IF YOU’RE READING this, we guess you’re on a first-name basis with the mega-headache known as migraine. Perhaps you’ve just been introduced and need to confirm some information. Or maybe your concentration issues are caused by this monster’s sneaky cousin: silent migraine. (Yes, it really does exist.) Whatever migraine questions you may have, get answers. Here, top neurologists give you the lowdown on migraine causes, symptoms, and the best headache-zapping treatments & lifestyle changes so you can get your life back with a lot less pain.
So, What Exactly Is A Migraine?
You’d be forgiven for thinking migraine attacks are just really horrible headaches. They can be, but you can have a migraine without much pain at all.
Instead, you might have troubling focusing at work, feel queasy, or even vomit. You might be super sensitive to light or find that you’re seeing zigzags.
And that’s because migraine is an inherited neurological disorder, and head pain is just one of its symptoms. So-called regular headaches can cause a lot of discomfort, but they’re usually caused by a variety of external factors, from tension and hunger to blocked sinuses, neck pain, or (worst-case scenario) tumors.
Migraines can also sometimes be triggered by external stimuli, especially when such stimuli accumulate. (First, you sleep badly, and then you have a stressful day and skip lunch, for instance). Still, people with migraines have a sensitive brain that reacts to these triggers in a particular way that’s still not entirely understood.
There are three regions in the brain that seem to play an important role in migraine headaches—the hypothalamus, which is the part of the brain that regulates body temperature, sleep, and hormones, among other things—and the upper and lower brain stems.
Leading up to the migraine, these three areas of the brain start to change in the way they relate to one another:
First, the neural cells in these areas begin sending out messages via neurotransmitters, including serotonin and glutamate. These signals activate some areas of the brain, like the parts that control sensory information (such as light and pain), and suppress others (such as the areas that control concentration and attention).
In many people, this flood of serotonin and other neurotransmitters causes the release of a small protein-like molecule called calcitonin gene-related peptide (CGRP). When CGRP gets released, it leads to inflammation in the covering of the brain (called the meninges) as well as in the blood vessels, causing them to dilate. It’s that combination of inflammation and dilation that produces throbbing pain.
The whole process can last anywhere from four to 72 hours.
This experience is not uncommon—migraine headaches plague 39 million Americans, or one in four American households, according to the American Migraine Foundation. Women are three times more likely to experience migraine than men (18% versus 6%), but the 10% of school-age kids who suffer from them are evenly split between boys and girls. Most people who have them are between 18 and 44, and half had their first attack before they turned 12.
These brain attacks can derail your day—and for some people, their lives. In fact, migraine is the sixth-most debilitating condition in the world, according to the World Health Organization (WHO). The American Journal of Managed Care estimates that lost productivity and health care costs tally to $78 billion a year in the U.S. alone.
Migraine Causes
So, what causes migraine? No one knows for sure. But there are some risk factors that make you more susceptible to experiencing this condition.
Genetics
About 60% of people who experience migraine attacks typically have (or had) a parent (usually a mother) who had them, too. Doctors think you inherit the sensitivity in the brain that sets the stage for an attack when your specific triggers line up. For example, if you’re predisposed to migraines and you aren’t getting enough sleep, then that lack of sleep along with, say, flickering lights can bring on a migraine.
That genetic link is strong. If your mom or dad has (or had) migraines, you have a 50% chance of having them, too. Both parents? That risk factor jumps up to 75%. Kids can suffer from migraine, as well, with symptoms ranging from dizziness to stomachaches. And there is even a theory that colicky babies cry because they have migraine, not gas. In a study of 1,400 new parents, researchers from the University of California, San Francisco, discovered that moms who had a history of migraine headaches were 2.5 times more likely to have infants with colic.
Gender
More women have migraine than men, and that may have something to do with the relationship between estrogen and serotonin, concludes one systematic review published in 2021. When estrogen levels plummet—as they do quickly, right before the menstrual cycle—this drop affects serotonin and possibly other brain chemicals responsible for triggering migraine. Going through perimenopause is another high-risk time, because estrogen is fluctuating so wildly. Interestingly, at least half of pregnant women report that migraine symptoms improve during pregnancy (especially after the first trimester) in some research, likely because of the relatively high and stable levels of estrogen. The same is true for breastfeeding, which also keeps your estrogen levels from falling too fast. Yet only about a third of women don’t experience migraine during pregnancy, per the American Migraine Foundation.
So while a drop in estrogen is a trigger, not a cause of migraine, it can play an important role in this condition for many women.
Serotonin Levels
Serotonin is a neurotransmitter, a chemical molecule that carries messages from one brain cell to another. People with migraine tend to have abnormal levels, per the American Academy of Neurology, during an attack, but what role serotonin plays in this condition isn’t clear. It could be that serotonin activates the pain pathways in the brain, causing the release of CGRP, or it could simply help activate the parts of the brain most susceptible to an attack.
Head or Brain Injury
A concussion or whiplash can cause migraine, and so can stroke, lesions from multiple sclerosis (MS), and infections. All of these can damage the brain so that neurons are firing sporadically or continuously in a pathological manner, generating the symptoms of a migraine.
Types of Migraine Triggers
All sorts of things can set off a migraine attack in people who are prone to them, but everyone’s triggers are different. To make things even more complicated, the very things that set you up for a migraine one day may not set it off the following week. That is because it could be the accumulation of triggers that push you over your personal threshold for migraine, not just any one thing.
Common triggers include:
Bright lights
Certain foods, especially ones that have their own chemicals that can affect your nervous system or mimic brain chemicals, like red wine or caffeine
Dehydration
Fatigue
Going too long between meals
Motion sickness
Poor sleep (or too much sleep)
Stress
Weather changes (like high humidity or changes in barometric pressure)
When To See A Doctor
When migraine starts to interfere with your daily activities, or you’ve progressed from episodic migraine to more than 15 attacks per month, it’s time to get help. In the last couple of years, there have been advancements in treatments for both types—and they can be life-changing.
Trouble is that many people—especially those who experience chronic migraine attacks—don’t get the help they need. It is estimated that less than 50% of those who battle migraine seek medical assistance. One study found that fewer than 5% of those dealing with symptoms have consulted with a doctor, got treated, and then followed through with treatments.
And while primary doctors can diagnose migraine attacks, sometimes it makes more sense to see a neurologist or even go to a dedicated headache doctor or find a center that can manage your care and treat all your migraine symptoms. (Find what you’re looking for at Carrie Landess, MD — help is just a telephone call away.
Migraine Treatment
Pain Relievers
These are used when headaches strike and are usually sold over the counter (OTC), though sometimes a doctor can write Rx for stronger doses. Some of the more common ones include:
Aleve (naproxen sodium)
Advil (ibuprofen)
Excedrin (which contains aspirin, acetaminophen, and caffeine)
Tylenol (acetaminophen)
It’s best not to take more than the recommended dose, nor should you rely on them if you have more than 10 attacks per month. Overusing OTC pain relievers like those listed above can cause rebound headaches in people with migraine—the medication itself triggers more headaches that follow the attack. These rebound headaches go away once you stop taking too many pain relievers, according to the Mayo Clinic.
Triptans
These (mostly) oral meds target serotonin receptors in your brain and are meant to be taken as soon as you feel a migraine coming on. They usually provide relief in about 30 to 60 minutes, though they can reportedly worsen nausea.
These Rx medications aren’t recommended during pregnancy, nor for people with high blood pressure, history of strokes, or those with Raynaud syndrome, because they can narrow the arteries. And you can overuse them, too, making your migraine worse.
Medications include:
Imitrex (sumatriptan), which also comes in a nasal spray
Maxalt (rizatriptan)
Preventative Migraine Medications
These medications and injections are typically prescribed to prevent a migraine attack. They include:
Botox Shots
The same injections that can make wrinkles disappear can also prevent a migraine attack, although they are only approved for people with chronic migraine and tend to work better for those who have many headaches a month, according to a review published in Pain Research & Management. A doctor gives you several shots (sometimes as many as a dozen or more) around your head, neck, and shoulders, and the toxin blocks the pain receptors in those muscles and nerves, preventing them from sending signals to the brain.
There are some rare but scary side effects (like drooping eyes), but the most common one is a dull pain after the injections, according to the Mayo Clinic. Each set of injections last about 12 weeks, and you have to prove that you’ve tried other treatments without success before getting the Botox green light from your doctor.
CGRP-Targeting Medications
These new drugs, some of which prevent attacks in the first place, come in the form of shots (either done in a doctor’s office or by you at home) or tablets. They block CGRP molecules or its receptors, so the chemical doesn’t flood the brain during an attack.
The preventatives, most monthly injections, are designed to cut the number of migraine attacks and have few side effects, mostly pain at the injection site and constipation. And the preventatives can be so effective at decreasing the intensity of a migraine (as well as how often it happens) that you might just need an OTC pain reliever during an attack. They include:
Aimovig (erenumab)
Ajovy (fremanezumab)
Emgality (galcanezumab)
A new, once-daily oral medication that is also a preventative was approved and launched by the FDA in late September 2021. It is called:
Qulipta (atogepant)
Other oral meds are taken during an attack to relieve the pain. These include:
Nurtec (rimegepant)
Ubrelvy (ubrogepant)
All these CGRP-targeting medications are FDA-approved for both chronic and episodic migraine attacks. In order to get insurance to pay for them, you have to prove you have tried the older meds (like triptans) and they’ve failed.
Off-Label Drugs
Sometimes doctors will prescribe drugs that are meant for other conditions in an effort to prevent headaches. These include:
Antidepressants. These include Prozac (fluoxetine) or Zoloft (sertraline) to help raise serotonin levels
Anti-seizure drugs. These include Topamax (topiramate); they block excess glutamate, another neurotransmitter involved in migraine
Birth control pills. These are for women who have migraine before their periods unless they have migraine attacks with aura. Those women have a higher risk of stroke, so doctors are reluctant to put them on hormonal contraception, which raise the risk about seven times higher than women who have migraine attacks without aura and who are not on birth control.
Non-Drug Devices
If you don’t want to go the drug route, you can try a pulsating device that blocks migraine pain by sending electrical signals to the brain. These devices include:
Cefaly device. This electrode is attached to a strap (it looks a bit like a small heart-monitor) that you wear on your forehead. You can use it during an attack, leaving it on for an hour as it buzzes the nerves going into the brain. You can also use it every evening for 20 minutes to prevent pain.
Nervio. This is a patch you wear on your arm that you activate during a migraine with a cellphone app. It sends signals to your brain stem to block the pain. It’s only approved for people with episodic migraine attacks.
Single-pulse transcranial magnetic stimulation device (sTMS). This is about the size of a shoe and contains a magnet that pulses. You put it on the back of your head and the magnetic pulses stimulate electrical activity in the brain. You used to twice a day to prevent migraine and give yourself four more pulses during an attack.
Preventing Your Next Migraine Attack
Along with medical treatments, you can also try improving your daily habits that may be setting you up for migraine attacks. Some of the more common lifestyle suggestions by doctors include:
Eating Healthier
No shock here, large amount of caffeine and alcohol intake can be associated with increased frequency of migraine. The correct kind of diet can help alleviate triggers that spark a migraine attack. Obesity has also been found to cause or worsen migraine symptoms, so it is important to consult with your doctor to find out what diet and exercise plans are best for you.
Getting Better Sleep
People with migraine often have trouble drifting off or staying asleep, according to the American Migraine Foundation. They also may have sleep apnea and other sleep busters that leave them feeling unrefreshed when they wake up. If this is true for you, a doctor may work with you to ensure better sleep. A few ways to do this include:
Ditch digital devices before bed. The blue light of your screen right before you go to bed can keep you awake, and if it’s out of sight, you won’t be tempted to look at it if you wake up at 3 a.m.
Good sleep hygiene. Going to bed and waking up at the same time help regulate our bodies circadian rhythm, making it easier to fall asleep and wake up every day.
Managing Stress
While the scientific relationship between stress and migraine remains a mystery, research shows that those with better stress management skills do see relief alongside proper medical treatment. Stress can often be a trigger of migraine. Meditation, mindfulness, yoga, biofeedback—all these are proven stress relievers. Finding the best method for you may help alleviate symptoms and hopefully decrease triggers that could cause bad episodes. Read this article from the American Migraine Foundation for additional ways to deal with stress as a migraine trigger.