What is a migraine?
Migraine is a neurological condition causing recurring attacks of moderate to severe head pain, usually one-sided, often accompanied by nausea and extreme light and sound sensitivity.It occurs in about 12% of the population in the United States and is three times more common in women than men. The disease begins during adolescence, with peak incidence occurring in the 30s and 40s, and it has a strong genetic component. Up to 80% of patients have a first-degree relative with the condition.
Phases of a Migraine Attack
A migraine unfolds across up to four phases. Not everyone experiences all four in every attack.
Prodrome (Up to 24 Hours Before)
This early warning phase can start a day or more before the headache, with mood changes, fatigue, difficulty concentrating, increased thirst, neck stiffness, and light or sound sensitivity.
Aura (Up to 60 Minutes Before)
Around 1 in 3 people experience an aura, a temporary neurological disturbance lasting up to 60 minutes that can include visual zigzag lines or blind spots, numbness or tingling spreading up one arm, and difficulty speaking. Aura is not dangerous but can be alarming the first time it occurs.
Headache Phase (4 to 72 Hours)
The headache is throbbing or pulsing, typically one-sided, and worsens with physical activity. Nausea, vomiting, and extreme sensitivity to light, sound, and smell are common. Without treatment, an attack lasts 4 to 72 hours in adults.
Postdrome (Up to 48 Hours After)
Post-headache fatigue, brain fog, and problems in concentration can be experienced, which can last for about 48 hours. This “migraine hangover” stage is often underrecognised but can be as disabling as the headache itself.
What Causes Migraines?
Migraine involves abnormal brain activity that affects the trigeminal nerve and releases inflammatory substances around nerves and blood vessels in the head. The exact process of how this occurs is not fully understood, but it has been noted that people who experience migraines have a higher degree of neurologic sensitivity, which has a genetic link.
Common Migraine Triggers
Triggers raise the likelihood of an attack, but do not cause migraine on their own; they interact with underlying neurological sensitivity. Common triggers include:
- Stress is the most frequently reported trigger
- Hormonal changes, including falling oestrogen before menstruation, during perimenopause, or from hormonal contraception
- Sleep disruption, too little, too much, or irregular patterns
- Skipping meals or dehydration
- Bright lights, loud noises, or strong smells
- Weather and barometric pressure changes
- Caffeine withdrawal
- Alcohol intake, especially red wine, may trigger migraines. At the same time, different foods may have such effects, such as aged cheese, nitrate-cured meat products, and MSG.
Keeping a migraine diary is the most reliable way to identify your personal triggers.
How Is Migraine Diagnosed?
Diagnosis is clinical; no blood tests or scans confirm migraine. Your doctor takes a detailed history of your attacks, frequency, and daily impact.
Diagnostic Criteria (ICHD-3)
Migraine without aura requires:
- At least five attacks lasting 4 to 72 hours
- At least two of: one-sided, throbbing, moderate-to-severe, worsening with activity
- Nausea/vomiting, or sensitivity to light and sound
MRI or CT scans are used only to rule out secondary causes, such as if the headache becomes thunderclap in onset, reaching peak intensity over 60 seconds, or if neurological symptoms persist or worsen, or if there is a sudden change in the headache’s pattern.
Migraine Treatment
Treatment is either acute, stopping an attack in progress, or preventive, reducing how often attacks occur.
Acute Treatments
- Analgesics, including Aspirin, Ibuprofen, and Paracetamol, work best if taken at the first sign of an attack.
- Triptans, including Sumatriptan and Rizatriptan, come in different forms, including tablets, sprays, and injections, and should be used if over-the-counter drugs do not provide adequate relief.
- In addition, anti-nausea drugs, including Metoclopramide and Prochlorperazine, can be used to control associated symptoms.
- Gepants rimegepant, Ubrogepant; newer CGRP receptor antagonists for patients who cannot take Triptans
Preventive Treatments
Recommended for four or more attacks per month or when acute medication is overused:
- Beta-blockers such as Propranolol and Metoprolol (first-line)
- Anticonvulsants like Topiramate and Sodium Valproate
- Antidepressants, such as Amitriptyline, are particularly useful when sleep disruption or depression co-exist
- CGRP monoclonal antibodies Erenumab, Fremanezumab, Galcanezumab; the first drug class developed specifically to prevent migraine
- Botulinum toxin injections every 12 weeks are also approved for chronic migraine
Lifestyle Measures That Help
Regular sleep and mealtimes, drinking enough water, stress management through cognitive behavioral therapy or relaxation techniques, reducing the intake of caffeine and alcohol, and moderate aerobic exercises have been backed by research to have a positive impact on migraine.
Conclusion
Migraine is a lot more than just a simple headache, it is a complex neurological condition. Recognizing the various steps involved in a migraine attack, determining personal migraine triggers, and using contemporary therapies are steps that most people take to manage migraine. Whether immediate relief or long-term treatment is required, there are many medical therapies available to help you get migraine headaches under control. If you are experiencing frequent migraine headaches, it is recommended that you seek professional help.
