Migraine Headache

Migraines are severe, recurrent headaches that are generally accompanied by other symptoms such as visual disturbances or nausea. There are two types of migraine – classic and common. A classic migraine has an "aura" or warning associated with it that precedes the headache. The aura is often a visual disturbance (like seeing stars or zigzag lines or a temporary blind spot.) A common migraine does not have such a warning before the head pain begins. The experience of migraines, which affect 6 out of 100 people, tend to start between the ages of 10 and 46. More women than men have migraines.

Signs and Symptoms

The headache from a migraine, classic or common, has the following characteristics:

Throbbing, pounding, or pulsating pain
Often, begins on one side of your head and may spread to both or stay localized
Most intense pain is often concentrated around the temple(s) (side of the forehead)
Commonly lasts from 6 to 48 hours

Accompanying symptoms that may precede or occur at the same time as the migraine include:

Nausea and vomiting
Dizziness described as lightheadedness or even vertigo (feeling like the room is spinning)
Loss of appetite
Fatigue
Visual disturbances, like seeing flashing lights or zigzag lines, temporary blind spots (for example, loss of your peripheral vision), or blurred vision
Eye pain
Extreme sensitivitity to light (called photophobia)
Parts of your body may feel numb, weak, or tingly
Light, noise, and movement—especially bending over—make your head hurt worse; you want to lie down in a dark, quiet room
Irritability

Symptoms that may linger even after the migraine has resolved:

Feeling mentally dull, like your thinking is not clear or sharp
Increased need for sleep
Neck pain

Causes

The symptoms of migraines occur as a result of changes in the diameter of blood vessels to the brain and surrounding structures. Initially, the blood vessles constrict (narrow), reducing blood flow to these areas and leading to visual disturbances, difficulty speaking, weakness, numbness, or tingling sensation in one area of the body, or other similar symptoms. When these symptoms start before the actual headache (as in classical migraine), it is called an aura. Minutes to hours later, the blood vessels dilate (enlarge) leading to increased blood flow and a severe headache. Things that can trigger migraine (that is, the change in the diameter of blood vessels) include the following:

Alcohol
Low blood sugar from, for example, missing meals
Certain foods such as those containing the amino acid tyramine (found in red wine, aged cheese, smoked fish, chicken livers, figs, and some beans), chocolate, nuts, peanut butter, some fruits (like avocado, banana, and citrus), foods with monosodium glutamate (MSG – an additive in many foods), onions, dairy products, meats containing nitrates (bacon, hot dogs, salami, cured meats) fermented or pickled foods
Fluctuations in hormones (for example, menstruation)
Certain odors, such as perfume
Allergic reaction
Bright lights
Loud noises
Stress, physical or emotional (often, the headache occurs during the period of relaxation just following a particularly stressful time)
Sleeping too little or too much
Caffeine
Smoking or exposure to tobacco smoke
Prolonged muscle tension (for example, from a tension headache can lead to a mixed migraine-tension headache)

Risk Factors

Women are more likely to get migraines than men
Having other family members with migraine headaches
Use of birth control pills, especially if you also smoke or have high blood pressure
Being under age 40; after that point, the likelihood of migraine declines for both men and women
Exposure and sensitivity to any of the potential triggers listed above

Diagnosis

When you see your health care provider, he or she will take a detailed history in order to distinguish migraine headaches from other types of headaches, such as tension or sinus. Sometimes, headaches are a combination, like mixed migraine and tension. Your health care provider will ask questions about when your headaches occur, how long they last, how frequently they come on, the location of the pain, and any symptoms that accompany or precede the headaches. Sometimes it helps to keep a diary about your headaches prior to seeing the doctor; this way, you'll have an accurate recording of how often they happen and you won't forget the details related to your headaces. (See Lifestyle section for what information to include in a diary.)

When you do see your physician, the physical exam will include assessing your head, neck, eyes, and sinuses as well as performance of a neurologic examination. Don't be surprised if the doctor asks you some questions to test your short term memory. On exam, the physician is likely to find nothing wrong.

Tests that your doctor may order, depending on your symptoms and exam, include:

CT scan or MRI to look for a mass or other brain disorder or to check for sinusitis
Xray of the neck to look for arthritis or spinal problems; xray of the sinuses to look for sinusitis
Electroencephalogram (EEG) – a brain wave study , looking for any seizure activity
Lumbar puncture

You should contact your physician right away if any of the following apply:

You have unusual neurologic symptoms that you have not experienced before like speech disturbance, change in vision, loss of balance, or difficulty moving a limb.
Your headache pattern or intensity is different
You are experiencing "the worst headache of your life"
Your headache worsens when you are lying down

These may indicate a stroke, a bleed in the brain, or other serious condition that warrants immediate attention and evaluation.

Treatment Approach

There is no specific cure for migraine headaches. The treatment is geared toward preventing such symptoms by avoiding or altering triggers. Once migraine symptoms begin, however, treatment is aimed at preventing the headache pain if you have an aura (namely, associated symptoms that precede the headache) or treating the head pain once it has set in. There are a number of ways to accomplish all three of these – reduce the number and intensity of your headaches, quickly abort the onset of a headache by treating the migraine at the time of the aura, or successfully diminish the head pain once you have it.

A combination of medications for symptom relief together with lifestyle change and complementary therapies to reduce recurrence can offer effective management of migraines. Biofeedback (see Mind/Body Medicine) may help to control the initial contraction of blood vessels and stress management may reduce both the frequency and intensity of attacks. Whenever possible, preventing migraines should be done without the use of medication. The treatment of migraines when the symptoms set in almost always requires medication, however.

Lifestyle

Keeping a headache diary, particularly when you first begin to experience migraines, can help identify the triggers for your headaches and how to modify your environment and habits to avoid them. When a migraine occurs, write down the date and time it began. Note what you ate for the preceding 24 hours, how long you slept the night before, what you were experiencing just before the headache, any unusual stress in your life, how long the headache lasted, and what you did to make it stop.

Other lifestyle measures that may reduce the number of your headaches include:

Avoidance of smoking, caffeine, and alcohol
Exercising regularly
Getting adequate sleep each night
Relaxing and reducing stress in your life or your negative bodily responses to stress (see Mind/Body Medicine section)

Once a headache or associated migraine symptoms begin, measures that are helpful include:

Rest in a quiet, darkened room
Drink fluids to avoid dehydration (especially if you have vomited)

Medications

Medications for migraines serve two general purposes: prevent headaches altogether or treat the symptoms once they have begun. The latter includes trying to abort the headache before it starts if you have an aura (see earlier explanation). Preventing headaches by taking a prescription medication every day is generally reserved for those who have at least three headaches per month.

Drugs for Prevention

Beta-blockers, such as propranolol or timolol
Anti-depressants, including tricyclics (like amitriptyline), serotonin re-uptake inhibitors or SSRIs (like fluoxetine, fluvoxamine, paroxetine, and sertraline), nefazodone, and venlafaxine
Anti-convulsants, such as valproic acid and divalproex sodium
Calcium channel blockers, such as verapamil

Drugs for Treatment
Medications that are used if you have an aura, such as visual disturbances with classical migraines, or very soon after the symptoms of a migraine begin include those listed below. It is important to note that the intention of several of these medications is to keep the blood vessels narrow, thereby avoiding the headache that comes from the subsequent blood vessel widening. Therefore, these drugs should not be used by anyone with a heart condition.

Ergots, including ergotamine and dihydroergotamine
Serotonin agonists or triptans, including almotriptan, naratriptan, sumatriptan, rizatriptan, and zolmitriptan
Isometheptene

Other medications are used to treat the headache pain or associated symptoms:

Anti-emetics – that is, drugs (like metoclopramide or prochlorperazine) to relieve nausea and vomiting; may be given as a suppository if your vomiting is significant enough to not be able to keep medication down
Acetaminophen for pain
Ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs)
Narcotics (like propoxyphene)
Barbiturates (like butalbital)

Nutrition and Dietary Supplements

Diet
Certain foods can trigger migraine headaches; these include:

Chocolate
Cheese
Monosodium glutamate (MSG), a flavor enhancer found most notably in food from Chinese restaurants; you can always ask them to prepare the food without MSG
Foods containing the amino acid tyramine (found in red wine, aged cheese, smoked fish, chicken livers, figs, and some beans)
Nuts
Peanut butter
Some fruits (like avocado, banana, and citrus)
Onions
Dairy products
Meats containing nitrates (bacon, hot dogs, salami, cured meats)
Fermented or pickled foods

If you suspect that any of these foods contribute to how often you get migraines, you could follow an elimination-rechallange diet. This involves eliminating all of the items on this list and then reintroducing them one at a time. During this process, you should keep track of the frequency of your headaches (in a headache diary), paying close attention to when the number of headaches increases relative to particular foods. Then you know the trigger foods to avoid.

On the other hand, incorporating foods rich in omega-3 fatty acids, like flaxseed, walnuts (which contain alpha-linolenic acid [ALA], an important omega-3 fatty acid), and fish, into your diet may help stave off migraines. More research in this area would be helpful. 5-hydroxytryptophan (5-HTP)
5-hydroxytryptophan for migraine prevention. 5-hydroxytryptophan (5-HTP) is an amino acid. The body makes 5-HTP from tryptophan (an amino acid that is obtained from the diet) and converts it to an important brain chemical known as serotonin. 5-HTP dietary supplements help raise serotonin levels in the brain, which may have a positive effect on sleep, mood, anxiety, aggression, appetite, temperature, sexual behavior, and pain sensation. Some studies suggest that 5-HTP supplements may be effective in children and adults with various types of headaches including migraines.

Magnesium
Magnesium levels tend to be lower in those with migraine headaches, including children and teenagers, when compared to those who do not get headaches. A few studies suggest that taking a magnesium supplement may decrease the length of time that a migraine headache lasts and reduce the amount of medication you need to relieve the pain from a migraine.

Combining magnesium with the herb feverfew along with vitamin B2 (riboflavin) may be particularly helpful when you have a headache. This is a welcome alternative for many, especially if you have trouble taking medications because of side effects.

However, if you have 3 or more headaches per month, magnesium does not seem to work as well as prescription medications to prevent migraine headaches (that is, reduce their frequency by taking the medication or supplement every day). Unless, you are a woman and your migraines tend to happen around the time of your menstrual period; then, magnesium can be an effective way to prevent such headaches.

Magnesium sulfate may even be administered intravenously in the hospital if home remedies for the migraine symptoms are not working. The physician in the emergency room will determine if this or another therapy is most appropriate. S-Adenosylmethionine (SAMe)
In a preliminary study, SAMe decreased the frequency, intensity, and duration of migraines for most of the 124 people included in this evaluation. In addition, many reported an improved sense of well-being and use of fewer pain killers.

Vitamin B2 (Riboflavin)
For many migraine sufferers, taking riboflavin regularly may help decrease the frequency and shorten the duration of migraine headaches. It is not clear how riboflavin compares to conventional medications used to prevent migraine headaches, however. As mentioned above, often the combination of riboflavin, magnesium, and feverfew is particularly helpful.

Other
Early information and individual reports suggest that glucosamine (a supplement often used for arthritis) and coenzyme Q10 (an antioxidant that helps protect us from damage to cells in our bodies that can occur from normal metabolic processes) may each help to reduce the frequency of migraine headaches.

Herbs

The use of herbs is a time-honored approach to strengthen the body and treat disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and only under the supervision of a practitioner knowledgeable in the field of herbal medicine.

Feverfew (Tanacetum parthenium)
Feverfew, traditionally used for headaches, is very popular for migraines. In fact, a survey conducted in the 1980s of 270 migraine sufferers in Great Britain revealed that more than 70% of individuals felt substantially better when taking fresh feverfew leaves every day. Since then, several well-designed studies have been conducted to evaluate the safety and effectiveness of feverfew for the prevention and treatment of migraine headaches. Most, but not all, of these studies have found beneficial results. For example, in a study of 76 migraine sufferers, those who took feverfew capsules every day for 4 months experienced a substantial drop in the number of attacks as well as far fewer symptoms that often accompany migraines, such as nausea and vomiting, compared to those who received placebo.

It is particularly important when using feverfew to do so with guidance from a specialist because there is wide variability in the formulations of this herb sold over the counter. This may explain why some studies show improvement in migraines while others do not.

For now, some suggest that feverfew may be most appropriate for migraine sufferers who have not gotten better using conventional therapies or cannot tolerate standard medications due to side effects. Other specialists point out that many prescription medications used for headaches do not have the strongest data to support their use either. They go on to say that given that feverfew has fewer side effects and greater tolerability, this herb is definitely an important option for people with migraines.

Others
Although studies are lacking, the following herbs have been used clinically by herbal specialist to treat migraine and other types of headaches:

Dong quai (Angelica sinensis)
Devil's claw (Harpagophytum procumbens)
Ginger (Zingiber officinale)
Ginkgo biloba (Ginkgo biloba)
Jamaica dogwood (Piscidia erythrina/Piscidia piscipula)
Lavender (Lavandula angustifolia)
Linden (Tilia cordata/platypus ) flowers
Peppermint (Mentha x piperita)
Valerian (Valeriana officinalis)
Willow bark (Salix spp.)

Acupuncture

An acupuncturist diagnoses headaches not as migraine, tension, or sinus, but rather as conditions deriving from "energetic" imbalances. Headaches are commonly seen and often successfully treated by acupuncturists.

Acupuncture has been studied as a treatment for migraine headache for over 20 years, and the National Institutes of Health, as well as other groups of experts, recommend acupuncture as a treatment for headache. While not all studies have shown benefit with acupuncture, researchers do agree that acupuncture appears to be safe and that headache patients who wish to try this therapy should not be discouraged from doing so. Results from a study published in 2003 suggest that receiving an acupuncture treatment when migraine symptoms first begin is as effective as sumatriptan (one of the main medications used during the early stages of a migraine); later on in the course of the symptoms, however, the medication works better than acupuncture.

In addition to needling treatment, acupuncturists may recommend lifestyle changes, such as suggestions for specific breathing techniques, qi gong exercise, and dietary modifications.

Chiropractic

Several well-designed trials support the effectiveness of spinal manipulation therapy in the treatment of migraine headaches.

In one study, for example, including 127 people with migraine headaches, 22% of those who received chiropractic manipulation reported more than a 90% reduction of migraines and 49% reported a significant reduction of the intensity of each episode.

In another study, 218 individuals with migraine headaches were randomly assigned to receive spinal manipulation, a daily medication (amitryptiline—a drug used to prevent pain in chronic conditions such as migraine headache), or a combination of both. Spinal manipulation was as effective as the medication and had fewer side effects. There was no added benefit to combining the two therapies.

In addition, a review article evaluating nine studies that tested spinal manipulative therapy for tension or migraine headaches concluded that this chiropractic technique is comparable to medications used to try to prevent either of these two types of headaches.

Massage and Physical Therapy

Reflexology, a technique involving massage of "reflex points" on the hands and feet that correspond to areas throughout the body, helps you become more aware of you own body signals. This may allow you to anticipate the onset of a migraine sooner because of subtle symptoms that begin before the headache sets in. Reflexology also helps improve general well-being and energy level.

Homeopathy

One of the most common reasons people seek homeopathic care is to relieve the pain associated with chronic headaches. Interestingly however, only one out of four studies included in a recent review concluded that individually prescribed homeopathic remedies significantly reduces the frequency, severity, and duration of migraine symptoms. Some of these effective remedies are listed below. Professional homeopaths may also recommend various treatments based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account the individual's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

The following are some of the remedies found to be effective in the previously mentioned studies:

Belladonna — for throbbing headaches that come on suddenly; these types of headaches tend to worsen with motion and light, but are partially relieved by pressure, standing, sitting, or leaning backwards
Bryonia — for headaches with a steady, sharp pain in the forehead that may radiate to the back of the head; these types of headaches worsen with movement and light touch, but improve with firm pressure; this remedy is most appropriate for individuals who are irritable and may also experience nausea, vomiting, and constipation
Gelsemium — for pain that extends around the head and feels like a tight band of constriction; pain usually originates in the back of the head and may be relieved following urination; this remedy is most appropriate for individuals who feel extremely weak and have difficulty keeping their eyes open
Ignatia — for pain that may be described as a feeling of something being driven into the skull; these types of headaches tend to be triggered by emotion, including grief or anxiety, and the treatment is appropriate for both children and adults
Iris versicolor — for periodic migraines that begin with blurred vision, especially after eating sweets; pain usually occurs on one side of the head and may be partially relieved by gentle movement and/or fresh air
Kali bichromicum — for aching and pressing pains on the forehead (particularly between and behind the eyes); may be accompanied by sinus congestion or nausea and vomiting; this remedy is most appropriate for individuals who prefer to lie down in a dark room and who experience relief from warmth and eating
Lachesis — for migraines on the left side of the head that are typically worse in the mornings and before menstruation; this type of headache is aggravated by warmth and sunlight and relieved by open air and firm pressure
Natrum muriaticum — one of the most common remedies used for migraine headaches, particularly those that are described as "hammers beating the head;" pain is relieved when the individual is lying down, alone, in a quiet dark room; these migraines may be associated with either menstruation or a grieving experience and are worse in the middle of the day; this remedy is most appropriate for children who look pale and feel nauseated, nervous, and emotional
Nux vomica — for headaches that are described as a "nail being driving into the head;" often accompanied by nausea and/or dizziness; this remedy is most appropriate for individuals who are constipated and irritable
Sanguinaria — for right-sided headaches that begin in the neck and move upwards, recur in a predictable pattern (such as every seven days), and are accompanied by nausea and vomiting; pain is aggravated by motion, light or sun exposure, odors, and noise; this remedy is appropriate for children who may have a craving for spicy or acidic foods, despite having a general aversion to eating due to the headache
Sepia — for migraines that are accompanied by nausea and are relieved when the individual is lying down; light and movement tend to worsen symptoms; this remedy is most appropriate for individuals who are moody and don't like being alone, but worry about being with others

Homeopaths may also prescribe the following remedies based on their knowledge and clinical experience:

Pulsatilla — for headaches triggered by eating rich, fatty foods, particularly ice cream; pain tends to move but may be concentrated in the forehead or on one side of the head; may be accompanied by digestive problems or occur around the time of menstruation; children for whom this remedy is appropriate often develop these symptoms while at school
Spigelia — for migraines described as a stinging, burning, or throbbing pain, often on the left side of the head; symptoms tend to worsen with exposure to cold weather and with motion, but are temporarily relieved by cold compresses and when the individual is lying on the right side with the head propped up

Mind/Body Medicine

Reducing and learning to cope with stress effectively are important for trying to limit the number and intensity of your headaches. Techniques that can help include:

Self-hypnosis
Biofeedback
Joining a support group
Relaxation techniques such as progressive muscle relaxation (a practice that involves contracting and releasing muscles throughout your body), meditation, and guided imagery

Other Considerations

Pregnancy

Many of the medications, herbs, and supplements used to prevent or treat migraines should not be used during pregnancy. Please refer to monographs on the individual substances discussed in this article. Talk to your doctor before using any substance available over the counter or that you received by prescription prior to becoming pregnant.

Warnings and Precautions

It is important to use medications only as directed. Rebound headaches may occur from overuse of medications.

Call your health care provider if you experience a new headache, a change in quality of a previous headache or previous headache pattern, or if you are unable to manage your symptoms in the usual way (for example, a medication that usually takes away the pain no longer works).

Prognosis and Complications

Migraine headaches generally represent no significant threat to your overall health, although they can be chronic, recurrent, frustrating, and interfere with your day to day life on occasion. Stroke is an extremely rare complication from severe migraines. This may be due to prolonged constriction (narrowing) of blood vessels, reducing the blood flow to parts of the brain.

For many, migraines go into remission (meaning that they stop for a long time and happen only very infrequently) or even disappear altogether. This happens as you age in particular; for women, this may be related to declining levels of estrogen.

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