Causes of Migraine

Migraine Overview

A migraine episode is a type of headache. An episode usually occurs in stages and can last for several days. Severe cases can affect a person’s daily life, including their ability to work or study.

Migraine can affect people in different ways, and the triggers, severity, symptoms, and frequency can vary. Some people have more than one episode each week, while others have them only occasionally.

In 2018, researchers found that more than 15% of adults in the United States had experienced a migraine episode or a severe headache within the last 3 months.

Research from 2015 found that migraine affects just over 19% of females and 9% of males. Episodes often occur in people aged 18–44 years, but they can happen at any time, including during childhood.

Migraine vs Headaches 

A migraine episode is different from a typical headache. The experience is different, and they can have different causes.

Writing down the symptoms and when they occur can help a patients and their doctor identify migraine episodes. Keep this journal for at least 8 weeks, and note down:

• Any medications and their effects
• The time that symptoms start
• Possible triggers, such as stress or menstruation
• The nature of the headache
• Any other symptoms
• How long the symptoms last
• Any noticeable indicators of migraine, such as an aura

There are over 150 types of headaches, divided into two categories: primary headaches and secondary headaches.

A migraine is a primary headache, meaning that it isn’t caused by a different medical condition. Primary headache disorders are clinical diagnoses, meaning there’s no blood test or imaging study to diagnose it. A secondary headache is a symptom of another health issue.

Signs and Symptoms of Migraines

The frequency of a migraine could be once a year, once a week or any amount of time in between. Having two to four migraine headaches per month is the most common.

Symptoms of migraine tend to occur in stages:

Before the headache: According to research from 2008, 20–60% of patients with migraine experience symptoms that start hours or days before the headache.

At this stage, the patient  might experience a “prodrome,” which may involve emotional changes, specifically depression and irritability. A prodrome can also include yawning, dizziness, thirst, frequent urination, and sensitivity to light and sound.

Sometimes an aura can occur. This involves physical or sensory symptoms, such as flashing lights in the field of vision.

During the headache: Alongside a mild to severe, throbbing or pulsing headache, symptoms may include nausea, vomiting, neck pain, dizziness, and nasal congestion.

Resolution: After the headache, fatigue, tiredness and irritability may last another 2 days. This is sometimes called the “migraine hangover.”

Other common features of migraine are:

• An inability to perform regular activities due to the pain
• Head pain that worsens during physical activity or straining
• Increased sensitivity to light and sound that can sometimes be relived by lying quietly in a darkened room

Other symptoms may include sweating, feeling unusually hot or cold, a stomachache, and diarrhea.

Other symptoms of migraine headaches include the following:

• Blurry vision 
• Diarrhea 
• Dizziness 
• Fatigue and feeling of tiredness 
• Fever
• Feeling very warm (sweating) or cold (chills)
• Nausea and vomiting, upset stomach and abdominal pain
• Sensitivity to light, noise and odors 
• Loss of appetite
• Pale skin color (pallor)
• Tender scalp

Most migraines last about four hours, although severe ones can last much longer.

Each phase of the migraine attack can come with different symptoms:

Aura symptoms:

• Numbness and tingling
• Temporary loss of sight
• Speech changes
• Visual disturbances. You might be seeing the world as if through a kaleidoscope, have blurry spots or see sparkles or lines
• Weakness on one side of the body

Headache symptoms:

• Depression, giddiness and or anxiety
• Insomnia
• Nausea
• Neck pain, stiffness
• Nasal congestion
• Sensitivity to light, smell and sound
• Vomiting

Prodrome symptoms:

• Food cravings
• Difficulty speaking and reading
• Fatigue
• Increased urination
• Irritability and/or depression
• Difficulty sleeping. Yawning
• Muscle stiffness
• Nausea
• Problems concentrating
• Sensitivity to light and sound

Postdrome symptoms:

• Euphoric mood
• Fatigue
• Depressed mood
• Inability to concentrate
• Lack of comprehension
• Euphoric mood

Causes and Triggers of Migraine

The cause of migraine headaches is complicated and not fully understood. When you have a headache it’s because specific nerves in your blood vessels send pain signals to your brain. This releases inflammatory substances into the nerves and blood vessels of your head. It’s unclear why the nerves do that.

Doctors think that migraine episodes may stem from changes in the brain that affect the:

• Blood vessels
• Balance of chemicals
• Way nerves communicate

Genetic features may also play a role,  having a family history of migraine is a common risk factor.

Migraine triggers vary from patient to patient. They commonly include the following:

• Environmental factors, including flickering screens, strong smells, secondhand smoke, loud noises, humidity, stuffy rooms, temperature changes, and bright lights
• Emotional triggers, such as anxiety, stress, depression,  and excitement
• Dietary factors, including alcohol, caffeine, chocolate, nuts, cheese, citrus fruits, and foods containing the additives tyramine and monosodium glutamate (MSG) 
• Hormonal changes, such as those related to menstruation
• Medications, such as sleeping pills, hormone replacement therapy (HRT), and some birth control pills

Some other possible triggers include the following:

• A lack of sleep
• Dehydration
• Irregular mealtimes
• Jet lag
• Poor posture
• Physical overexertion 
• Shoulder and neck tension
• Tiredness
• Low blood sugar

Avoiding triggers, when possible, may help reduce the frequency of migraine episodes.

Migraine attacks can be triggered by a variety of factors. Common triggers include:

• Caffeine: Having too much caffeine or withdrawal from caffeine can cause headaches when the caffeine level abruptly drops. Your blood vessels seem to become sensitized to caffeine and when you don’t get it, a headache may occur. Caffeine is sometimes recommended by healthcare providers to help with treating acute migraine attacks but should not be used frequently.
• Daily use of pain-relieving medications: If you use medicine meant to relieve headache pain too often, that can cause a rebound headache.
• Emotional Stress: Emotional stress is one of the most common triggers of migraine headaches. During stressful events, certain chemicals in the brain are released to combat the situation (known as the “flight or fight” response). The release of these chemicals can bring on a migraine. Other emotions like anxiety, worry and excitement can increase muscle tension and dilate blood vessels. That can make your migraine more severe.
• Hormonal changes in women: Migraines in women are more common around the time of their menstruation periods. The abrupt drop in estrogen that triggers menses can also trigger migraines. Hormonal changes can also be brought on by birth control pills and hormone replacement therapy. Migraines are generally worse between puberty and menopause since these estrogen fluctuations generally don’t occur in young girls and post-menopausal women. If your hormones are a strong factor in your migraines, you may have fewer headaches after menopause. Hormonal changes do not appear to trigger migraines in men.
• Light: Flashing lights, fluorescent lights, light from the TV or computer and sunlight can trigger you.
• Missing a meal: Delaying a meal might also trigger your migraine headache.
• Sensitivity to specific chemicals and preservatives in foods: Certain foods and beverages such as aged cheese, beverages containing alcohol, chocolate and food additives such as nitrates (found in pepperoni, hot dogs and luncheon meats) and fermented or pickled foods may be responsible for triggering up to 30% of migraines.

Other possible triggers include:

• Being overly tired. Overexertion
• Changing weather conditions such as storm fronts, barometric pressure changes, strong winds or changes in altitude
• Certain medications cause blood vessels to swell
• Changes in your normal sleep pattern
• Dieting, or not drinking enough water
• Exposure to smoke, perfumes or other odors
• Loud noises

What is Aura?

An aura is a group of sensory, motor and speech symptoms that usually act like warning signals that a migraine headache is about to begin. Commonly misinterpreted as a seizures or stroke, it typically happens before the headache pain, but can sometimes appear during or even after. An aura can last from 10 to 60 minutes. About 15% to 20% of patients who experience migraines have auras.

Aura symptoms are reversible, meaning that they can be stopped/healed. An aura produces symptoms that may include:

• A “funny” feeling.
• Blind spots in your vision.
• Changes in smell or taste.
• Numb or tingling skin.
• Ringing in your ears (tinnitus).
• Speech changes.
• Seeing bright flashing dots, sparkles, or lights.
• Temporary vision loss.
• Seeing wavy or jagged lines.

Types of Migraines

There are several types of migraine. A major distinguishing factor is whether they involve aura, sensory changes.

Migraine With Aura

Aura is a disturbance of the senses in the early stages of a migraine episode.

Aura can involve:

• Confusing thoughts or experiences
• Having blind spots or blank patches in the field of vision
• Seeing strange, sparkling, or flashing lights that are not there
• Having difficulty speaking
• Seeing zig-zagging lines of light
• Having weakness in the shoulders, neck, or limbs
• Seeing things that are not there out of one eye, such as transparent strings of objects
• Having a pins and needles sensation in an arm or leg
• Not being able to see part of something clearly
• Having part of the field of vision disappear, then reappear

A visual aura may feel like the aftermath of a very bright camera flash, but the visual changes may last for several minutes or up to 1 hour.

Anyone experiencing an aura for the first time should contact a healthcare professional to rule out serious neurological problems, such as a stroke or a brain tumor.

Migraine Without Aura

More commonly, the patient experiences no sensory disturbances before an episode. According to the Migraine Trust, 70–90% of episodes occur without aura.

Other Types of Migraine

Some other types of migraine include the following:

• Abdominal migraine: This involves migraine episodes with irregular function in the gut and abdomen, often with nausea or vomiting. It mainly affects children under 14 years of age.
• Basilar Migraine: This rare type is also called “migraine with brainstem aura,” and it can affect neurological functions, such as speech.
• Chronic Migraine: This involves having an episode on more than 15 days per month.
• Hemiplegic Migraine: This causes temporary weakness on one side of the body, and it is very rare.
• Menstrual Migraine: This occurs in a pattern that follows the menstrual cycle.
• Vestibular migraine: Severe vertigo is a symptom of this type. 

The Four Stages or Phases of a Migraine and the Timeline

The four stages in chronological order are the prodrome (pre-monitory), aura, headache and postdrome. About 30% of patients experience symptoms before their headache starts.

Following are the four phases of migraine:

1. Prodrome: The first stage lasts a few hours, or it can last days. You may or may not experience it as it may not happen every time. Some know it as the “preheadache” or “premonitory” phase.
2. Aura: The aura phase can last as long as 60 minutes or as little as five. Most patients don’t experience an aura, and some have both the aura and the headache at the same time.
3. Headache: About four hours to 72 hours is how long the headache lasts. The word “ache” doesn’t do the pain justice because sometimes it’s mild, but usually, it’s described as drilling, throbbing or you may feel the sensation of an icepick in your head. Typically it starts on one side of your head and then spreads to the other side.
4. Postdrome: The postdrome stage goes on for a day or two. It’s often called a migraine “hangover” and 80% of those who have migraines experience it.

It can take about eight to 72 hours to go through the four stages.

Diagnosis of Migraine

To diagnose a migraine, your doctor will get the patients detailed medical history, not just the history of headaches but the family’s history too. Also, they’ll want to establish a history of the patients migraine-related symptoms, likely asking the following:

• Describe your headache symptoms. How severe are they?
• Remember when you get them. During your period, for example?
• Describe the type and location of your pain. Is the pain pounding? Pulsing? Throbbing?
• Remember if anything makes your headache better or worse.
• Tell how often you get migraine headaches.
• Talk about the activities, foods, stressors or the situations that may have brought on the migraine.
• Discuss what medications you take to relieve the pain and how often you take them.
• Tell how you felt before, during and after the headache.
• Remember if anyone in your family gets migraine headaches.

Your doctor may also order blood tests and imaging tests (such as a computerized tomography (CT) Scan or a magnetic resonance imaging (MRI)) to make sure there are no other causes for your headache. An electroencephalogram (EEG) may be ordered to rule out seizures.

The International Headache Society recommends the “5, 4, 3, 2, 1” criteria to diagnose migraine without aura. These numbers stand for:

• A headache with at least 2 of the following qualities:
  – occurring on one side
  – pulsating
  – causing moderate-to-severe pain aggravated by activity
• Having 5 or more episodes, each lasting 4 hours to 3 days
• At least 1 additional symptom, such as:
  – Nausea
  – Vomiting
  – Sensitivity to light and sound 

Your healthcare provider may recommend imaging or other tests to exclude other causes of the symptoms, such as a tumor, meningitis, or a stroke.

Treatment of Migraine

Migraine headaches are chronic. They can’t be cured, but they can be managed and possibly improved. There are two main treatment approaches that use medications: abortive and preventive.

• Abortive medications are most effective when you use them at the first sign of a migraine. Take them while the pain is mild. By possibly stopping the headache process, abortive medications help stop or decrease your migraine symptoms, including pain, nausea, light sensitivity, etc. Some abortive medications work by constricting your blood vessels, bringing them back to normal and relieving the throbbing pain.
• Preventive (prophylactic) medications may be prescribed when your headaches are severe, occur more than four times a month and are significantly interfering with your normal activities. Preventive medications reduce the frequency and severity of the headaches. Medications are generally taken on a regular, daily basis to help prevent migraines.

Medications

Over-the-counter medications are effective for some patients with mild to moderate migraines. The main ingredients in pain relieving medications are ibuprofen, aspirin, acetaminophen, naproxen and caffeine.

Three over-the-counter products approved by the Food and Drug Administration (FDA) for migraine headaches are:

• Advil Migraine
• Excedrin Migraine
• Motrin Migraine Pain

Patients must be cautious when taking over-the-counter pain relieving medications. Sometimes overusing them can cause analgesic-rebound headaches or a dependency problem. If you’re taking any over-the-counter pain medications more than two to three times a week, report that to your healthcare provider. They may suggest prescription medications that may be more effective.

Prescription drugs for migraine headaches include the following:

Triptan class of drugs (these are abortives):

• Sumatriptan.
• Zolmitriptan.
• Naratriptan.

Calcium channel blockers:

• Verapamil.

Calcitonin gene-related (CGRP) monoclonal antibodies:

• Erenumab.
• Fremanezumab.
• Galcanezumab.
• Eptinezumab.

Beta blockers:

• Atenolol.
• Propranolol.
• Nadolol.

Antidepressants:

• Amitriptyline.
• Nortriptyline.
• Doxepin.
• Venlafaxine.
• Duloxetine.

Antiseizure drugs:

• Valproic acid.
• Topiramate.

Other:

• Steroids.
• Phenothiazines.
• Corticosteroids.

Your healthcare provider might recommend vitamins, minerals, or herbs, including:

• Riboflavin (vitamin B2).
• Magnesium.
• Feverfew.
• Butterbur.
• Co-enzyme Q10.

Drugs to relieve migraine pain come in a variety of formulations including pills, tablets, injections, suppositories and nasal sprays. You and your healthcare provider will discuss the specific medication, combination of medications and formulations to best meet your unique headache pain.

Drugs to relieve nausea are also prescribed, if needed.

All medications should be used under the direction of a headache specialist or healthcare provider familiar with migraine therapy. As with any medication, it’s important to carefully follow the label instructions and your healthcare provider’s advice.

Prevention of Migraines

There is no cure for migraine headaches, but you can take an active role in managing them, maybe reducing how often you get them and possibly controlling how severe they are by following these tips:

• Consider trying a transcutaneous supraorbital nerve stimulation device. This battery-powered electrical stimulator device is approved by the Food and Drug Administration to prevent migraines. The device, worn like a headband or on your arm, emits electrical charges. The charge stimulates the nerve that transmits some of the pain experienced in migraine headaches. (The device may not be covered by your health insurance.) 
• Discuss with your doctor about hormone therapy if your migraines are thought to be linked to your menstrual cycle.
• Eat at regular intervals. Don’t skip meals. Drink plenty of water.
• Get seven to nine hours of sleep a night.
• Keep a migraine diary. Take notes about any foods and other triggers that you think may have caused you to develop a migraine. Make changes in your diet and avoid those triggers as much as possible.
• Getting a prescription for CGRP monoclonal antibodies. This injection was created specifically to help with migraines.
• Learn techniques to control stress such as meditation, yoga, relaxation training, or mindful breathing.
• Regularly exercise and maintain a healthy weight. 
• Seeking counseling from a therapist for help controlling your stress. Ask your healthcare provider for a referral.
• Take medications as directed by your healthcare provider. Preventative medications include antidepressants, anti-seizure medications, calcitonin gene-related peptides, medicines that lower blood pressure and Botox injections.

Prognosis of Migraine

Migraines are unique to each individual. Likewise, how migraines are managed is also unique. The best outcomes are usually achieved by learning and avoiding personal migraine triggers, managing symptoms, practicing preventive methods, following the advice of your doctor and reporting any significant changes as soon as they occur.

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