Pain Medicine & Palliative Care: Pain Medicine
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Migraine Headache
Common Features of a Migraine
How Is the Diagnosis of Migraine Made?
What Causes Migraine and Who Gets Migraine Headaches?
Who Gets Migraine Headaches?
Treatments for Migraine - Drug Therapy
Treatments for Migraine - Nondrug Therapy
Migraine Headache Websites
Need More Information on Headache Treatments?
Migraine headache is a very common condition that varies
remarkably from person to person. It can be very mild in some (for example,
rare headaches that respond to acetaminophen or ibuprofen) but can be
totally disabling in others.
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episodic headache |
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one-sided headache (typically temple or forehead) |
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nausea and/or vomiting |
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phonophobia (sensitivity to sound) |
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family history |
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pulsating (throbbing) pain |
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photophobia (sensitivity to light) |
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sensitivity to odors |
The diagnosis of migraine headache is based only on the patient's
description. The neurological examination is usually normal. The following
diagnostic criteria have been developed by the International Headache
Society (IHS):
- At least five attacks that fulfill the criteria below (Items 2 -
4)
- Headache attacks last 4 to 72 hours (untreated or unsuccessfully
treated)
- Headache has at least two of the following characteristics:
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unilateral (one-sided) |
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pulsating quality |
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moderate or severe intensity (inhibits or prohibits
daily activities) |
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made worse by walking stairs or similar routine
physical activity |
- During headache, at least one of the following occurs:
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nausea and/or vomiting |
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photophobia (sensitivity to light) and phonophobia
(sensitivity to sound) |
- History, physical and neurologic examination do not suggest a brain
tumor, infection, or blood vessel abnormality (all very rare)
Migraine headache is subdivided into two different types: Migraine With
Aura and Migraine Without Aura. Most patients do not have an aura, which
is a brief period immediately prior to the headache during which a neurological
event occurs. This event is most commonly a brief period of abnormal vision,
such as seeing spots, zig-zag lines, or unusual colors. Less common auras
include weakness in an arm or leg, funny feelings (tingling, pins and
needles) in an arm or leg, and trouble speaking or understanding other's
speech. Auras typically last less than one hour and completely resolve.
IMPORTANT: A patient experiencing symptoms of an aura for the first time
should be evaluated by a physician.
In migraine headache, a brain MRI and CAT scan are normal. This type of
test is often not needed if the headache description fits the diagnosis
of migraine, the neurological examination is normal, and the person's
age and other factors do not suggest another diagnosis. Patients often
need the evaluation of a physician, who is best able to judge whether
a test would be helpful, when headaches first start or when mild headaches
suddenly become more severe or more frequent.
Migraine headache is thought to be a genetically inherited disorder strongly
influenced by environmental factors. A person may inherent a predisposition
for developing migraine headaches, but other factors such as stress, hormonal
changes, or sleep disturbances are necessary to experience a migraine.
Pathophysiology or abnormalities in the body that cause migraines are
still not known. Several theories exist, but none has been proven to be
the sole cause of migraine. The theories include:
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The vascular theory
-- brain blood vessels first constrict and then dilate (causing
throbbing pain) |
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The spreading depression
theory -- a slow spreading of abnormal nerve impulses
that move over the brain and trigger migraine |
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The serotonergic theory
-- abnormal changes in the neurotransmitter serotonin cause migraine |
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The neurovascular theory
-- an abnormal inflammatory response in the trigeminovascular system
(nerves and blood vessels outside of the brain) results in a series
of events ultimately causing migraine |
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The vascular-supraspinal-myogenic
theory -- several abnormal reactions interact to
cause migraine, including changes in blood vessels, changes in the
central nervous system (brain, serotonin, and stress), and myofascial
triggers (spasm of deep muscles in the neck and shoulders) |
Currently, the neurovascular theory and the vascular-supraspinal-myogenic
theory have the most scientific support. More research is needed to truly
understand the mechanisms of migraine headache.
Many studies have reported that approximately 15-20% of women and 5-6%
of men around the world suffer from migraine. Most patients develop their
first migraine headache in adolescence or early adulthood. Many women
report that headaches worsen before or during the menstrual period. Headache
tends to gradually improve after menopause. Pregnancy may improve, worsen,
or have no effect on migraine. In any individual woman, each pregnancy
may affect migraine differently.
For information about migraine headaches in children,
follow this link.
Drug therapy is the most often recommended treatment for migraine (with
and without aura). Drugs for headache are divided into two types:
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abortive/symptomatic medications |
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prophylactic medications |
Abortive/symptomatic medications
are those drugs that are taken at the onset or during a headache attack
in the hopes of stopping the headache from occurring or decreasing the
symptoms associated with the headache. When prescribing abortive/symptomatic
medications, it is very important to remember the following points:
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Each migraine patient is different; it is not possible
to predict whether a particular person will respond favorably to
a drug. |
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If abortive/symptomatic medication is used excessively,
the development of
Rebound Headache Syndrome can result. (Rebound
headache means headache that is actually worsened by the overuse
of short-acting abortive medication). Some authorities recommend
that a patient take no more than 10 doses of abortive/symptomatic
headache medication per month. Others allow more but become very
concerned when abortive/symptomatic drugs are needed more than a
few times each week. |
Abortive/symptomatic headache medications include:
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over-the-counter analgesics (such as aspirin, acetaminophen, ibuprofen, naproxen, etc.) |
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prescription nonsteroidal anti-inflammatory drugs
(such as diclofenac, ketorolac, etc.) |
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barbiturates (such as butalbital) |
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ergots (such as ergotamine or dihydroergotamine) |
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antiemetics (such as prochlorperazine) |
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opioids (such as meperidine, morphine, etc.) |
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triptans (such as sumitriptan, naratriptan, etc.) |
Prophylactic headache medications
are those drugs that are taken every day, regardless of whether a headache
is being experienced, in the hopes of preventing headache attacks. These
daily medications should only be prescribed when patients have frequent
headaches (e.g., three or more times per month) that are significantly
interfering with quality of life.
When prescribing prophylactic headache medication, it is very important
to remember the following points:
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every migraine patient is different; response to a
drug cannot be predicted |
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only one drug should be prescribed at a time |
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most drugs should have careful dose adjustment. The
first dose is relatively low, and the dose is gradually increased
if a headache occurs and if no intolerable side effects are experienced
by the patient. |
Prophylactic headache medications include:
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beta-blockers (such as propranolol, nadolol, atenolol,
etc.) |
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calcium channel blockers (such as verapamil, etc.) |
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antidepressants (such as amitriptyline, nortriptyline,
desipramine, doxepin, venlafaxine, etc.) |
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anticonvulsants (such as valproic acid and gabapentin) |
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nonsteroidal anti-inflammatory drugs (regular doses
of indomethacin, naproxen, or other drugs) |
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ergots (such as regular doses of ergotamine or methysergide) |
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alpha-2 adrenergic agonists (such as clonidine or
tizanidine) |
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Feverfew (nutraceutical with some confirmatory scientific
evidence) |
Biofeedback
Many studies have shown that biofeedback can be effective as both abortive
and prophylactic treatment for migraine.
Stress Management
Many studies have found that stress is a common trigger for migraine (in
over 60% of patients). Techniques that help relieve stress, such as relaxation,
imagery, and even yoga, have been shown in studies to be very effective.
Acupuncture
Some migraine patients may obtain benefit from acupuncture.
Physical Therapy
Studies have shown that aerobic conditioning (getting in shape) can reduce
the amount and intensity of migraine. Also, some patients find that techniques
that may reduce the degree of muscle tension in the neck and shoulder
musculature can reduce the frequency of headache; methods include trained
stretching exercises, osteopathic manipulation, and craniosacral manipulation.
Dietary Alterations
In some individuals with migraine, certain foods may trigger an attack.
These foods include alcohol, chocolate, coffee, foods that contain MSG
(monosodium glutamate) and tyramine-containing foods. Patients vary in
their response to foods, and it is not necessary to recommend that all
migraine patients stop eating potential triggering foods. Patients should
become aware of the foods that trigger their headaches and avoid these.
Headache/Pain Clinic Treatment
Most often, migraine headache patients can be successfully managed by
one physician without the need for a comprehensive pain clinic treatment.
However, some migraine patients with severe headaches that fail to respond
to routine measures may need a multidisciplinary approach involving several
headache specialists, which may be provided in headache and pain clinics.
American Council for
Headache Education (ACHE)
eMedicine: Headache, Migraine
National Headache Foundation: Headache Modules
National Institutes of Health: Medline Plus
US Headache Consortium Guidelines
See our
Treatments or
Mind-Body pages.
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