Decoding Pain: Are My Headaches Migraines?

• What is a Migraine?
• What Causes Migraines?
• What are the Four Phases (Symptoms) of Migraine?
• What are Migraine Triggers?
• How is Migraine Diagnosed?
• Migraine Subtypes
  • Migraines with or without aura
  • Episodic vs Chronic Migraine
• Treatments for Migraines
  • Acute Medications
  • Preventative Medications
  • Neuromodulation
• Surgical Treatments for Migraine
  • Where Can I Get More Information?

Key Takeaways

• A migraine is a brain disorder that usually leads to attacks of severe headaches along with other neurological symptoms.
• Genetics plays a significant role in migraines. If you have migraine, you very likely have another relative who has had it also.
• Migraines affect more than 10% of people worldwide. A 2022 survey showed that they affect 17.1% of women and 5.6% of men in the US.
• We don’t know what causes migraines, but we know that they are a neurological disorder of the brain.
• Migraines have four phases: prodrome, aura, headache, and postdrome.
• Almost everyone who experiences migraines can identify triggers or things that seem to make them more susceptible to having a migraine attack. However, these vary from person to person. Triggers can include certain foods, stress, irregular sleep patterns, alcohol, and bright light, but some migraines occur without triggers.
• There is no specific test for migraine, and imaging tests like a brain/head MRI are not routinely necessary.
• The Classification Committee of The International Headache Society has set the criteria for migraines. Your doctor will use these criteria to determine if you have migraines in conjunction with your exam findings and medical history.
• There is no cure for migraines, but many effective treatments are available.

What is a Migraine?

A migraine is a brain disorder that usually leads to attacks of severe headaches along with other neurological symptoms. Genetics plays a significant role in migraines. Studies of monozygotic (identical) twins have demonstrated that migraines can be up to 60% genetic. Migraines are common. They affect more than 10% of people worldwide. A 2022 survey showed that they affect 17.1% of women and 5.6% of men in the US. They are three times more common in females than in males.

It is a common misconception that migraines are due to psychological problems, such as too much stress, anxiety, or depression. While these conditions can impact migraines, they are not the cause.

This article focuses on migraines in adults, but it can often start in childhood, as having migraines can be lifelong. One of the main differences in children is that some of the medications and treatments that are used in adults either do not work, cannot be used, or have not been adequately studied in children.

What Causes Migraines?

The short answer to this is that we do not know. However, we do know that it is a neurological disorder of the brain.

It is a common misconception that migraines are due to psychological problems, such as too much stress, anxiety, or depression. But the fact is that a migraine is a medical condition, as is epilepsy, Parkinson’s disease, and diabetes. While stress, anxiety, depression, and other psychological problems can impact any of these medical problems, including migraine, they are not causes.

Research has clearly shown a genetic or inherited basis for migraine. This means that if you have migraine, you very likely have another relative who has had it also. However, the inheritance pattern is complex. It is not as simple as inheriting brown eyes if your parent has brown eyes. There appear to be many different genes involved, with many factors still unknown, and this is an area of active research.

Sometimes, relatives won’t call their headaches “migraines,” as many people go undiagnosed. Some people used to call them “sick headaches.” Also, as migraine headaches can occur in the same area as sinus headaches, some doctors have misdiagnosed them and called them “sinus headaches.” So, if you are looking into your family history, you should ask about any headache to try to find out if there is a family tendency toward having migraines.

A lot is unknown about migraines, but our understanding of them has increased over recent years. Current evidence suggests that specific areas in the brain of people with migraines function abnormally. These areas include sensory pathways, meaning the nerves involved in sensation (sight, hearing, smell, taste, touch).

This abnormal brain function makes people living with migraine susceptible to migraine attacks, more so if they are exposed to triggers. Triggers vary from person to person but can include certain foods, stress, irregular sleep patterns, alcohol, and bright light, but some migraines occur without triggers.

Scientists don’t fully understand why certain triggers cause migraines in some people but not others. Nor do they know all the details of what exactly is happening in the brain when a migraine is triggered, but it is clear that it is a complex process. There are abnormal levels of multiple chemicals in the brain with migraine attacks, including chemicals that your nerves use to communicate with each other (neurotransmitters) and chemicals explicitly involved in pain signals and inflammation.

What are the Four Phases (Symptoms) of Migraine?

We used to think that a migraine attack started with a severe headache. However, we now recognize that there are 4 phases to a migraine. Only some people have all the phases. An attack can last several hours to a few days and varies from person to person and from attack to attack.

The phases and common related symptoms are:

1. Prodrome. Approximately 77% of people experience prodromal symptoms 1-2 days before the headache. This phase occurs in 81% of women and 64% of men. Prodromal symptoms include yawning, mood changes, fatigue, neck pain, and food cravings.
2. Aura. Only about 25% of people with migraine experience an aura. This is usually the shortest phase of the attack and lasts between 5–60 minutes. The most common aura symptoms are visual changes such as a blurry spot in your vision, possibly with shimmering or zigzagging lines, that gradually increase in size before resolving altogether.
   Less commonly, your aura may be numbness or tingling in your arm, leg, or one side of your face, or speech problems. Weakness of a part of your body, such as your arm or leg or one side of your face, can also be a migraine aura, but this is rare. People who have this type of aura usually have a sub-type of migraine called hemiplegic migraine and have a strong family inheritance.
   Some people only have the aura phase of a migraine, without the headache. This is more common in older people. Some of these migraine aura symptoms can be difficult to distinguish from stroke symptoms, especially the first time you have them. If you have these types of stroke symptoms, such as weakness or numbness on one side of your body, difficulty speaking, or abrupt loss of vision, and they are not a known part of your migraine attacks, you should call 911 immediately. Getting immediate care for a stroke can be the difference between life and death.
3. Headache. During this phase, a severe throbbing, usually one-sided headache occurs. Nausea and vomiting are common, as are light, sound and smell sensitivity.
4. Postdrome. This is also known as a “migraine hangover.” You might have symptoms such as fatigue, moodiness, and cognitive dysfunction (“brain fog”) for up to one day after the headache resolves.

What are Migraine Triggers?

Almost everyone who experiences migraines can identify triggers or things that seem to make them more susceptible to having a migraine attack. However, these vary from person to person.

If you have migraine, it is a good idea to keep a journal or log of your attacks as this can help you identify triggers. For example, with a journal, you might see that you often get a migraine on Saturday when you sleep in to catch up from the work week. If you can identify a trigger like that, you can modify it and reduce your attacks. For example, getting up at the same time every day if you find oversleeping triggers migraine.

Common Triggers for Migraines:

• Stress
• Hormonal changes such as your period, puberty, pregnancy, menopause, or hormonal medications such as birth control pills
• Bright lights or flashing lights, such as fluorescent lights, which have a more subtle effect
• Barometric pressure changes such as with weather changes or thunderstorms, high altitude, or air travel
• Alcohol (particularly red wine)
• Artificial sweeteners such as aspartame
• Nitrates, which are found in foods like bacon and hot dogs
• Low blood sugar, which can occur if you skip meals or as a rebound if you eat a high-sugar meal
• Irregular sleep pattern, either too much or too little sleep
• Certain smells, like perfume or cleaning products
• Heat exposure
• Exercise, particularly high intensity
• Loud noises
• Dehydration
• Certain foods. This varies a lot from person to person. Foods that are well-known migraine triggers include chocolate, nuts, monosodium glutamate (MSG), pickled or fermented foods, yogurt, and food additives such as dyes. Still, other foods, such as tomatoes, mint, and onion, will not affect most people but will trigger a migraine for others.

It can sometimes be difficult to tell if a food is a trigger or a symptom of a migraine. For example, a lot of people who have migraines will tell you that eating chocolate is a trigger for their migraine attacks because they often get a headache after eating chocolate. However, research has shown that many people crave food during the prodrome phase. For example, you may have a chocolate craving during your prodrome phase. A few days later, you develop a migraine. You then feel that the chocolate triggered your migraine when, in fact, the chocolate craving was part of the migraine symptoms you experienced during the prodrome phase. So, what happens is that you may be having a migraine prodrome and not even realize it, as those symptoms can be subtle. This can be a bit confusing, a type of “which came first, the chicken or the egg” question, but it is an excellent example of the complicated nature of migraine and triggers.

How is Migraine Diagnosed?

There is no specific test for migraines, and imaging tests such as a brain MRI are not routinely necessary. However, your doctor might order these tests in some cases to ensure that other conditions are not causing your headaches.

New guidelines published in Headache, The Journal of Head and Face Pain recommend only neuroimaging for specific reasons, including a prolonged aura, increasing frequency, severity, or change in migraines. If you do not meet the criteria for migraine and do not have risk factors for other conditions, such as an immune deficiency, you don’t need a scan.

The Classification Committee of The International Headache Society has set the criteria for migraines. Your doctor will use these criteria to determine if you have migraines in conjunction with your exam findings and medical history.

Migraine Without Aura Headache Diagnostic Criteria (per ICHD: International Classification of Headache Disorders)

1. Headaches lasting 4 to 72 hours
2. Headache has at least two of the following:
   • One-sided
   • Pulsating quality
   • Moderate or severe pain intensity
   • Worsened by routine physical activity (like walking or climbing stairs)
3. During the headache, at least one of the following occurs:
   • Nausea, vomiting, or both
   • Light and sound sensitivity
4. These symptoms occur at least five times.

Migraine Subtypes

Many types of migraine disorders exist. The same person can experience different types of migraines. You may also experience different headache types at different stages of life. Just as each person is unique, each person’s migraine experience is also unique. Your migraine experience may stand in contrast to your friends or even your family members. Various genes and environmental exposures are involved in migraine development. The treatment for migraine headaches will, therefore, vary.

While some migraine medications can be used to treat various types of migraines, we do know that certain medications work better for specific subtypes.

Migraines with or without aura

The first sub-typing is based on whether or not you have an aura. (See section of Migraine Phases above). If you have an aura with your migraine attacks, then you have Migraine with Aura (MWA). If you do not have an aura, you have Migraine without Aura (MWOA). This is an important distinction because if you have MWA, you have a higher risk of having a stroke at a young age compared to someone who does not have an aura with their migraine. Women with migraines with aura, for instance, should not take birth control pills because the pills can also increase their stroke risk.

Episodic vs Chronic Migraine

The next subtyping is based on how many days a month you get headaches. If you get them 14 days a month or less, then you have Episodic Migraine (EM), and if you get them 15 days a month or more, then you have Chronic Migraine (CM). In general, CM is more disabling and difficult to treat. Most people who have CM started with EM, which later changed to CM. If you have EM, it is crucial that you talk to your doctor about whether you are at risk for your EM transforming to CM and what can be done to decrease the chance of that happening.

Other migraine subtypes include:

• Vestibular migraine: where you have vertigo or spinning, off-balance sensations related to migraine.
• Hemiplegic migraine: a rare subtype where you have more neurological symptoms than other migraine types. For example, if you have this type of migraine, you might have symptoms that look like a stroke with weakness, numbness, or even paralysis on one side of your body during your attacks.
• Migraine aura without headache, which used to be called ocular migraine, is where you have the aura of a migraine but do not get a headache with it. You may have a zig-zagging blind spot. This is more common over the age of 50 and requires a medical evaluation to be sure that this is not related to a stroke or a predisposition toward stroke.
• Menstrual migraine is when you get your migraines around the time of your period. This is usually up to 2 days before the start of your period to your third day of flow.

Treatments for Migraines

While there is no cure for migraines, many effective treatments are available. Since migraines vary a lot based on different subtypes, from person to person, and even within subtypes, it is essential to have a doctor familiar with this condition to optimize your care. This could be a family doctor, internist, pediatrician, neurologist, or headache specialist, depending on the severity of your migraine disorder and the skills and knowledge of the doctors in your area.
The main categories of migraine treatments include:

• Medicines to treat headaches immediately (acute medications)
• Preventative medications ( take to prevent headache from occurring)
• Herbal Supplements
• Neuromodulation
• Other non-medication treatments
• Lifestyle modifications

Acute Medications

These are medications that you take when you have a migraine to try to make it go away. In general, acute medications work best when you take them at the start of pain before your headache is severe. So, while you should always follow your doctor’s directions, it is recommended that you take your acute medications as soon as you identify that you are having a headache from migraine.

Most of these medications have been available for many years and have generics that keep the cost down, except for the newest Gepants and Ditans, which are too new to have a generic. The general categories of these medications are listed below, along with some basic information about them. Please talk to your doctor or pharmacist for the full prescribing information of any medication.

• Over-the-counter medications. These include medications such as ibuprofen, naproxen, acetaminophen, or combinations of these medications. Some prescription anti-inflammatories are also used. Over-the-counter medications are often effective for children or adults who are newly diagnosed with migraine. Sometimes, they don’t work as well after years of migraine as they may have at first.
• Triptans. This includes sumatriptan, zolmitriptan, almotriptan, eletriptan, frovatriptan, rizatriptan, and naratriptan. While most triptans are ordinary pills, some are available in nasal sprays, auto-injectors, or rapidly dissolving tablets. These alternate forms can be helpful if you are prone to nausea and vomiting with your migraine attacks. These medications are used exclusively for migraine and cluster headaches. We do not know exactly how they help migraines. Still, they are known to affect serotonin levels. Serotonin is a neurotransmitter chemical that your nerves use to communicate with each other. They cause your blood vessels to constrict (get smaller), which plays a role in migraine treatment.
  Because of the blood vessel constriction, you cannot take triptans if you have hemiplegic migraine, a history of heart attack or stroke, or other vascular disorders. These are all prescriptions, so you should talk to your doctor about whether they are a good choice for you. This class is one of the most commonly prescribed medication types for acute relief of migraine.
• Anti-nausea medications. Examples include prochlorperazine, promethazine, and metoclopramide. These are used for the nausea and vomiting associated with migraines but also have some benefits for the headache part of the attack. The benefits occur due to these medications affecting your brain’s dopamine (another neurotransmitter) system. These medications can also be given intravenously (IV) if you are in the emergency room for your migraine attack.
• ­­Gepants. These are a class of migraine medications that came out in the US in early 2020. The two medications in this class, ubrogepant (brand name Ubrelvy) and rimegepant (Nurtec® ODT), are pills. While they are no more effective than other migraine medications, or possibly even less so, they appear, so far, to rarely have side effects. They are a promising new option for you if you have vascular disease that prevents you from taking triptans or if you have not had good results with the other medications listed above. Unfortunately, since these are new, there are no generics, and they are very expensive. Also, long-term side effects are always unknown with new medications.
• Ditans. These are another new migraine-specific class that came out in 2020. The only medication in this category so far is lasmiditan (Reyvow). Its mechanism involves the serotonin neurotransmitter. There is a strong caution against using other medicines that affect the serotonin system along with it, such as triptans or antidepressants, due to the risk of severe side effects. Tell your doctor about all the other medications you take so they can check for drug interactions with any new prescription. This medication appears to be safe if you have vascular problems. Again, long-term side effects are still unknown. If you take lasmiditan, you cannot drive for 8 hours afterward, even if you feel fine, as it can affect your vehicle safety.
• Other acute medications. Other specialized medications can sometimes be used in unique circumstances, such as if you are in the emergency room. Some of those are IV medications, including ergotamines and steroids. Controlled substances such as narcotics (codeine, hydrocodone), benzodiazepines (diazepam, alprazolam), or barbiturates (butalbital, which is found in Fioricet/Fiorinal pills) are not recommended in most instances for treating migraines. All of these medications have a much higher potential to cause medication overuse headaches (MOH). If MOH occurs, stopping these medications can be much more difficult as they are prone to dependence (can be habit-forming). The only effective treatment for MOH is stopping the medication involved, and sometimes, people have to be hospitalized to withdraw from these controlled substances with migraine and MOH. Therefore, it is best to avoid them whenever possible. Some people need these controlled substances if they have a refractory headache disorder, which means it is difficult to treat and does not respond well to the usual medications. However, these medications should always be used cautiously and in small quantities, as well as in close follow-ups with your doctor.

Another warning about MOH is that all the over-the-counter pain medications and triptans are prone to this difficult-to-treat and potentially disabling complication if taken more than 2 days a week over several weeks. If you are finding you need to use your acute medications more than once a week on average, you should talk to your doctor about other options to better control and treat your migraine.

Preventative Medications

These are medications that you take all the time, such as once a day, whether you have a migraine that day or not, to try to prevent migraine attacks. Generally, if you have infrequent migraine attacks, such as 1–2 times a month, preventative medications usually are not recommended unless you have a severe form such as hemiplegic migraine. If you have migraine attacks on average 4 times a month or more, most experts would recommend that you should consider a preventative medication. This is not only to decrease your time spent with a migraine but to decrease your risk of developing migraine overuse headache (MOH) or chronic migraine, both of which are more difficult to treat conditions.

Many medications can be used to help prevent migraines. Most of them are medications that were first put on the market for something else, like high blood pressure, and were coincidentally found to decrease migraine headaches.

Once studies confirm that the medication is beneficial for migraine, it becomes a recommended treatment. We often do not understand fully why these medications work. Besides multiple medications for hypertension, scientists have found some antidepressants, anti-seizure medications, nerve block injections, herbal supplements, and vitamins to be effective for migraine prevention. There is a newer class of medications called calcitonin gene-related peptide (CGRP) antagonists that first came out in 2018 and are the only class of medications for preventing migraines that were developed specifically for migraines. You take them by injection every 1–3 months.

Your doctor will examine your entire health history to determine the best medications to use. For example, if you also have depression, it might make the most sense to start with one of the antidepressant medications that are also used for migraine so that one medication might benefit two medical problems. However, you don’t have to have depression; you can also use these medications as they can decrease migraine even in people without depression.

The type of migraine disorder you have also may affect the recommendations, in that some medications are better for certain types of migraine. While certain medicines have shown more consistent good results in studies than in others, there isn’t one medication for prevention that is best for everyone. This is another reason why you need a doctor who is very knowledgeable about migraines to help you decide which medication is best for you.

Be aware that while preventative medications can lead to improvement in migraine frequency in as little as 2 weeks, it isn’t uncommon for it to take 2 to 3 months to see their full effect. Therefore, you should give this type of medication a long trial unless it has significant side effects. And remember that there is no cure for migraine. A good response to a preventative medication is considered a decrease in your migraines by 50%. So, if you were getting 10 migraine attacks per month, a preventative medication would be considered successful if, after taking the medication for 2–3 months, you were only having 5 attacks per month.

Neuromodulation

Several devices provide electric stimulation to nerves to prevent or treat migraines. Neuromodulation is one of the newest categories of migraine treatment and, if effective for you, can be a way to limit medication use. This can be especially important if you have not tolerated migraine medications or if you have chronic migraine and, therefore, have very frequent headaches and have to limit your medication use to avoid medication overuse headaches (MOH).

Neuromodulation treatments provide electricity to different body parts. The electricity targets a specific nerve to change your brain’s electrical and nerve system to improve migraine. These treatments are all FDA-cleared as safe. The data on effectiveness varies from one device to another, as newer devices may not have as much data. Another reason for limited data is the limited studies on the device. It is a challenge designing scientific studies with a medical device. In medical studies examining the effectiveness of medications, the study compares the effectiveness of the medicated pill to a placebo. A placebo is a sugar pill or known non-effective treatment. When the treatment is a medical device, it is difficult to make a placebo comparison. Because the data in effectiveness is limiting, and treatment can be costly, your insurance may not cover it.

Here is a list of some of these devices and the nerves that they affect:

1. Cefaly. This transcutaneous electrical nerve stimulator (TENS) is placed on the forehead to stimulate the nerves above your eyes (supra-orbital nerves). These connect to the larger nerves coming directly from your brain (trigeminal nerve) and provide sensation to your forehead and scalp. The trigeminal nerve is one of the main nerves involved in migraine attacks. It is one of your cranial nerves, which are nerves that go directly to your brain.
2. Spring Transcranial Magnetic Stimulator (TMS). This is a transcranial magnetic stimulator. Your physician or technician holds it up against the back of your head, and it delivers an electromagnetic pulse to your brain.
3. GammaCore. The gammaCore is a device that stimulates your vagal nerve. The vagus nerve is also a cranial nerve. It regulates the function of many internal organs in your body. Placing the GammaCore device on your neck stimulates the vagus nerve.
4. Nerivio. This device uses electric signals to stimulate nerves in your upper arm.

Surgical Treatments for Migraine

• Patent Foramen Ovale (PFO) Heart Surgery: There is an association between a patent foramen ovale (PFO) and migraine. The foramen ovale is a connection or hole between the two sides of your heart. This communication is normal when you are a fetus, but should close shortly after birth. If the hole does not close, this condition is called a patent foramen ovale (PFO). Small PFOs are common and does not cause harm. Larger ones can be problematic as it increases your risk for strokes. Patent foramen ovale is more commonly associated in those who experience migraine with aura, than those without auras. At this time, we do not understand why this association exists. Some early studies suggested that surgery to close the PFO led to improvement in migraine. However, more recent and better-designed studies have not found this benefit. Currently, unless you are a part of a research study, doctors do not recommend this surgery as a treatment for migraine.
• Migraine surgeries. These surgeries deactivate migraine trigger points by surgically releasing these areas about the head. Scientists don’t know if these procedures are effective as they haven’t done adequate studies. Concerns include the high placebo rate with procedural treatments in migraine, and long-term side effects are unknown. As a result, unless you are a part of a research study, The American Headache Society recommends against this type of surgery.

Where Can I Get More Information?

In addition to medications and supplements, there are also lifestyle modifications that can help with the treatment of migraine. Living with a pain diagnosis is challenging. You can learn more about some of the coping strategies for living with chronic (non-cancer) pain. Prioritizing your mental health is an important strategy to thrive despite living with pain. Speaking with counselors, friends, and support groups can go a long way.
While there is abundant information about migraines online, be sure to vet your source to ensure you are receiving medically accurate information. Exploitation of vulnerable persons with chronic pain can and does occur. One general rule is to avoid any source claiming a cure for migraines or claims that a single treatment works for everyone. Neither of these statements are true. Here are a few reputable, evidence-based websites:

• The American Migraine Foundation is a non-profit organization dedicated to the advancement of research and awareness surrounding migraine.
• The American Headache Society is a professional society of healthcare providers dedicated to the study and treatment of headaches and face pain.
  Both have additional information on migraines and other headache disorders, how to find a doctor and other resources, as well as how to connect with the migraine community.

Written by: myObMD writing team | Editor: Jennifer Abayowa and Dayna Smith, MD | Reviewed October 18, 2024 | Copyright: myObMD Media, Inc 2024

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