision. But the term is often used interchangeably to refer to two different conditions: migraine aura, which usually isn’t serious, and retinal migraine, which could signal something serious ³⁷.

Migraine aura affecting your vision

Ocular migraine sometimes describes a migraine aura that involves your vision. Migraine auras include a variety of sensations that are often visual. Auras may also include other sensations, such as numbness, that precede or accompany a migraine. Aura can sometimes occur without a headache.

A migraine aura that affects your vision is common. Visual symptoms don’t last long. A migraine aura involving your vision will affect both eyes, and you may see:

• Flashes of light
• Zigzagging patterns
• Blind spots
• Shimmering spots or stars

These symptoms can temporarily interfere with certain activities, such as reading or driving, but the condition usually isn’t considered serious.

Retinal migraine

Ocular migraine sometimes is used as a synonym for the medical term “retinal migraine.” A retinal migraine is a rare condition occurring in a person who has experienced other symptoms of migraine. Retinal migraine involves repeated attacks of monocular visual disturbance, including scintillations, scotomata or blindness, associated with migraine headache ¹.

A retinal migraine — unlike a migraine aura — will affect only one eye, not both. But usually, loss of vision in one eye isn’t related to migraine. It’s generally caused by some other more serious condition. So if you experience visual loss in one eye, be sure to see a doctor right away for prompt treatment.

Retinal migraine Diagnostic criteria:

1. At least two attacks fulfilling criteria 2 and 3
2. Aura consisting of fully reversible monocular positive and/or negative visual phenomena (e.g. scintillations, scotomata or blindness) confirmed during an attack by either or both of the following:
   1. clinical visual field examination
   2. the patient’s drawing (made after clear instruction) of a monocular field defect
3. At least two of the following three characteristics
   1. the aura spreads gradually over ≥5 minutes
   2. aura symptoms last 5-60 minutes
   3. the aura is accompanied, or followed within 60 minutes, by headache
4. Not better accounted for by another ICHD-3 diagnosis, and other causes of amaurosis fugax have been excluded.

Comments:

Some patients who complain of monocular visual disturbance in fact have hemianopia. Some cases without headache have been reported, but migraine cannot be ascertained as the underlying aetiology.

Retinal migraine is an extremely rare cause of transient monocular visual loss. Cases of permanent monocular visual loss associated with migraine have been described. Appropriate investigations are required to exclude other causes of transient monocular blindness.

What causes migraines

Though nobody knows what causes migraines, genetics and environmental factors appear to play a role. Migraines can run in families, but don’t have to.

Migraines may be caused by changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway.

Imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system — also may be involved. Researchers are still studying the role of serotonin in migraines.

Serotonin levels drop during migraine attacks. This may cause your trigeminal nerve to release substances called neuropeptides, which travel to your brain’s outer covering (meninges). The result is migraine pain. Other neurotransmitters play a role in the pain of migraine, including calcitonin gene-related peptide (CGRP).

Migraine triggers

Some people find that migraines are triggered by certain things such as:

• Foods. Cheese, chocolate and red wine. Aged cheeses, salty foods and processed foods may trigger migraines. Skipping meals or fasting also can trigger attacks.
• Food additives. The sweetener aspartame and the preservative monosodium glutamate (MSG), found in many foods, may trigger migraines.
• Stress and changes of routine. Stress at work or home can cause migraines.
• Changes in the weather
• Hormonal changes and the oral contraceptive pill for women. Hormonal changes in women. Fluctuations in estrogen seem to trigger headaches in many women. Women with a history of migraines often report headaches immediately before or during their periods, when they have a major drop in estrogen.
• Hormonal medications, such as oral contraceptives and hormone replacement therapy, also may worsen migraines. Some women, however, find their migraines occur less often when taking these medications.
• Others have an increased tendency to develop migraines during pregnancy or menopause.
• Alcoholic drinks (especially red wine and beer).
• Drinks. Highly caffeinated beverages may trigger migraines.
• Sensory stimuli. Bright lights and sun glare can induce migraines, as can loud sounds. Strong smells — including perfume, paint thinner, secondhand smoke and others — can trigger migraines in some people.
• Changes in wake-sleep pattern. Missing sleep or getting too much sleep may trigger migraines in some people, as can jet lag.
• Physical factors. Intense physical exertion, including sexual activity, may provoke migraines.
• Changes in the environment. A change of weather or barometric pressure can prompt a migraine.
• Medications. Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines.

Risk factors for migraine

Several factors make you more prone to having migraines, including:

• Family history. If you have a family member with migraines, then you have a good chance of developing them too.
• Age. Migraines can begin at any age, though the first often occurs during adolescence. Migraines tend to peak during your 30s, and gradually become less severe and less frequent in the following decades.
• Sex. Women are three times more likely to have migraines. Headaches tend to affect boys more than girls during childhood, but by the time of puberty and beyond, more girls are affected.
• Hormonal changes. If you are a woman who has migraines, you may find that your headaches begin just before or shortly after onset of menstruation. They may also change during pregnancy or menopause. Migraines generally improve after menopause. Some women report that migraine attacks begin during pregnancy, or their attacks worsen. For many, the attacks improved or didn’t occur during later stages in the pregnancy. Migraines often return during the postpartum period.

Complications of migraine

Sometimes your efforts to control your migraine pain cause problems, such as:

• Abdominal problems. Certain pain relievers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others), may cause abdominal pain, bleeding, ulcers and other complications, especially if taken in large doses or for a long period of time.

• Medication-overuse headaches. Taking over-the-counter or prescription headache medications more than 10 days a month for three months or in high doses may trigger serious medication-overuse headaches. Medication-overuse headaches occur when medications stop relieving pain and begin to cause headaches. You then use more pain medication, which continues the cycle.

• Serotonin syndrome. Serotonin syndrome is a rare, potentially life-threatening condition that occurs when your body has too much of the nervous system chemical called serotonin. While the risk is considered extremely low, taking migraine medications called triptans and antidepressants known as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) may increase the risk of serotonin syndrome. These medications naturally raise serotonin levels, and it is possible that combining them could cause levels that are too high. Triptans and SSRIs or SNRIs may be used together, but it’s important to watch out for possible symptoms of serotonin syndrome such as changes in cognition, behavior and muscle control (such as involuntary jerking). Triptans include medications such as sumatriptan (Imitrex) or zolmitriptan (Zomig). Some common SSRIs include sertraline (Zoloft), fluoxetine (Sarafem, Prozac) and paroxetine (Paxil). SNRIs include duloxetine (Cymbalta) and venlafaxine (Effexor XR).

Also, some people experience complications from migraines such as:

• Chronic migraine. If your migraine lasts for 15 or more days a month for more than three months, you have chronic migraine.
• Status migrainosus. People with this complication have severe migraine attacks that last for longer than three days.
• Persistent aura without infarction. Usually an aura goes away after the migraine attack, but sometimes aura lasts for more than one week afterward. A persistent aura may have similar symptoms to bleeding in the brain (stroke), but without signs of bleeding in the brain, tissue damage or other problems.
• Migrainous infarction. Aura symptoms that last longer than one hour can signal a loss of blood supply to an area of the brain (stroke), and should be evaluated. Doctors can conduct neuroimaging tests to identify bleeding in the brain.
• Stroke. An ischemic stroke occurs when the blood supply to the brain is blocked by a blood clot or fatty material in the arteries. It is unclear why ischemic strokes are linked to migraine. Studies have shown that people who experience migraines (particularly migraine with aura) have about twice the risk of having an ischaemic stroke at some point compared to people without migraines. However, this risk is still small.
• The risk of having an ischemic stroke is increased by the use of the combined contraceptive pill. Medical professionals generally advise women who experience migraine with aura not to use the combined contraceptive pill. Women who have migraine without aura can usually take the combined contraceptive pill safely, unless they have other stroke risk factors such as high blood pressure or a family history of cardiovascular disease. If you take the combined contraceptive pill and you experience aura symptoms, talk to your GP about alternative forms of contraception.
• Mental health problemsMigraine is associated with a very small increased risk of mental health problems, including:
  • depression
  • bipolar disorder
  • anxiety disorder
  • panic disorder

Prevention of migraine

Until recently, experts recommended avoiding common migraine triggers. Some triggers can’t be avoided, and avoidance isn’t always effective. But some of these lifestyle changes and coping strategies may help you reduce the number and severity of your migraines:

• Transcutaneous supraorbital nerve stimulation (t-SNS). This device (Cefaly), similar to a headband with attached electrodes, was recently approved by the Food and Drug Administration as a preventive therapy for migraines. In research, those that used the device experienced fewer migraines.
• Learn to cope. Recent research shows that a strategy called learning to cope (LTC) may help prevent migraines. In this practice, you are gradually exposed to headache triggers to help desensitize you to them. Learning to cope may also be combined with cognitive behavioral therapy. More research is needed to better understand the effectiveness of learning to cope.
• Create a consistent daily schedule. Establish a daily routine with regular sleep patterns and regular meals. In addition, try to control stress.
• Exercise regularly. Regular aerobic exercise reduces tension and can help prevent migraines. If your doctor agrees, choose any aerobic exercise you enjoy, including walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches. Regular exercise can also help you lose weight or maintain a healthy body weight, and obesity is thought to be a factor in migraines.
• Reduce the effects of estrogen. If you are a woman who has migraines and estrogen seems to trigger or make your headaches worse, you may want to avoid or reduce the medications you take that contain estrogen.

These medications include birth control pills and hormone replacement therapy. Talk with your doctor about the appropriate alternatives or dosages for you.

Migraine symptoms

Migraines often begin in childhood, adolescence or early adulthood.

Migraines may progress through four stages (though you may not experience all stages):

• prodrome,
• aura,
• headache and
• post-drome,

Prodrome

One or two days before a migraine, you may notice subtle changes that warn of an upcoming migraine, including:

• Constipation
• Mood changes, from depression to euphoria
• Food cravings
• Neck stiffness
• Increased thirst and urination
• Frequent yawning

Migraine Aura

Aura may occur before or during migraines. Most people experience migraines without aura.

Auras are symptoms of the nervous system. They are usually visual disturbances, such as flashes of light or wavy, zigzag vision.

Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Your muscles may get weak, or you may feel as though someone is touching you.

Each of these symptoms usually begins gradually, builds up over several minutes and lasts for 20 to 60 minutes.

Examples of migraine aura include:

• Visual phenomena, such as seeing various shapes, bright spots or flashes of light
• Vision loss
• Pins and needles sensations in an arm or leg
• Weakness or numbness in the face or one side of the body
• Difficulty speaking
• Hearing noises or music
• Uncontrollable jerking or other movements

Sometimes, a migraine with aura may be associated with limb weakness (hemiplegic migraine).

Migraine Attack

A migraine usually lasts from four to 72 hours if untreated. The frequency with which headaches occur varies from person to person. Migraines may be rare, or strike several times a month. During a migraine, you may experience:

• Pain on one side or both sides of your head
• Pain that feels throbbing or pulsing
• Sensitivity to light, sounds, and sometimes smells and touch
• Nausea and vomiting
• Blurred vision
• Lightheadedness, sometimes followed by fainting

Post-drome

The final phase, known as post-drome, occurs after a migraine attack. You may feel drained and washed out, while some people feel elated. For about 24 hours, you may also experience:

• Confusion
• Moodiness
• Dizziness
• Weakness
• Sensitivity to light and sound

Migraines Diagnosis

There’s no specific test to diagnose migraines. For an accurate diagnosis to be made, your doctor must identify a pattern of recurring headaches along with the associated symptoms.

Migraines can be unpredictable, sometimes occurring without the other symptoms. Obtaining an accurate diagnosis can sometimes take time.

If you have migraines or a family history of migraines, a doctor trained in treating headaches (neurologist) will likely diagnose migraines based on your medical history, symptoms, and a physical and neurological examination.

Your doctor may also recommend more tests to rule out other possible causes for your pain if your condition is unusual, complex or suddenly becomes severe.

• Blood tests. Your doctor may order these to test for blood vessel problems, infections in your spinal cord or brain, and toxins in your system.
• Magnetic resonance imaging (MRI). An MRI uses a powerful magnetic field and radio waves to produce detailed images of the brain and blood vessels. MRI scans help doctors diagnose tumors, strokes, bleeding in the brain, infections, and other brain and nervous system (neurological) conditions.
• Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed cross-sectional images of the brain. This helps doctors diagnose tumors, infections, brain damage, bleeding in the brain and other possible medical problems that may be causing headaches.
• Spinal tap (lumbar puncture). Your doctor may recommend a spinal tap (lumbar puncture) if he or she suspects infections, bleeding in the brain or another underlying condition.

In this procedure, a thin needle is inserted between two vertebrae in the lower back to remove a sample of cerebrospinal fluid for analysis in a lab.

Migraine treatment

There’s currently no cure for migraines, although a number of treatments are available to help ease the symptoms.

It may take time to work out the best treatment for you. You may need to try different types or combinations of medicines before you find the most effective ones.

If you find you can’t manage your migraines using over-the-counter medicines, your doctor may prescribe something stronger.

Migraine treatments can help stop symptoms and prevent future attacks.

Many medications have been designed to treat migraines. Some drugs often used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:

• Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms.
• Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.

Your treatment strategy depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions.

Some medications aren’t recommended if you’re pregnant or breast-feeding. Some medications aren’t given to children. Your doctor can help find the right medication for you.

During a migraine attack

Most people find that sleeping or lying in a darkened room is the best thing to do when having a migraine attack.

Others find that eating something helps, or they start to feel better once they’ve been sick.

Pain-relieving medications

Take pain-relieving drugs as soon as you experience signs or symptoms of a migraine for the best results. It may help if you rest or sleep in a dark room after taking them. Medications include:

Painkillers

Many people who have migraines find that over-the-counter painkillers, such as paracetamol, aspirin and ibuprofen, can help to reduce their symptoms.

They tend to be most effective if taken at the first signs of a migraine attack, as this gives them time to absorb into your bloodstream and ease your symptoms.

It’s not advisable to wait until the headache worsens before taking painkillers as it’s often too late for the medication to work. Soluble painkillers (tablets you dissolve in a glass of water) are a good alternative because they’re absorbed quickly by your body.

If you can’t swallow painkillers because of nausea or vomiting, suppositories may be a better option. These are capsules that are inserted into the anus (back passage).

Cautions

When taking over-the-counter painkillers, always make sure you read the instructions on the packaging and follow the dosage recommendations.

Children under 16 shouldn’t take aspirin unless it’s under the guidance of a healthcare professional. Aspirin and ibuprofen are also not recommended for adults who have a history of stomach problems, such as stomach ulcers, liver problems or kidney problems.

Taking any form of painkiller frequently can make migraines worse. This is sometimes called “medication overuse headache” or “painkiller headache”.

Speak to your doctor if you find yourself needing to use painkillers repeatedly or if over-the-counter painkillers aren’t effective. Your doctor may prescribe stronger painkillers or recommend using painkillers along with triptans (see below). If they suspect the frequent use of painkillers may be contributing your headaches, they may recommended that you stop using them.

Treatment for pregnant and breastfeeding women

In general, migraine treatment with medicines should be limited as much as possible when you’re pregnant or breastfeeding. Instead, trying to identify and avoid potential migraine triggers is often recommended.

If medication is essential, then your doctor may prescribe you a low-dose painkiller, such as paracetamol. In some cases, anti-inflammatory drugs or triptans may be prescribed. Speak to your doctor or midwife before taking medication when you are pregnant or breastfeeding.

Triptans

If ordinary painkillers aren’t helping to relieve your migraine symptoms, you should make an appointment to see your doctor. They may recommend taking painkillers in addition to a type of medication called a triptan and possibly anti-sickness medication (see below).

• Triptans aren’t recommended for people at risk of strokes and heart attacks.

Triptan medications include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax).

Triptan medicines are a specific painkiller for migraine headaches. They’re thought to work by reversing the changes in the brain that may cause migraine headaches.

They cause the blood vessels around the brain to contract (narrow). This reverses the dilating (widening) of blood vessels that’s believed to be part of the migraine process.

Triptans are available as tablets, injections and nasal sprays.

Common side effects of triptans include:

• warm-sensations
• tightness
• tingling
• flushing
• feelings of heaviness in the face, limbs or chest
• reactions at the injection site, nausea, dizziness, drowsiness and muscle weakness.

Some people also experience nausea, dry mouth and drowsiness. These side effects are usually mild and improve on their own.

• As with other painkillers, taking too many triptans can lead to medication overuse headache.

Your doctor will usually recommend having a follow-up appointment once you’ve finished your first course of treatment with triptans. This is so you can discuss their effectiveness and whether you had any side effects.

If the medication was helpful, treatment will usually be continued. If they weren’t effective or caused unpleasant side effects, your doctor may try prescribing a different type of triptan since responses can be highly variable.

Ergots

Ergotamine and caffeine combination drugs (Migergot, Cafergot) are less effective than triptans. Ergots seem most effective in those whose pain lasts for more than 48 hours. Ergots are most effective when taken soon after migraine symptoms start.

Ergotamine may worsen nausea and vomiting related to your migraines, and it may also lead to medication-overuse headaches.

Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine. It’s also less likely to lead to medication-overuse headaches. It’s available as a nasal spray and in injection form.

Anti-sickness medicines

Anti-sickness medicines, known as anti-emetics, can successfully treat migraine in some people even if you don’t experience nausea or vomiting. These are prescribed by your doctor and can be taken alongside painkillers and triptans.

Frequently prescribed medications are chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro).

As with painkillers, anti-sickness medicines work better if taken as soon as your migraine symptoms begin. They usually come in the form of a tablet, but are also available as a suppository.

• Side effects of anti-emetics include drowsiness and diarrhea.

Opioid medications

Opioid medications containing narcotics, particularly codeine, are sometimes used to treat migraine pain for people who can’t take triptans or ergots. Narcotics are habit-forming and are usually used only if no other treatments provide relief.

Glucocorticoids (prednisone, dexamethasone)

A glucocorticoid may be used with other medications to improve pain relief. Glucocorticoids shouldn’t be used frequently to avoid side effects.

Combination medicines

You can buy a number of combination medicines for migraine without a prescription at your local pharmacy. These medicines contain both painkillers and anti-sickness medicines. If you’re not sure which one is best for you, ask your pharmacist.

It can also be very effective to combine a triptan with another painkiller, such as ibuprofen.

Many people find combination medicines convenient. However, the dose of painkillers or anti-sickness medicine may not be high enough to relieve your symptoms. If this is the case, it may be better to take painkillers and anti-sickness medicines separately. This allows you to easily control the doses of each.

Preventive medications

You may be a candidate for preventive therapy if:

• You have four or more debilitating attacks a month
• If attacks last more than 12 hours
• If pain-relieving medications aren’t helping
• If your migraine signs and symptoms include a prolonged aura or numbness and weakness

Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. It may take several weeks to see improvements in your symptoms.

Your doctor may recommend daily preventive medications, or only when a predictable trigger, such as menstruation, is approaching.

Preventive medications don’t always stop headaches completely, and some drugs cause serious side effects. If you have had good results from preventive medicine and your migraines are well-controlled, your doctor may recommend tapering off the medication to see if your migraines return without it.

The most common medications for migraine prevention include:

• Cardiovascular drugs. Beta blockers, which are commonly used to treat high blood pressure and coronary artery disease, may reduce the frequency and severity of migraines.

The beta blockers propranolol (Inderal LA, Innopran XL, others), metoprolol tartrate (Lopressor) and timolol (Betimol) have proved effective for preventing migraines. Other beta blockers are also sometimes used for treatment of migraine. You may not notice improvement in symptoms for several weeks after taking these medications.

If you’re older than age 60, use tobacco, or have certain heart or blood vessel conditions, doctors may recommend you take a different medication.

Another class of cardiovascular medications (calcium channel blockers) used to treat high blood pressure also may be helpful in preventing migraines and relieving symptoms. Verapamil (Calan, Verelan, others) is a calcium channel blocker that may help prevent migraines with aura.

In addition, the angiotensin-converting enzyme inhibitor lisinopril (Zestril) may be useful in reducing the length and severity of migraines.

• Antidepressants. Tricyclic antidepressants may be effective in preventing migraines, even in people without depression.

Tricyclic antidepressants may reduce the frequency of migraines by affecting the level of serotonin and other brain chemicals. Amitriptyline is the only tricyclic antidepressant proved to effectively prevent migraines. Other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline.

These medications can cause sleepiness, dry mouth, constipation, weight gain and other side effects.

Another class of antidepressants called selective serotonin reuptake inhibitors hasn’t been proved to be effective for migraine prevention. These drugs may even worsen or trigger headaches.

However, research suggests that one serotonin and norepinephrine reuptake inhibitor, venlafaxine (Effexor XR), may be helpful in preventing migraines.

• Anti-seizure drugs. Some anti-seizure drugs, such as valproate (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraines.

In high doses, however, these anti-seizure drugs may cause side effects. Valproate sodium may cause nausea, tremor, weight gain, hair loss and dizziness. Valproate products should not be used in pregnant women or women who may become pregnant.

Topiramate may cause diarrhea, nausea, weight loss, memory difficulties and concentration problems.

• OnabotulinumtoxinA (Botox). OnabotulinumtoxinA (Botox) has been shown to be helpful in treating chronic migraines in adults.

During this procedure, onabotulinumtoxinA is injected into the muscles of the forehead and neck. When this is effective, the treatment usually needs to be repeated every 12 weeks.

• Pain relievers. Taking nonsteroidal anti-inflammatory drugs, especially naproxen (Naprosyn), may help prevent migraines and reduce symptoms.

Acupuncture

If medication is unsuitable, or it doesn’t help to prevent migraines, you may want to consider acupuncture.

The National Institute for Health and Care Excellence ³⁸ states that a course of up to 10 sessions over a five to eight week period may be beneficial.

In a 2016 Cochrane review ³⁹ the available evidence suggests that adding acupuncture to symptomatic treatment of migraine attacks reduces the frequency of headaches. The available evidence also suggest that acupuncture may be at least similarly effective as treatment with prophylactic drugs ³⁹. Acupuncture can be considered a treatment option for patients willing to undergo this treatment. As for other migraine treatments, long-term studies, more than one year in duration, are lacking.

Transcranial magnetic stimulation

In January 2014, the National Institute for Health and Care Excellence ⁴⁰ approved the use of a treatment called transcranial magnetic stimulation (TMS) for the treatment and prevention of migraines.

Transcranial magnetic stimulation involves holding a small electrical device to your head that delivers magnetic pulses through your skin. It’s not clear exactly how transcranial magnetic stimulation works in treating migraines, but studies have shown that using it at the start of a migraine can reduce its severity. It can also be used in combination with the medications mentioned above without interfering with them.

However, transcranial magnetic stimulation isn’t a cure for migraines and it doesn’t work for everyone. The evidence for its effectiveness isn’t strong and is limited to people who have migraine with aura.

There’s also little evidence about the potential long-term effects of the treatment, although studies into the treatment have so far only reported minor and temporary side effects, including:

• slight dizziness
• drowsiness and tiredness
• a muscle tremor that can make it difficult to stand
• irritability

The National Institute for Health and Care Excellence recommends that transcranial magnetic stimulation should only be provided by headache specialists in specialist centers, because of the uncertainty about the potential long-term side effects. The specialist will keep a record of your experiences using the treatment.

Home remedies for migraine

Self-care measures can help ease migraine pain.

• Practice muscle relaxation exercises. Relaxation techniques may include progressive muscle relaxation, meditation or yoga.
• Get enough sleep, but don’t oversleep. Get the right balance of sleep each night, making sure to go to bed and wake up at consistent times.
• Rest and relax. Try to rest in a dark, quiet room when you feel a headache coming on. Place an ice pack wrapped in a cloth on the back of your neck and apply gentle pressure to painful areas on your scalp.
• Keep a headache diary. Continue recording in your headache diary even after you see your doctor. It will help you learn more about what triggers your migraines and what treatment is most effective.

Alternative medicine

Nontraditional therapies may be helpful if you have chronic migraine pain.

• 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.
• Massage therapy. Massage therapy may help reduce the frequency of migraines. Researchers continue to study the effectiveness of massage therapy in preventing migraines.
• 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.
• Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur may prevent migraines or reduce their severity, though study results are mixed. Butterbur isn’t recommended because of long-term safety concerns.
• A high dose of riboflavin (vitamin B-2) also may prevent migraines or reduce the frequency of headaches.
• Coenzyme Q10 supplements may decrease the frequency of migraines, but larger studies are needed.
• Due to low magnesium levels in some people with migraines, magnesium supplements have been used to treat migraines, but with mixed results.

Ask your doctor if these treatments are right for you. Don’t use feverfew, riboflavin or butterbur if you’re pregnant or without first talking with your doctor.

1. The International Classification of Headache Disorders, 3rd edition (beta version). Headache Classification Committee of the International Headache Society (IHS). Cephalalgia Vol 33, Issue 9, pp. 629 – 808. First Published June 14, 2013 https://doi.org/10.1177/0333102413485658[↩][↩][↩][↩][↩]
2. Olesen J, Lekander I, Andlin-Sobocki P, Jönsson B. Funding of headache research in Europe. Cephalalgia 2007;27(9):995-9. https://www.ncbi.nlm.nih.gov/pubmed/17727472[↩]
3. Andlin-Sobocki P, Jonsson B, Wittchen HU, Olesen J. Cost of disorders of the brain in Europe. European Journal of Neurology 2005;12 Suppl 1:1-27. https://www.ncbi.nlm.nih.gov/pubmed/15877774[↩]
4. Linde M, Mulleners WM, Chronicle EP, McCrory DC. Topiramate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. DOI: 10.1002/14651858.CD010610[↩]
5. Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain 2007;128(1-2):111-27. https://www.ncbi.nlm.nih.gov/pubmed/17084028[↩]
6. Gagliardi S, Grieco GS, Gualandi F, et al. De novo exonic duplication of ATP1A2 in Italian patient with hemiplegic migraine: a case report. The Journal of Headache and Pain. 2017;18(1):63. doi:10.1186/s10194-017-0770-x. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5462664/[↩][↩]
7. Cortical spreading depression as a target for anti-migraine agents. Costa C, Tozzi A, Rainero I, Cupini LM, Calabresi P, Ayata C, Sarchielli P. J Headache Pain. 2013 Jul 23; 14:62. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3728002/[↩]
8. Carreño O, Corominas R, Serra SA, et al. Screening of CACNA1A and ATP1A2 genes in hemiplegic migraine: clinical, genetic, and functional studies. Mol Genet Genomic Med. 2013;1(4):206–222. doi: 10.1002/mgg3.24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865589/[↩][↩]
9. Riant F, Roze E, Barbance C, et al. PRRT2 mutations cause hemiplegic migraine. Neurology. 2012;79(21):2122–2124. doi: 10.1212/WNL.0b013e3182752cb8. https://www.ncbi.nlm.nih.gov/pubmed/23077016[↩][↩]
10. de Vries B, Stam AH, Kirkpatrick M, et al. Familial hemiplegic migraine is associated with febrile seizures in an FHM2 family with a novel de novo ATP1A2 mutation. Epilepsia. 2009;50(11):2503–2504. doi: 10.1111/j.1528-1167.2009.02186.x. https://www.ncbi.nlm.nih.gov/pubmed/19874388[↩][↩][↩]
11. Familial hemiplegic migraine. https://ghr.nlm.nih.gov/condition/familial-hemiplegic-migraine[↩]
12. Global prevalence of chronic migraine: a systematic review. Natoli JL, Manack A, Dean B, Butler Q, Turkel CC, Stovner L, Lipton RB. Cephalalgia. 2010 May; 30(5):599-609. https://www.ncbi.nlm.nih.gov/pubmed/19614702/[↩]
13. The International Classification of Headache Disorders, 3rd edition (beta version). Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2013 Jul; 33(9):629-808. http://journals.sagepub.com/doi/pdf/10.1177/0333102413485658[↩]
14. Wang SJ, Wang PJ, Fuh JL, et al. Comparisons of disability, quality of life, and resource use between chronic and episodic migraineurs: A clinic-based study in Taiwan. Cephalalgia 2013; 33: 171–181. https://www.ncbi.nlm.nih.gov/pubmed/23203506[↩]
15. Blumenfeld AM, Varon SF, Wilcox TK, et al. Disability, HRQoL and resource use among chronic and episodic migraineurs: Results from the International Burden of Migraine Study (IBMS). Cephalalgia 2011; 31: 301–315. https://www.ncbi.nlm.nih.gov/pubmed/20813784[↩]
16. Moon HJ, Seo JG, Park SP. Perceived stress in patients with migraine: A case-control study. J Headache Pain 2017; 18: 73. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5520838/[↩]
17. Dodick DW, Loder EW, Manack Adams A, et al. Assessing barriers to chronic migraine consultation, diagnosis, and treatment: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. Headache. Epub ahead of print 3 May 2016. DOI: 10.1111/head.12774. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5084794/[↩]
18. Evers S, Afra J, Frese A, et al. ; European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine: Revised report of an EFNS task force. Eur J Neurol 2009; 16: 968–981. https://www.ncbi.nlm.nih.gov/pubmed/19708964[↩][↩][↩]
19. Rizzoli PB. Acute and preventive treatment of migraine. Continuum (Minneap Minn) 2012; 18: 764–782. https://www.ncbi.nlm.nih.gov/pubmed/22868540[↩]
20. Starling AJ, Vargas BB. A narrative review of evidence-based preventive options for chronic migraine. Curr Pain Headache Rep 2015; 19: 49. https://www.ncbi.nlm.nih.gov/pubmed/26286071[↩]
21. Starling AJ, Dodick DW. Best practices for patients with chronic migraine: Burden, diagnosis, and management in primary care. Mayo Clin Proc 2015; 90: 408–414. https://www.ncbi.nlm.nih.gov/pubmed/25744118[↩]
22. The International Classification of Headache Disorders, 3rd edition (beta version). Headache Classification Committee of the International Headache Society (IHS). Cephalalgia Vol 33, Issue 9, pp. 629 – 808. http://journals.sagepub.com/doi/10.1177/0333102413485658[↩][↩]
23. Shepard NT. Differentiation of Meniere’s disease and migraine-associated dizziness: a review. J Am Acad Audiol. 2006;17(1):69–80. doi: 10.3766/jaaa.17.1.7. https://www.ncbi.nlm.nih.gov/pubmed/16640061[↩]
24. Baloh RW. Neurotology of migraine. Headache. 1997;37(10):615–621. doi: 10.1046/j.1526-4610.1997.3710615.x. https://www.ncbi.nlm.nih.gov/pubmed/9439080[↩]
25. Vass Z, Steyger PS, Hordichok AJ, Trune DR, Jancso G, Nuttall AL. Capsaicin stimulation of the cochlea and electric stimulation of the trigeminal ganglion mediate vascular permeability in cochlear and vertebro-basilar arteries: a potential cause of inner ear dysfunction in headache. Neuroscience. 2001;103(1):189–201. doi: 10.1016/S0306-4522(00)00521-2. https://www.ncbi.nlm.nih.gov/pubmed/11311800[↩]
26. Espinosa-Sanchez JM, Lopez-Escamez JA. New insights into pathophysiology of vestibular migraine. Front Neurol. 2015;6:12. doi: 10.3389/fneur.2015.00012. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4319397/[↩]
27. von Brevern M, Ta N, Shankar A, Wiste A, Siegel A, Radtke A, Sander T. et al. Migrainous vertigo: mutation analysis of the candidate genes CACNA1A, ATP1A2, SCN1A, and CACNB4. Headache. 2006;46(7):1136–1141. doi: 10.1111/j.1526-4610.2006.00504.x. https://www.ncbi.nlm.nih.gov/pubmed/16866717[↩][↩]
28. Lee H, Jen JC, Cha YH, Nelson SF, Baloh RW. Phenotypic and genetic analysis of a large family with migraine-associated vertigo. Headache. 2008;48(10):1460–1467. doi: 10.1111/j.1526-4610.2007.01002.x. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2846425/[↩]
29. Bahmad F Jr, DePalma SR, Merchant SN, Bezerra RL, Oliveira CA, Seidman CE, Seidman JG. Locus for familial migrainous vertigo disease maps to chromosome 5q35. Ann Otol Rhinol Laryngol. 2009;118(9):670–676. doi: 10.1177/000348940911800912. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2767209/[↩]
30. Jen JC, Wang H, Lee H, Sabatti C, Trent R, Hannigan I, Brantberg K. et al. Suggestive linkage to chromosome 6q in families with bilateral vestibulopathy. Neurology. 2004;63(12):2376–2379. doi: 10.1212/01.WNL.0000149498.79541.49. https://www.ncbi.nlm.nih.gov/pubmed/15623703[↩]
31. Carabotti M, Scirocco A, Maselli MA, Severi C. The gut-brain axis: interactions between enteric microbiota, central and enteric nervous systems. Ann Gastroenterol. 2015;28:203–209. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4367209/[↩][↩]
32. Aamodt AH, Stovner LJ, Hagen K, Zwart JA. Comorbidity of headache and gastrointestinal complaints. The Head-HUNT Study. Cephalalgia. 2008;28:144–151. https://www.ncbi.nlm.nih.gov/pubmed/18197884[↩]
33. Newman LC. Why triptan treatment can fail: focus on gastrointestinal manifestations of migraine. Headache. 2013;53(Suppl 1):11–16. https://www.ncbi.nlm.nih.gov/pubmed/23721285[↩]
34. Roberts JE, deShazo RD. Abdominal migraine, another cause of abdominal pain in adults. Am J Med. 2012;125:1135–1139. https://www.ncbi.nlm.nih.gov/pubmed/22939361[↩]
35. Mormile R. Celiac disease and migraine: is there a common backstage? Int J Colorectal Dis. 2014;29:1571. https://www.ncbi.nlm.nih.gov/pubmed/24965856[↩]
36. Konturek PC, Brzozowski T, Konturek SJ. Stress and the gut: pathophysiology, clinical consequences, diagnostic approach and treatment options. J Physiol Pharmacol. 2011;62:591–599. https://www.ncbi.nlm.nih.gov/pubmed/22314561[↩]
37. Ocular migraine: When to seek help. https://www.mayoclinic.org/diseases-conditions/migraine-headache/expert-answers/ocular-migraine/faq-20058113[↩]
38. The National Institute for Health and Care Excellence. https://www.nice.org.uk/[↩]
39. Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Vertosick EA, Vickers A, White AR. Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD001218. DOI: 10.1002/14651858.CD001218.pub3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001218.pub3/full[↩][↩]
40. Transcranial magnetic stimulation for treating and preventing migraine. https://www.nice.org.uk/guidance/ipg477[↩]