A migraine isn’t just a bad headache; it’s a specific type of headache that comes with severe throbbing or pulsing pain on one side of the head – or sometimes both sides. Migraines are often accompanied by nausea or vomiting and they’re made worse by light or noise. A migraine can last for hours or days and can make its victim unable to function until it passes.
No one really knows what causes migraines, but environment, gender, and genetics play a role. Women are three times more likely to have migraines than men, according to the Mayo Clinic, and family history is also part of the equation. So is age – migraines tend to peak in your 30s and become less frequent and less severe as you get older.
Researchers believe that an imbalance in your brain chemicals – especially serotonin – may be involved in causing migraines but it could also have to do with the way your brainstem interacts with the trigeminal nerve, which is a major pain pathway.
Whatever the underlying cause, we do know a lot about things that can trigger a migraine and we know about the phases of migraines.
The important thing to understand about a migraine is that it’s not usually a sudden attack; there are stages and if you’re paying attention, you know it’s coming.
The Prodrome phase lasts for a few hours to a few days. It’s also called the “preheadache” or “premonitory” phase and it comes with irritability, depression, difficulty sleeping, fatigue and muscle stiffness, nausea, food cravings, sensitivity to light and sound, an increased need to urinate, problems concentrating, excessive yawning and sometimes even difficulty speaking or reading. That’s a long and complex list so for many people, it’s often hard to identify whether you’ve got a migraine coming on or whether you just had trouble sleeping last night. For some people though, the pattern is consistent and clear so they know at the first symptom that a migraine is imminent.
The second phase is the Aura phase and it lasts for anywhere from five minutes to an hour. Auras come with visual disturbances, sometimes a temporary loss of vision and numbness or tingling in parts of the body. The Aura phase is much easier to identify and if you’ve had regular migraines, you probably know one is coming by the time you feel an Aura.
The Headache phase is usually the worst. It runs from four hours to three days and is often described as feeling like an icepick to the head, or as a drilling or throbbing pain. The pain isn’t the only part of the Headache phase though; it also comes with neck stiffness, nausea, vomiting, nasal congestion, sensitivity to light, smell and sound, and, as you might expect with all of that, trouble sleeping.
Afterward, the final phase is the Postdrome phase, which runs for one or two days. Postdrome is characterized by fatigue, an inability to concentrate and trouble comprehending, along with either depressed mood or euphoric mood – or sometimes one and then the other.
There isn’t much good about the phases of migraines, but if there is any silver lining, it’s that being able to recognize the Prodrome phase can help you to catch and treat the migraine attack early to lessen or even stop the headache before it starts. And of course, the best answer is for each patient to be able to recognize their own migraine triggers – and then avoid them.
Stress is one of the biggest factors – and one of the hardest to avoid. Telling a patient “don’t get stressed out” isn’t a very helpful treatment plan, so we try to focus on the more controllable triggers instead.
Sleep changes can also trigger migraines, so if you are prone to the condition, try hard to get enough sleep but not to get too much sleep; basically, stick to your regular sleep schedule as much as possible without going significantly under or over.
Alcohol and caffeine are big triggers and wine is a particular problem. Most people who suffer from migraines don’t have to avoid caffeine and alcohol altogether, but they do need to be careful about how much they consume.
Strong smells trigger migraines in some people. The common ones are perfume, second-hand smoke, and chemicals like paint thinner or nail polish remover. Other intense sensory stimuli can do it too; loud noises, bright lights, and even sun glare can launch a migraine.
Then, of course, there’s food. Food triggers are different for everyone, but there are some known culprits – salt, heavily processed foods, and aged cheeses are pretty common triggers, but the two biggest ones aren’t exactly foods, but food additives: aspartame and monosodium glutamate. Aspartame is the sugar substitute packaged as Equal and is used in Diet Coke, Diet Pepsi, and a thousand other diet products. Monosodium glutamate is more commonly known as MSG. It’s a “flavor enhancer” that’s used in a lot of packaged foods, like canned soup or potato chips, and often in Asian restaurants in America. Aspartame and MSG aren’t triggers for everyone with migraines, but they’re such a common trigger that it’s one of the first things we look at.
The best preventative medications for migraines were developed for other issues. Botox and antidepressants are among the most widely used preventatives, but migraine prevention is an off-label use for both.
Botox – an injection to make wrinkles go away – is a very effective weapon against migraines. The off-label use was discovered by coincidence; people getting Botox injections to lessen the wrinkles in their foreheads noticed that their migraines became less severe or less frequent after they started getting the shots.
So why doesn’t everyone with migraines just get Botox shots? Mostly because the Food and Drug Administration only approves it for chronic migraines, which means 15 or more headache days per month. Two million Americans with migraines qualify for Botox under that definition, while 40 million Americans with migraines do not, since they have fewer than 15 headache days per month. There isn’t a lot of research into how helpful Botox is, so it hasn’t gotten wider approval. However, doctors, patients and pain clinics report it’s helpful and it has very few side effects.
Antidepressants are also widely used for migraines and that can be very off-putting to a patient who talks to a doctor about blinding pain and nausea and is written a prescription for a depression drug. But it’s not exactly about depression – it’s about chemicals. Depression is caused by an imbalance in the brain chemicals and with the ways that neurotransmitters function. Since migraines may also be caused by an imbalance in brain chemicals, the same drugs can help both conditions.
Serotonin is one of the key factors. Serotonin is the brain chemical that is most associated with your mood; happiness, anxiety and coping mechanisms are all related to serotonin, which is why many antidepressants aim to increase serotonin levels. But low serotonin can also increase your pain sensitivity and can exacerbate migraines in general. So even though you might not be suffering from depression, your doctor may prescribe an antidepressant for your migraines.
Why don’t all migraine patients get antidepressants? Partly because antidepressants have a lot of side effects that many patients find especially difficult to cope with. The three most common complaints are weight gain, sexual issues, and fatigue. Those three side effects are enough to turn many people off to antidepressants if they can find any other way to deal with migraines. Then also, antidepressants don’t help reduce migraines in everyone because as with everything else, each person’s case is unique.
Other medications work best when they’re taken at the first sign of a migraine. Over-the-counter pain relievers like aspirin or ibuprofen can help, although they can’t be taken too often because they can cause ulcers.
Triptans, like Imitrex, are prescription drugs that block pain pathways in the brain. They can also relieve the symptoms but they’re not safe for everyone. And anti-nausea drugs can be taken in conjunction with pain relievers if your symptoms include nausea.
In addition, acupuncture is a great nontraditional therapy with no side effects. There isn’t a lot of research on acupuncture, but what there is suggests that it is extremely beneficial to many people – although not all – with migraines.
But treatment isn’t the only answer and it’s not always even the best answer. Lifestyle changes are absolutely necessary when it comes to prevention. If you suffer from migraines and you don’t already keep a migraine diary, it’s time to start because the first step is finding the pattern.
Keep track of your food, medications, sleep habits and exercise and also keep track of your migraines and their phases. When you visit your doctor or pain clinic, bring the diary with you. If you and your doctor can figure out the pattern and triggers, great. If not, do your best to follow these guidelines:
- Drink plenty of fluid, especially water.
- Do your best to go to bed and wake up at the same time every day.
- Do your best to eat meals and snacks at the same time every day.
- Exercise regularly but be sure to warm up slowly – sudden intensity can trigger a migraine.
As with most types of pain, there’s no one answer. Most patients find that they have more than one trigger and most also find that they need more than one type of treatment. For almost everyone though, prevention works better than treatment and that means paying attention to your body and environment.
Emily Leisy, PA-C, joined Integrative Pain Specialists in 2017. She has extensive training in pain management and rehabilitation and specializes in the treatment of migraine and cervicogenic headaches. Emily graduated at the top of her class from the Surgical Physician Assistant Program at the University of Alabama Birmingham. She received her undergraduate degree from James Madison University in Health Sciences with a minor in Biology.