What is Migraine Disorder?
Migraines are usually thought of as severe chronic headaches, but for most sufferers, the experience of a migraine is more complicated than that. While head pain is a common symptom of one stage of a migraine episode, there are often other symptoms, such as visual and sensory disturbances, and side effects such as nausea and vomiting.
Migraines may last as little as a few hours, or they can hang on for days. Some sufferers experience attacks relatively infrequently, perhaps twice a month, but some sufferers have attacks daily or near-daily.
The experience of a migraine attack varies widely from sufferer to sufferer, but a typical pattern has the attack divided into four distinct phases: the prodrome phase, the aura phase, the attack phase, and the post-drome phase. Not all sufferers experience all four phases, and the symptoms of each phase are different for everyone.
The prodrome phase often occurs a day or two before the other phases, and it’s characterized by subtle symptoms that indicate an attack is coming on. These symptoms may include:
- Changes in mood, either positive or negative
- Increased thirst or urination, fluid retention, or constipation
- Unusual food cravings
- Stiffness in the neck
- Bouts of yawning
The aura phase typically precedes the attack phase, but the aura phase’s symptoms sometimes continue after the attack begins. The symptoms may include:
- Visual disturbances such as colors, shapes, or flashes in your field of vision
- Impaired vision or vision loss
- Weakness, numbness, or tingling in the arms or legs or on one side of the body
- Problems speaking
- Auditory disturbances or hallucinations
- Uncontrollable twitching or jerky movements
The attack phase is when the headache sets in. If left untreated, the pain may last anywhere from 4 hours to 72 hours. The pain is commonly felt on one side of the head, but it may encompass the whole head. The pain often throbs or pulses, as well.
Side effects during this phase often include nausea, vomiting, and extreme sensitivity to light and sound.
The post-drome phase begins when the headache ends and typically lasts for about a day. Sufferers usually feel lingering effects, including exhaustion, mood changes, or disorientation.
What Causes Migraine Disorder?
Scientists don’t yet know exactly what causes migraines, but research indicates that they are neurological, meaning that some brain function or brain chemistry problem is the root cause. Migraines also run in families, which suggests that there is a genetic component that is passed down from generation to generation.
Although the brain’s exact mechanisms that cause migraines are still unknown, there seem to be environmental or physiological triggers that can sometimes bring on an attack. These triggers vary from person to person, but common triggers include:
- Hormonal fluctuations. Many women experience migraines in association with their menstrual periods, pregnancy, or menopause. Hormonal birth control and therapies can also trigger (or, in some cases, possibly prevent) migraines.
- Alcohol or caffeine consumption. Both substances have been linked to migraines, and wine seems to be a particularly effective trigger.
- Eating habits. Skipping meals may trigger a migraine, and some sufferers are sensitive to specific foods, such as processed or salty foods.
- Chemical food additives. Some people seem sensitive to the preservative monosodium glutamate (MSG) or artificial sweeteners.
- Sensory stimuli such as loud noises or bright lights.
Is Migraine Disorder Hereditary?
The fact that almost all migraine sufferers have a family history of migraines strongly suggests that they have a genetic predisposition [Definition: A genetic predisposition is a person’s increased likelihood of developing a condition because of DNA inherited from his or her parents] for developing the disorder. Researchers haven’t yet figured out exactly which genes [Definition: A gene is a specific unit of DNA that is passed from parent to child] may increase the risk of developing migraines, but some genes seem to be linked to migraines with auras, while others are linked to migraines without auras. While these genes don’t cause migraines directly, they may cause differences in brain structure or function that increase the risk of developing migraines.
Overall, you have a 50-75% chance of developing migraines at some point if one or both of your parents have experienced migraines in the past.
How Is Migraine Disorder Detected?
A key to effectively treating a migraine attack is recognizing when an attack is beginning. Treatments are generally more effective when they’re administered in the prodrome or aura phases. Waiting for the attack phase to begin decreases the chance that you’ll be able to end the episode quickly.
With that in mind, remain watchful for the symptoms of the prodrome phase, which may include:
- Depression or irritability
- Sleep disturbances
- Frequent yawning
- Food cravings
- Light or sound sensitivity
These symptoms may occur only a few hours before the aura or attack phases, or they may occur as early as a day or more before the subsequent phases. Not everyone will experience the prodrome phase, and not everyone will experience a prodrome phase during every migraine episode.
How Is Migraine Disorder Diagnosed?
To diagnose migraines, doctors look for a pattern of symptoms, risk factors, and family history. Because the symptoms of migraines often closely resemble the signs of other severe neurological problems, your doctor will likely focus on ruling out those other problems before moving on to treatment for migraines.
Diagnostic steps may include:
- A physical exam. This exam will is aimed at ruling out specific physical conditions that could be causing the symptoms.
- Blood and laboratory tests. These tests look at the patient’s blood chemistry for issues that may be causing the symptoms.
- MRI scans. An MRI uses a strong magnetic field to create images of a patient’s brain and circulatory system. A doctor may call for an MRI scan to rule out other problems that may be causing your headaches if they are especially severe or are getting worse.
- CT scans. A CT scan uses X-rays to create images of your brain. Again, your doctor may prescribe a CT scan to look for other problems–such as a tumor, bleeding, or infection–that could be causing your symptoms.
How Is Migraine Disorder Treated?
Treatment for migraines usually involves medications, and the medicines prescribed generally fall into one of two categories. Pain-relieving medications are taken during an attack, and their goal is to lessen the severity of symptoms or decrease the duration of the attack. Preventive medications are intended to prevent migraines from occurring or to reduce their severity when they do occur.
Medications taken during attacks are most effective when administered at the earliest possible sign of an impending migraine. Many sufferers find relief by taking over-the-counter pain relievers such as aspirin or ibuprofen, but if taken excessively over a long period, they can cause side effects such as overuse headaches and gastrointestinal problems.
Other pain-relieving medications include:
- Triptans. Prescription pain relievers such as sumatriptan and rizatriptan are often prescribed for migraine sufferers, but they may not be suitable for patients at risk for heart attack or stroke.
- Dihydroergotamines. These drugs are effective at treating long-lasting migraines when they’re administered early. They may cause nausea, and they are not suitable for patients with coronary artery disease, high blood pressure, or kidney or liver disease.
- Opioid pain relievers. These strong pain relievers are sometimes prescribed for those who are unable to use other medications. The high risk of addiction to these drugs, however, makes them a less-than-ideal choice.
- Anti-nausea drugs. Chlorpromazine, metoclopramide, or prochlorperazine are sometimes used to treat the symptoms of the aura phase.
Preventive medications are sometimes prescribed when a sufferer has frequent migraines or when their migraines don’t respond well to other treatments. Some blood pressure medications, antidepressants, and anti-seizure medications have shown effectiveness at preventing migraines or decreasing their severity. For some people, botox injections seem to prevent migraines, as well.
The Food and Drug Administration has recently approved a class of drugs called calcitonin gene-related peptide (CGRP) monoclonal antibodies for the preventive treatment of migraines. These drugs–erenumab-aooe, fremanezumab-vfrm, and galcanezumab-gnlm–are administered via monthly injections.
Many non-drug treatments may also help to prevent migraines or make them less debilitating when they do occur. Alternative therapies include:
- Relaxation or meditation techniques
- Psychotherapy, especially cognitive behavioral therapy (CBT)
- Nutritional supplements such as vitamin B-2, magnesium, and coenzyme Q10
How Does Migraine Disorder Progress?
Fortunately, the long-term prognosis for most migraine sufferers is hopeful. Unlike many brain disorders that tend to get worse over time, migraines very often decrease in severity and/or frequency in the long term, and in some cases, migraine attacks eventually cease entirely.
A long-term study of migraine sufferers published in 2009 found that in most cases, participants experienced fewer and less severe migraine attacks within 12 years of the beginning of the study. Specific findings of the study included:
- Almost 30% of the participants were experiencing no migraine attacks by the end of the study.
- Of those who were still experiencing attacks, 80% reported that they were experiencing fewer attacks at the end of the study than at the beginning.
- Of those still having attacks, 83% reported that their migraines were less painful than they had been at the beginning of the study.
- A small percentage of participants–1.6%–reported that their attacks had progressed to a chronic level, meaning that they experienced 15 or more episodes per month.
How Is Migraine Disorder Prevented?
Aside from taking preventive medications, there are a few strategies that you can use to help prevent migraines from happening. Not all of these strategies will work for everyone, and even if a strategy works for you sometimes, it might not be able to stop every migraine.
- Get plenty of exercise. Regular exercise not only improves your overall health, but also can help to reduce the effects of stress, anxiety, and tension, all of which may be migraine triggers.
- Explore relaxation or meditation techniques. These techniques will also help lower your stress level and decrease the frequency or severity of your migraines.
- Get plenty of sleep. Disruptions in sleep schedule may trigger migraines, and staying well-rested can help prevent them. Aim for a consistent sleep schedule, and avoid sleeping too much.
- Don’t skip meals. Maintain a consistent eating schedule, too, as skipping meals is a common migraine trigger.
- Use a headache diary. Write down the details of every headache you experience, including what you were doing before the headache began and any symptoms that you noticed. The log can help you to recognize–and avoid–any triggers that you might otherwise miss.
Migraine Disorder Caregiver Tips
During a migraine attack, sufferers are likely to be unable to do even the simplest tasks for themselves. As a caregiver, you have the opportunity to make the experience as bearable as possible, but you should also know when the best thing you can do is to step aside. When someone you love is experiencing a migraine, keep these tips in mind:
- Be on hand and ready to help. Be prepared to get medication, water, an ice pack, or anything else the sufferer needs.
- Run interference. The sufferer is likely to be extremely sensitive to light and sound, so you can help by providing a dark, quiet environment. Draw the curtains and keep visitors at bay.
- Know when to stay out of the way. The pain of the migraine is intense, and sometimes the sufferer will simply want to be left alone. Stay close by, but respect your loved one’s need for quiet solitude.
- Don’t take it personally. The pain is also likely to make the sufferer irritable, and she may express frustration with you. Understand that the pain is real, and the frustration is caused by the symptom, not you.
- Learn as much as you can about migraines. It will help you to be empathetic and an effective caregiver.
Many people with migraines also suffer from other brain-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with migraine disorder:
- Many people with migraines suffer from mood disorders such as depression. The association between migraines and depression is bi-directional, meaning that both disorders increase the risk of the other.
- People with migraines are also at increased risk of bipolar disorder.
- Migraine disorder is often associated with anxiety disorders such as generalized anxiety disorder and panic disorder.
Migraine Disorder Brain Science
At one time, scientists thought that migraines were caused simply by blood flow changes in the brain. Research in recent years, however, has focused on finding the root causes of the headaches, and a complex chain of cause and effect is emerging.
Current thinking suggests that a genetic predisposition causes the brains of certain people to develop uniquely. Their unique brain structure then causes an unusual reaction to certain brain chemicals, such as the neurotransmitter serotonin and the hormone estrogen, resulting in blood vessels’ restriction. This blood flow restriction, in turn, causes migraine symptoms.
The current understanding of how this all works is incomplete. Researchers are trying to determine, for example, which genes cause the unusual brain development, which parts of the brain are different in migraine sufferers, which brain chemicals trigger migraines, and how migraine sufferers react differently to those chemicals as compared to those people who don’t have migraines.
Migraine Disorder Research
Title: Vagus Nerve Stimulation and Stress Reduction Training for Migraine
Principal Investigator: Vitaly Napadow, PhD,Lic.Ac.
Massachusetts General Hospital
Chronic pain is the most prevalent and disabling medical condition, and no single therapy has proven to be completely successful for alleviating pain, such as migraine headache. It is well documented, and recommended in the recent Institute of Medicine (IOM) report, that a multimodal approach is optimal for pain management. This study will evaluate a combination of transcutaneous vagus nerve stimulation and stress reduction training for migraine.
Investigators will recruit participants who have migraines and randomize them to one of four potential treatment arms (real or sham stimulation + real or sham stress reduction training). Brain imaging (MRI and PET) and clinical data will be collected before and after 8 weeks of the combination therapy.
Title: Novel Insight Into Migraine Pathophysiology and Galcanezumab Mechanisms of Action
Principal Investigator: Rami Burstein
Beth Israel Deaconess Medical Center
The purpose of this study is to better understand the mechanisms of action of calcitonin gene-related peptide (CGRP) targeted monoclonal antibodies in migraine prevention. Specifically, the protocol will allow the investigators to determine whether the main site of action of this novel and recently-approved class of migraine prophylactic drugs act inside or outside the brain and, if so, where.
Title: Intranasal Lidocaine to Treat Pediatric Migraine in the Emergency DepartmentStage: Recruiting
Principal Investigator: Katherine Chou, MD
New York City Health and Hospitals Corporation
New York, NY
The purpose of the study is to determine the effect of intranasal lidocaine on pain scores in pediatric patients with migraine. Patients with significant pain after oral analgesics and plan for intravenous (IV) abortive therapy will be asked to participate. Half of the patients will be given intranasal lidocaine and the other half will be given a placebo. Pain scores and associated migraine symptoms (i.e., nausea, vomiting, photophobia, phonophobia, avoidance of activities, and aura) will be monitored and compared between the groups.