Migraine: Symptoms, Causes & Effective Treatment

Migraine is a common neurological condition characterized by intense, often one-sided headaches that can last from 4 to 72 hours. It affects approximately 12% of the global population and is the second most disabling condition worldwide. Migraines often come with nausea, sensitivity to light and sound, and sometimes visual disturbances called aura. While there is no cure, effective treatments can reduce frequency and severity of attacks.

What Is Migraine and How Does It Differ from Other Headaches?

Migraine is a primary headache disorder characterized by recurrent episodes of moderate to severe, typically one-sided, pulsating headache lasting 4-72 hours. Unlike tension-type headache, migraine is accompanied by nausea, light sensitivity (photophobia), and sound sensitivity (phonophobia), and is worsened by routine physical activity.

Migraine represents one of the most prevalent and disabling neurological conditions worldwide. According to the World Health Organization, it ranks as the second leading cause of years lived with disability globally. Understanding what distinguishes migraine from other headache types is essential for proper diagnosis and treatment.

The International Headache Society classifies headaches into primary and secondary types. Primary headaches, including migraine, are conditions in themselves rather than symptoms of another disease. Migraine specifically involves complex neurological changes in the brain, affecting neurotransmitters, blood vessels, and pain pathways in ways that scientists are still working to fully understand.

What makes migraine unique is its characteristic constellation of symptoms. While tension-type headaches typically cause a dull, pressing sensation on both sides of the head, migraine tends to produce intense, throbbing pain often concentrated on one side. The pain quality itself differs significantly - migraine pain is frequently described as pulsating in rhythm with the heartbeat, whereas tension headaches feel more like a tight band around the head.

Beyond the headache itself, migraine brings a package of associated symptoms that can be equally debilitating. Sensitivity to light becomes so pronounced that even normal indoor lighting feels painful. Sound sensitivity means that ordinary conversation volumes seem unbearably loud. Many migraine sufferers also experience nausea and sometimes vomiting, which can interfere with their ability to take oral medications.

Primary vs Secondary Headaches

Understanding the difference between primary and secondary headaches is crucial for appropriate management. Primary headaches like migraine, tension-type headache, and cluster headache are conditions where the headache is the main problem. Secondary headaches are symptoms of underlying conditions such as infections, head injuries, vascular disorders, or other diseases.

Migraine is diagnosed based on clinical history and the pattern of symptoms rather than through blood tests or imaging. However, your doctor may order tests to rule out secondary causes, particularly if your headache pattern changes or you develop new neurological symptoms.

The Two Main Types of Migraine

Migraine primarily manifests in two forms: migraine without aura and migraine with aura. Understanding which type you experience helps guide treatment decisions and expectations.

Migraine without aura is the more common form, affecting approximately 70-80% of migraine patients. It presents with the classic migraine symptoms - intense headache, nausea, and light/sound sensitivity - without the preceding neurological symptoms that characterize aura.

Migraine with aura affects 20-30% of migraine sufferers. The aura phase involves temporary, fully reversible neurological symptoms that typically develop gradually over 5-20 minutes and last less than 60 minutes. Visual symptoms are most common, but sensory and speech disturbances can also occur.

What Are the Symptoms of Migraine?

Migraine symptoms include moderate to severe one-sided headache with pulsating quality, nausea or vomiting, sensitivity to light and sound, and worsening with physical activity. In migraine with aura, visual disturbances like zigzag lines, blind spots, or flashing lights precede the headache by 5-60 minutes.

A migraine attack unfolds in distinct phases, each with characteristic symptoms. Understanding these phases helps you recognize attacks early and intervene more effectively. Not everyone experiences all phases, and the experience can vary between attacks in the same individual.

The complete migraine cycle can span several days when you include the prodrome (pre-headache) and postdrome (post-headache) phases. While the headache phase receives most attention, the other phases significantly impact daily function and quality of life.

Prodrome Phase (Warning Signs)

The prodrome phase occurs hours to a full day before the headache begins. Recognizing these early warning signs provides an opportunity for early intervention, which often proves more effective than treating an established headache.

Common prodrome symptoms include:

• Mood changes: Irritability, depression, or unusual euphoria
• Food cravings: Especially for sweet foods or carbohydrates
• Neck stiffness or tension: Often mistaken for a trigger rather than a symptom
• Increased yawning: Excessive yawning unrelated to tiredness
• Fluid retention: Swollen hands or feet
• Increased urination: More frequent bathroom visits
• Fatigue: Unusual tiredness or low energy
• Difficulty concentrating: Mental fog or reduced cognitive function

Aura Symptoms

Aura symptoms are temporary, fully reversible neurological disturbances that typically precede the headache phase. While aura can be frightening, especially during first experiences, it is not dangerous and resolves completely.

Visual aura is the most common type and can include:

• Scintillating scotoma - a growing blind spot often with shimmering, zigzag edges
• Flashing lights or sparkles (photopsia)
• Zigzag or wavy lines
• Blurred or distorted vision
• Temporary partial vision loss

Sensory aura typically involves:

• Tingling or numbness starting in one hand
• Gradual spread up the arm, sometimes reaching the face
• Numbness around one side of the mouth

Speech and language aura can include:

• Difficulty finding words
• Slurred speech
• Problems understanding spoken or written language

Headache Phase

The headache phase is typically the most disabling part of a migraine attack. Without treatment, it lasts between 4 and 72 hours in adults, though children may experience shorter attacks of 2-12 hours.

Characteristic headache phase symptoms include:

• Pain location: Usually one-sided, though can affect both sides or alternate
• Pain quality: Pulsating or throbbing, often synchronized with heartbeat
• Pain intensity: Moderate to severe, often interfering with normal activities
• Physical activity: Pain worsens with routine movement like walking or climbing stairs
• Photophobia: Strong sensitivity to light, requiring dimmed environments
• Phonophobia: Sensitivity to sound, even normal conversation levels
• Nausea: Often accompanied by reduced appetite
• Vomiting: Occurs in some attacks, can provide temporary relief
• Osmophobia: Sensitivity to odors or smells

Postdrome Phase

After the headache resolves, many people experience a "migraine hangover" or postdrome phase lasting up to 48 hours. During this time, you may feel drained, fatigued, and have difficulty concentrating. Some people report mild residual head discomfort or mood changes. Sudden head movements may briefly trigger mild pain.

What Causes Migraine?

Migraine is caused by complex interactions between genetic susceptibility and environmental triggers. The brain of someone with migraine is more sensitive to certain stimuli, leading to changes in brain activity, neurotransmitter release, and activation of the trigeminal pain pathway. Common triggers include stress, hormonal changes, sleep disruption, and certain foods.

Scientists' understanding of migraine mechanisms has evolved significantly. Earlier theories focused primarily on blood vessel changes, but current research emphasizes migraine as primarily a neurological disorder involving the brain's pain processing systems.

The trigeminal nerve system plays a central role in migraine pain. This nerve provides sensation to the face and head and is intimately connected with the blood vessels of the meninges (brain coverings). During a migraine, activation of the trigeminal system leads to release of inflammatory substances around blood vessels and transmission of pain signals to the brain.

Calcitonin gene-related peptide (CGRP) has emerged as a key molecule in migraine pathophysiology. Levels of CGRP increase during migraine attacks, and blocking CGRP or its receptor has proven highly effective for both acute treatment and prevention. This discovery has led to an entirely new class of migraine medications.

Genetic Factors

Migraine has a strong genetic component. If one parent has migraine, there's approximately a 50% chance their children will also develop the condition. If both parents are affected, the risk increases to about 75%. Scientists have identified numerous genetic variants that contribute to migraine susceptibility, though no single gene causes the condition.

Some rare forms of migraine, such as familial hemiplegic migraine, follow clear genetic inheritance patterns with identified causative genes. However, common migraine involves complex interactions between multiple genes and environmental factors.

Common Triggers

While genetics determine who is susceptible to migraine, environmental and lifestyle factors often trigger individual attacks. Triggers vary significantly between individuals, and keeping a headache diary can help identify your personal trigger patterns.

How Is Migraine Diagnosed?

Migraine is diagnosed based on clinical history using the International Classification of Headache Disorders (ICHD-3) criteria. There is no blood test or imaging that confirms migraine. Diagnosis requires at least 5 attacks meeting specific criteria for migraine without aura, or 2 attacks with typical aura features for migraine with aura.

The diagnosis of migraine is clinical, meaning it relies on a detailed history and physical examination rather than laboratory tests or imaging. Your healthcare provider will ask detailed questions about your headaches, including their frequency, duration, location, quality, associated symptoms, and triggering factors.

The International Headache Society has established specific diagnostic criteria that help standardize migraine diagnosis worldwide. For migraine without aura, you must have experienced at least five attacks meeting all the following criteria:

• Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
• Headache has at least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by routine physical activity
• During headache, at least one of: nausea and/or vomiting, photophobia and phonophobia
• Not better accounted for by another diagnosis

For migraine with aura, the diagnostic threshold is lower - only two attacks are required, but they must include typical aura symptoms that are fully reversible and develop gradually over minutes.

The Importance of a Headache Diary

A headache diary is one of the most valuable tools for diagnosis and management. Recording details about each attack helps identify patterns, triggers, and treatment effectiveness. Your diary should include:

• Date and time of headache onset and resolution
• Pain location, quality, and intensity (using a 0-10 scale)
• Associated symptoms (nausea, sensitivity to light/sound)
• Potential triggers (stress, foods, sleep changes)
• Medications taken and their effectiveness
• For women: relationship to menstrual cycle

When Testing May Be Needed

While migraine itself doesn't require imaging or laboratory tests, your doctor may order investigations to rule out secondary causes of headache. Testing is particularly important when:

• Your headache pattern changes significantly
• You develop new neurological symptoms
• Headaches start after age 50
• Headaches are triggered by exertion, coughing, or position changes
• There are signs suggesting a secondary cause

What Are the Treatment Options for Migraine?

Migraine treatment includes acute medications (taken during attacks) and preventive treatments (taken regularly to reduce frequency). Acute options range from over-the-counter pain relievers for mild attacks to prescription triptans and newer gepants for moderate-severe attacks. Preventive medications including beta-blockers, anticonvulsants, and CGRP inhibitors can reduce attack frequency by 50% or more.

Effective migraine management typically involves a combination approach including lifestyle modifications, acute treatment for attacks, and preventive therapy for those with frequent or disabling migraines. The goal is not just treating attacks but reducing their impact on daily life and preventing progression to chronic migraine.

Treatment strategies should be individualized based on attack frequency, severity, associated symptoms, and how migraines affect your daily activities. What works for one person may not work for another, and finding the optimal treatment often requires some trial and adjustment.

Acute Treatment

Timing is critical for acute migraine treatment. Medications work best when taken early in the attack, ideally during the prodrome or within the first 30-60 minutes of headache. Once migraine becomes established, many medications become less effective.

Over-the-counter options for mild to moderate attacks include:

• NSAIDs: Ibuprofen, naproxen, and aspirin are often effective for mild-moderate migraine
• Acetaminophen: May help for mild attacks, often combined with caffeine
• Combination products: Aspirin-acetaminophen-caffeine combinations can be effective

Prescription medications for moderate to severe attacks include:

• Triptans: The gold standard for moderate-severe migraine (sumatriptan, rizatriptan, eletriptan, others)
• Gepants: CGRP receptor antagonists (rimegepant, ubrogepant) - newer options without cardiovascular restrictions
• Ditans: Lasmiditan targets serotonin receptors differently than triptans
• Anti-nausea medications: Metoclopramide or prochlorperazine for significant nausea
• Ergotamines: Older options, less commonly used today

Preventive Treatment

Preventive therapy is recommended when you experience 4 or more migraine days per month, when attacks significantly impair daily function despite acute treatment, or when acute medications are overused or contraindicated.

Traditional preventive medications (often used off-label for migraine):

• Beta-blockers: Propranolol, metoprolol - particularly helpful for migraine with anxiety
• Anticonvulsants: Topiramate, valproate - can reduce frequency by 50%+
• Antidepressants: Amitriptyline, venlafaxine - useful when depression coexists
• Calcium channel blockers: Flunarizine, verapamil

CGRP-targeted preventive therapies represent a breakthrough in migraine treatment:

• Monoclonal antibodies: Erenumab, fremanezumab, galcanezumab, eptinezumab - monthly or quarterly injections
• Oral CGRP antagonists: Atogepant, rimegepant - daily tablets

These newer medications were specifically developed for migraine and often work when traditional preventives have failed. They have favorable side effect profiles and don't require the slow dose titration needed for many traditional preventives.

Non-Medication Approaches

Several evidence-based non-drug treatments can complement medication therapy:

• Neuromodulation devices: FDA-cleared devices for prevention and/or acute treatment
• Cognitive behavioral therapy (CBT): Particularly helpful for stress-related migraine
• Biofeedback: Learning to control physiological responses
• Acupuncture: Evidence supports effectiveness similar to preventive medications
• Physical therapy: For migraine associated with neck tension
• Botulinum toxin (Botox): Approved specifically for chronic migraine

What Can You Do Yourself During a Migraine Attack?

During a migraine attack, take medication early, rest in a dark quiet room, apply cold compresses to your head or neck, stay hydrated, and try to sleep if possible. Avoid triggers like bright lights, loud sounds, and strong smells. These self-care measures can complement medication and help reduce attack duration and severity.

While medications are often necessary for migraine relief, self-care strategies play an important complementary role. Many people develop personal routines that help them cope with attacks and may reduce their duration or severity.

The most important self-care action is recognizing an attack early. Prodrome symptoms like unusual fatigue, mood changes, or neck stiffness can signal an approaching migraine, providing an opportunity for early intervention that is typically more effective than treating an established attack.

Rest and Environmental Control

Finding a comfortable resting place is often one of the first priorities during an attack. Given the sensitivity to light and sound characteristic of migraine, many people seek dark, quiet environments. Some helpful strategies include:

• Darkening the room or wearing an eye mask
• Reducing noise or using white noise to mask disturbing sounds
• Lying down in a comfortable position
• Trying to sleep - many attacks resolve or improve after sleep
• Avoiding screens (phones, computers, televisions)

Temperature Therapy

Many people find relief from applying cold or warm compresses. Cold application to the forehead, temples, or back of the neck can help numb pain and reduce inflammation. Some prefer warmth, particularly on the back of the neck where muscle tension often accompanies migraine. Commercial migraine caps and wraps are available that combine cold therapy with gentle compression.

Hydration and Nutrition

Dehydration can trigger or worsen migraines, so sipping water or clear fluids during an attack is helpful. If nausea prevents drinking, small sips or ice chips may be tolerated better. Avoid alcohol and limit caffeine during attacks unless you know caffeine helps your migraines specifically.

If you're able to eat, simple carbohydrates or bland foods may be best tolerated. Some people find that eating something helps, particularly if the attack was triggered by skipping meals.

How Can You Reduce the Risk of Migraine Attacks?

Migraine prevention involves identifying and avoiding personal triggers, maintaining regular sleep schedules, managing stress through relaxation techniques, staying physically active, eating regular meals, staying hydrated, and potentially using preventive medications. Lifestyle modifications can reduce attack frequency by 30-50% even without medication.

Prevention is a cornerstone of migraine management, particularly for those with frequent attacks. Even when preventive medications aren't needed, lifestyle modifications can significantly reduce attack frequency and improve quality of life between attacks.

Maintain Regular Routines

The migraine brain seems to prefer consistency. Maintaining regular schedules for sleep, meals, and activities can help reduce attack frequency. This includes:

• Sleep: Go to bed and wake at consistent times, even on weekends. Aim for 7-8 hours of quality sleep.
• Meals: Eat at regular intervals without skipping meals. Include protein to maintain stable blood sugar.
• Hydration: Drink water throughout the day. Dehydration is a common trigger.
• Caffeine: If you consume caffeine, keep intake consistent day to day to avoid withdrawal headaches.

Stress Management

Stress is the most commonly reported migraine trigger. Both high stress and the "let-down" after stress (explaining weekend migraines) can trigger attacks. Effective stress management strategies include:

• Regular relaxation practices (deep breathing, progressive muscle relaxation)
• Mindfulness meditation
• Regular physical exercise
• Adequate leisure time and social connection
• Professional support through therapy when needed

Regular Exercise

Regular aerobic exercise is one of the most effective lifestyle interventions for migraine prevention. Research shows that consistent moderate exercise (30-40 minutes, 3-5 times weekly) can reduce attack frequency comparably to preventive medications. Start gradually if you're not currently active, as intense exercise in unfit individuals can actually trigger attacks.

Keep a Headache Diary

Tracking your headaches and potential triggers helps identify patterns you might otherwise miss. Record headache details, weather, foods eaten, sleep quality, stress levels, menstrual cycle (if applicable), and medications used. Over time, patterns often emerge that enable more targeted prevention strategies.

When Should You See a Doctor for Migraine?

See a doctor if you experience 4+ migraines monthly, if over-the-counter medications don't provide relief, if your headache pattern changes, or if you use pain medication more than 10 days per month. Seek immediate emergency care for sudden severe headache unlike any before, headache with fever and stiff neck, confusion, seizures, weakness, numbness, or vision problems.

Many people with infrequent migraines manage well with over-the-counter medications and lifestyle measures. However, several situations indicate that professional medical evaluation would be beneficial:

What Is Chronic Migraine?

Chronic migraine is defined as having headache on 15 or more days per month for at least 3 months, with migraine features on at least 8 of those days. It affects about 2% of the population and causes greater disability than episodic migraine. Treatment often requires a combination of preventive medications, acute treatments, and lifestyle modifications.

Chronic migraine represents a more disabling form of the condition where attacks become increasingly frequent until the person has headache more days than not. This transition from episodic to chronic migraine is one of the most important complications of the condition.

Several factors increase the risk of developing chronic migraine:

• Medication overuse: Using acute medications too frequently paradoxically increases headache frequency
• Depression and anxiety: Mental health conditions double the risk of chronification
• Sleep disorders: Poor sleep quality and sleep apnea increase risk
• Obesity: Higher body weight correlates with increased migraine frequency
• Caffeine overuse: High daily caffeine intake increases chronification risk
• Inadequate treatment: Undertreating episodic migraine may allow progression

The good news is that chronic migraine can often be reversed with appropriate treatment. Addressing medication overuse, optimizing preventive therapy, and managing comorbid conditions can return many people to episodic migraine patterns.

Migraine in Special Populations

Migraine presents unique considerations in children (shorter attacks, bilateral pain common), during pregnancy (often improves, but treatment options limited), and in older adults (new headache after 50 warrants investigation). Hormonal migraine in women often relates to menstrual cycles and may require specific treatment approaches.

Migraine in Children and Adolescents

Migraine can begin at any age, including childhood. In younger children, attacks tend to be shorter (1-2 hours rather than 4-72), more likely to be bilateral rather than one-sided, and more likely to feature gastrointestinal symptoms. Children may have difficulty describing their symptoms, so parents should watch for behavioral changes like seeking dark rooms, refusing food, or wanting to sleep.

Treatment approaches must be age-appropriate, with many adult medications having limited pediatric data. Lifestyle factors like adequate sleep, regular meals, and stress management are particularly important in children.

Migraine and Menstruation

Many women experience migraines that relate to their menstrual cycles, typically occurring in the days immediately before and during menstruation when estrogen levels drop. Menstrual migraine often proves more severe and longer-lasting than attacks at other times of the month.

Management strategies include continuous hormonal contraception to minimize hormonal fluctuations, scheduled preventive treatment around menstruation, and ensuring adequate acute treatment options are available during vulnerable periods.

Migraine During Pregnancy

Many women experience improvement in migraines during pregnancy, particularly in the second and third trimesters. However, some women have unchanged or worsened migraines. Treatment during pregnancy requires careful consideration of fetal safety, with many standard medications contraindicated. Acetaminophen remains the first-line acute treatment, while preventive options are limited to medications with established safety profiles.