Migraine: What You Need to Know

If you think a migraine is just a bad headache, you’ve never had a migraine. The fact is that migraine is a neurological disorder with symptoms reaching nearly every system in the body, from vision to digestion. And it’s more common than you might think. The National Institutes of Health list migraine as the third most prevalent disease in the U.S, just after obesity and hypertension. Some research places it second among the most debilitating conditions in the world.1

There’s a lot of misinformation and misconceptions about migraine out there, a fact made worse by the tortuous journey migraine researchers have undertaken to define, diagnose, and treat the disorder.2 As our understanding continues to evolve, new theories and potential treatments emerge that may dramatically improve the lives of millions. But what do we know right now?

This guide will review how our conception of migraine has changed over recent years and where it is today. The information here can help you recognize migraine symptoms in yourself or a loved one and give you the information you need to seek treatment.

We often think of a migraine as a particularly awful headache, but migraine is a disorder with profound effects beyond just head pain. An individual migraine consists of one or more severe symptoms stemming from a neurological disorder called migraine. It’s a little clunky, but the way we talk about migraine has evolved so that a patient who gets migraines (the attacks) can be said to have migraine (the disorder).

Migraine attacks commonly occur in four stages, each of which can last for several hours or even days. And while some symptoms overlap from one stage to the next, each is a distinct experience.3

Those stages are:

Prodrome

The prodrome consists of milder symptoms many migraine sufferers use to identify and anticipate an oncoming attack. It’s often one of the longest-lasting stages of a migraine and is the best time to take interceptive medicines. Symptoms include:

• Brain fog
• Aphasia4
• Nausea
• Constipation
• Drastic mood changes
• Water retention
• Frequent yawning
• Neck or body stiffness

Aura

Aura are often visual disturbances that immediately precede the onset of migraine pain, though other physical symptoms are not uncommon. They typically last up to 60 minutes, but some effects can linger for days.5 Aura include:

• Visual phenomena such as flashing lights, pulsations, or embedded shapes
• Loss of vision, either totally or partially
• Tunnel vision
• Hallucinations
• Difficulty speaking or understanding language
• Loss of strength
• Numbness or pins and needles sensations

Attack

Migraine pain is the hallmark of the attack stage, though accompanying symptoms are common. Pain often presents in a focused area on one side of the head, but it can also show up elsewhere in the head, neck, shoulders, and back. This stage can last up to 72 hours, though constant low-level pain is possible among chronic sufferers. Other attack symptoms include:

• Sensitivity to light and sound
• Sensitivity to smell and touch
• Nausea
• Vomiting

Post-drome

After the pain subsides, migraine sufferers often feel exhausted — physically and emotionally. Some prodrome symptoms may recur, such as brain fog, and sudden or dramatic head movements may bring about a brief recurrence of pain. The post-drome can quickly bleed into another prodrome phase for chronic migraine sufferers as the cycle begins anew.

Whether you’re pressed for time, or you’re a migraine sufferer who doesn’t want to spend too long staring at a bright screen, you’ll likely appreciate a quick breakdown of known migraine facts. Here are 12 of them:

1. Migraine is much more than a bad headache; it’s a neurological disorder with various debilitating symptoms.2
2. Migraine research is shamefully underfunded, with the NIH spending just $0.50 per suffer in 2017.6
3. One in four U.S. households has a member with migraine.
4. Migraine affects women disproportionately — 75% of sufferers are female.
5. Migraine runs in families. 90% of migraine sufferers have a family history of it.
6. Researchers estimate that nearly 150 million people worldwide suffer from chronic migraine.7
7. Chronic migraine is defined by 15 or more days per month spent with migraine pain.8
8. One-tenth of school-age kids — and up to 28% of adolescents — experience migraine.9
9. Around 25-30% of those with migraine experience visual disturbances in the aura stage.10
10. Medication overuse can turn episodic migraine into chronic migraine.11
11. Migraine costs the U.S. up to $36 billion in lost productivity annually.12
12. A typical medical student will receive 0-5 hours of training on headaches in general (including migraine training) in all four years of medical school.13

Too often are people with headaches or migraine told to tough it out. This view largely comes from a misconception that migraine is just a bad headache. The medical community doesn’t help too much with clarification either, as migraine is often classified as a headache disorder. Other headache disorders and even benign headaches experienced occasionally deserve medical consideration. But we must comprehend the distinction between headache and migraine to appreciate the latter disorder fully.

Pain in one or more parts of the head is an undeniable symptom of most migraines. Often, head pain is the most pronounced migraine symptom. This leads many migraine sufferers to believe their migraines are just bad headaches, and they may not receive the diagnosis and care they deserve.

Diagnosis becomes more likely when the condition is chronic or accompanied by pronounced aura symptoms like aphasia (difficulty speaking) or visual disturbances. These symptoms are among the most prominent differentiators between migraine and headache. Other differentiating factors include the duration and reported intensity of pain, as well as its location in the body.14

Unfortunately, the pathophysiologies of migraine and headache each remain poorly understood.

The scientific community is at odds over the causes of migraine. There is evidence that it is a purely neurological disorder related to things like sensory processing15 and the progressive disorganization of nerves in the brain stem and other parts of the central nervous system.8 There is also evidence of autoimmunity playing a significant role in migraine.16 Fluctuations in hormones like estrogen have been shown to instigate migraine and help account for the fact that the disorder affects so many more women than men.17 And other studies show a link between PTSD and the onset of episodic migraine.18

Could stress factors in a patient with PTSD influence hormones or autoimmunity to cause migraine? Could imbalances in hormones or the autoimmune system lead to a slow reorganization of nerve fibers associated with migraine? The answer to these and similar questions is a persistently confusing “yes.”

The likelihood is that sometime in the future, probably decades from now, migraine will be an umbrella term for various migraine disorders that we’ll hopefully be able to trace to one or more causes and treat with targeted therapies. Some of that terminology already exists, such as:

• Menstrual migraine
• Vestibular migraine
• Hemiplegic migraine
• Abdominal migraine

Even among these few examples, you can see that the classification system is deeply flawed. Menstrual migraine is connected to the cause, whereas the other three migraines listed are connected to the presentation of symptoms. And none of these systems currently consider migraine’s undeniable genetic predisposition.

The ultimate cause of a migraine disorder is hard to pin down, and an individual’s migraine pathophysiology even more so. However, we know that migraine sufferers often have sensory triggers that can initiate a migraine cycle. Triggers are different for everybody, and there doesn’t appear to be any direct link between triggers and underlying migraine origins.

Examples of triggers include:

• Intense or specific smells (often food or chemical smells)
• Bright or flashing lights
• Heat
• Stress
• Strained body positions
• Interrupted sleep
• Impacts to the head
• Too much caffeine
• Dehydration
• Rapid weather changes
• Medication overuse19

Medication overuse

Of all the known triggers, medication overuse can be the most surprising and difficult to prevent. It isn’t true of all medications, but some medications — both OTC and prescription — that help combat migraine can actually create migraine cycles. There is even evidence that chronic medication overuse can transform an episodic migraine condition into a chronic one.10

Common OTC and prescription medications associated with overuse include:

• NSAIDs such as ibuprofen and naproxen
• Aspirin
• Acetaminophen
• Triptans like Zomig or Imitrex
• Opiates20

Talk to your doctor if you regularly use any of these medications, and develop a plan for pain management as you approach safe limits.

Migraine is a huge problem for women, occurring in more than 30% of the female population.7 Given our partial understanding of migraine as a disorder, we have limited research into why migraine affects three times as many women as it does men. The most prominent theory has to do with fluctuations in hormones, particularly estrogen.21

Some women are diagnosed with menstrual migraine specifically. As their period approaches, changes in hormone levels trigger a series of events in the body and brain that result in a migraine attack. These women may see a reduction or elimination of migraine symptoms with menopause. But most women with migraine can expect a less predictable pattern that lasts most of their lives.22

Migraine and pregnancy

If you’re on any migraine medication and you intend to get pregnant, you should speak with your doctor about the potential risks. Some well-established migraine drugs have undergone testing in pregnant women and have been proven safe or unsafe for fetal development. Newer treatments — which, unfortunately, are among the most effective — often lack clinical evidence to support either safety or danger, so doctors generally advise that you stop taking them as soon as you begin trying to get pregnant.

The good news is that pregnancy comes with a flood of hormones, some of which are connected with symptom reductions in chronic pain conditions.23 Many migraine sufferers report a reduction in attack frequency or intensity during pregnancy. Some people even see reduced symptoms well after delivery, though this is less common.24

If you’re among the unfortunate group that doesn’t see a meaningful reduction in migraine symptoms during pregnancy, some effective treatments are still available.

Certain NSAIDs are generally safe between weeks 12-20 of pregnancy, but that still leaves 32 weeks to consider. Lidocaine-based peripheral nerve blocks are also an option, but they can be expensive and inconvenient when you’re already making so many trips to the doctor’s office.

Medications you definitely want to avoid during pregnancy include:

• Acetaminophen
• Other NSAIDs before week 12 or after week 20
• Ergots
• Gepants
• CGRP antagonists

This list is by no means exhaustive, so talk to your doctor about your risks and options.

A neuromodulation device is one of the best options for pregnant people to combat migraine. These are essentially targeted TENS devices designed to electrically stimulate certain nerves. You apply them at the onset of a migraine attack, and they beat back the attack entirely or at least prevent it from getting as bad as it would have.

Few human studies have been conducted on pregnant people using neuromodulation, but TENS devices have been proven safe throughout pregnancy. Those human studies (as well as some animal trials) have all been successful and safe.24

While the common image of a migraine sufferer may be an adult woman trying to find the quietest, darkest place possible, the fact is that about 10% of children experience migraine. Around 50% of all migraine sufferers report having had their first known attack before age 12. That’s because children with one parent who has migraine are about 50% likely to have it as well. And if both parents have migraine, that number skyrockets to 75%. There is even some evidence to suggest that colic may be an early sign of pediatric migraine.7

Pediatric migraine patients also don’t have the same access to prescription medications as adults. Given the state of migraine research funding, it’s taken until the last few years for meaningful new treatments to emerge. But these have yet to receive approval for use in children. Other than OTC painkillers like ibuprofen and acetaminophen, kids may receive a prescription for triptans or beta-blockers.

For many migraine sufferers, there is no silver bullet that can stop attacks in their tracks or completely prevent them from happening. Most patients find that a multifaceted approach works best.

Migraine medications

Frankly, it’s a little confounding that the pharmaceutical industry seems so disinterested in finding impactful treatments for migraine sufferers when the market for those services is nearly 40 million people strong in the U.S. alone. Fortunately, funding is on the rise, albeit slowly, and the past few years have seen the advent of new, effective treatments that have changed some people’s lives.

Here’s a quick look at available medical treatments for migraine.

Because several of these treatments are new to the market, they often require prior authorization and proof that you’ve exhausted other possible treatment avenues.

Non-medical migraine treatments

There are non-medical options available for those interested in keeping their drug intake at a minimum. Some of these are general treatments that get more targeted when you work with a provider, while others are devices that can fight migraine without drugs.

Lifestyle changes

There are certain lifestyle changes you can make that can help improve your migraine symptoms. These likely won’t eliminate attacks, but they might reduce their intensity, frequency, and duration.

Migraine can be an isolating condition, but more resources for sufferers show up every day. Some of these are great places to get information, while others can help you find the treatment you need or help you build a community of people with similar experiences.

Here’s a quick list of our favorite migraine resources:

• American Migraine Foundation
• Migraine World Summit
• Migraine.com
• Association of Migraine Disorders
• CHAMP, the Coalition for Headache And Migraine Patients
• National Headache Foundation
• American Headache Society
• International Headache Society
• The Migraine Trust