Diagnosis and treatment

Diagnosis

If you have migraines or a family history of migraines, a doctor trained in treating headaches (neurologist) will likely diagnose migraines based on your medical history, symptoms, and a physical and neurological examination.

Your doctor may also recommend more tests to rule out other possible causes for your pain if your condition is unusual, complex or suddenly becomes severe.

  • Blood tests. Your doctor may order these to test for blood vessel problems, infections in your spinal cord or brain, and toxins in your system.
  • Magnetic resonance imaging (MRI). An MRI uses a powerful magnetic field and radio waves to produce detailed images of the brain and blood vessels.

    MRI scans help doctors diagnose tumors, strokes, bleeding in the brain, infections, and other brain and nervous system (neurological) conditions.

  • Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed cross-sectional images of the brain. This helps doctors diagnose tumors, infections, brain damage, bleeding in the brain and other possible medical problems that may be causing headaches.
  • Spinal tap (lumbar puncture). Your doctor may recommend a spinal tap (lumbar puncture) if he or she suspects infections, bleeding in the brain or another underlying condition.

    In this procedure, a thin needle is inserted between two vertebrae in the lower back to remove a sample of cerebrospinal fluid for analysis in a lab.

Treatment

Migraine treatments can help stop symptoms and prevent future attacks.

Many medications have been designed to treat migraines. Some drugs often used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:

  • Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms.
  • Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.

Your treatment strategy depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions.

Some medications aren't recommended if you're pregnant or breast-feeding. Some medications aren't given to children. Your doctor can help find the right medication for you.

Pain-relieving medications

Take pain-relieving drugs as soon as you experience signs or symptoms of a migraine for the best results. It may help if you rest or sleep in a dark room after taking them. Medications include:

  • Pain relievers. Aspirin or ibuprofen (Advil, Motrin IB, others) may help relieve mild migraines.

    Acetaminophen (Tylenol, others), also may help relieve mild migraines in some people.

    Drugs marketed specifically for migraines, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraine pain. They aren't effective alone for severe migraines.

    If taken too often or for long periods of time, these medications can lead to ulcers, gastrointestinal bleeding and medication-overuse headaches.

    The prescription pain reliever indomethacin may help thwart a migraine and is available in suppository form, which may be helpful if you're nauseated.

  • Triptans. These medications are often used in treating migraines. Triptans make blood vessels constrict and block pain pathways in the brain.

    Triptans effectively relieve the pain and other symptoms that are associated with migraines. They are available in pill, nasal spray and injection form.

    Triptan medications include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax).

    Side effects of triptans include reactions at the injection site, nausea, dizziness, drowsiness and muscle weakness. They aren't recommended for people at risk of strokes and heart attacks.

    A single-tablet combination of sumatriptan and naproxen sodium (Treximet) has proved to be more effective in relieving migraine symptoms than either medication on its own.

  • Ergots. Ergotamine and caffeine combination drugs (Migergot, Cafergot) are less effective than triptans. Ergots seem most effective in those whose pain lasts for more than 48 hours. Ergots are most effective when taken soon after migraine symptoms start.

    Ergotamine may worsen nausea and vomiting related to your migraines, and it may also lead to medication-overuse headaches.

    Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine. It's also less likely to lead to medication-overuse headaches. It's available as a nasal spray and in injection form.

  • Anti-nausea medications. Medication for nausea is usually combined with other medications. Frequently prescribed medications are chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro).
  • Opioid medications. Opioid medications containing narcotics, particularly codeine, are sometimes used to treat migraine pain for people who can't take triptans or ergots. Narcotics are habit-forming and are usually used only if no other treatments provide relief.
  • Glucocorticoids (prednisone, dexamethasone). A glucocorticoid may be used with other medications to improve pain relief. Glucocorticoids shouldn't be used frequently to avoid side effects.

Preventive medications

You may be a candidate for preventive therapy if:

  • You have four or more debilitating attacks a month
  • If attacks last more than 12 hours
  • If pain-relieving medications aren't helping
  • If your migraine signs and symptoms include a prolonged aura or numbness and weakness

Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. It may take several weeks to see improvements in your symptoms.

Your doctor may recommend daily preventive medications, or only when a predictable trigger, such as menstruation, is approaching.

Preventive medications don't always stop headaches completely, and some drugs cause serious side effects. If you have had good results from preventive medicine and your migraines are well-controlled, your doctor may recommend tapering off the medication to see if your migraines return without it.

The most common medications for migraine prevention include:

  • Cardiovascular drugs. Beta blockers, which are commonly used to treat high blood pressure and coronary artery disease, may reduce the frequency and severity of migraines.

    The beta blockers propranolol (Inderal LA, Innopran XL, others), metoprolol tartrate (Lopressor) and timolol (Betimol) have proved effective for preventing migraines. Other beta blockers are also sometimes used for treatment of migraine. You may not notice improvement in symptoms for several weeks after taking these medications.

    If you're older than age 60, use tobacco, or have certain heart or blood vessel conditions, doctors may recommend you take a different medication.

    Another class of cardiovascular medications (calcium channel blockers) used to treat high blood pressure also may be helpful in preventing migraines and relieving symptoms. Verapamil (Calan, Verelan, others) is a calcium channel blocker that may help prevent migraines with aura.

    In addition, the angiotensin-converting enzyme inhibitor lisinopril (Zestril) may be useful in reducing the length and severity of migraines.

  • Antidepressants. Tricyclic antidepressants may be effective in preventing migraines, even in people without depression.

    Tricyclic antidepressants may reduce the frequency of migraines by affecting the level of serotonin and other brain chemicals. Amitriptyline is the only tricyclic antidepressant proved to effectively prevent migraines. Other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline.

    These medications can cause sleepiness, dry mouth, constipation, weight gain and other side effects.

    Another class of antidepressants called selective serotonin reuptake inhibitors hasn't been proved to be effective for migraine prevention. These drugs may even worsen or trigger headaches.

    However, research suggests that one serotonin and norepinephrine reuptake inhibitor, venlafaxine (Effexor XR), may be helpful in preventing migraines.

  • Anti-seizure drugs. Some anti-seizure drugs, such as valproate (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraines.

    In high doses, however, these anti-seizure drugs may cause side effects. Valproate sodium may cause nausea, tremor, weight gain, hair loss and dizziness. Valproate products should not be used in pregnant women or women who may become pregnant.

    Topiramate may cause diarrhea, nausea, weight loss, memory difficulties and concentration problems.

  • OnabotulinumtoxinA (Botox). OnabotulinumtoxinA (Botox) has been shown to be helpful in treating chronic migraines in adults.

    During this procedure, onabotulinumtoxinA is injected into the muscles of the forehead and neck. When this is effective, the treatment usually needs to be repeated every 12 weeks.

  • Pain relievers. Taking nonsteroidal anti-inflammatory drugs, especially naproxen (Naprosyn), may help prevent migraines and reduce symptoms.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease.

Alternative medicine

Nontraditional therapies may be helpful if you have chronic migraine pain.

  • Acupuncture. Clinical trials have found that acupuncture may be helpful for headache pain. In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin at defined points.
  • Biofeedback. Biofeedback appears to be effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses related to stress, such as muscle tension.
  • Massage therapy. Massage therapy may help reduce the frequency of migraines. Researchers continue to study the effectiveness of massage therapy in preventing migraines.
  • Cognitive behavioral therapy. Cognitive behavioral therapy may benefit some people with migraines. This type of psychotherapy teaches you how behaviors and thoughts affect how you perceive pain.
  • Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur may prevent migraines or reduce their severity, though study results are mixed. Butterbur isn't recommended because of long-term safety concerns.

    A high dose of riboflavin (vitamin B-2) also may prevent migraines or reduce the frequency of headaches.

    Coenzyme Q10 supplements may decrease the frequency of migraines, but larger studies are needed.

    Due to low magnesium levels in some people with migraines, magnesium supplements have been used to treat migraines, but with mixed results.

    Ask your doctor if these treatments are right for you. Don't use feverfew, riboflavin or butterbur if you're pregnant or without first talking with your doctor.

Lifestyle and home remedies

Self-care measures can help ease migraine pain.

  • Practice muscle relaxation exercises. Relaxation techniques may include progressive muscle relaxation, meditation or yoga.
  • Get enough sleep, but don't oversleep. Get the right balance of sleep each night, making sure to go to bed and wake up at consistent times.
  • Rest and relax. Try to rest in a dark, quiet room when you feel a headache coming on. Place an ice pack wrapped in a cloth on the back of your neck and apply gentle pressure to painful areas on your scalp.
  • Keep a headache diary. Continue recording in your headache diary even after you see your doctor. It will help you learn more about what triggers your migraines and what treatment is most effective.

Preparing for an appointment

You'll probably first see a primary care provider, but you may be referred to a doctor trained in evaluating and treating headaches (neurologist).

Because appointments can be brief and there's often a lot to discuss, prepare for your appointment. Here's some information to help you get ready, and what to expect from your doctor.

What you can do

  • Write down symptoms you're experiencing, even if they seem unrelated to your migraines.
  • Write down key personal information, including any major stresses or recent life changes.
  • Make a list of all medications, vitamins or supplements that you're taking. It's particularly important to list all medications, as well as the dosages you have used to treat your headaches.
  • Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important, in case time runs out. For migraines, some basic questions to ask your doctor include:

  • What is likely triggering my migraines?
  • Are there other possible causes for my migraine symptoms?
  • What kinds of tests do I need?
  • Are my migraines likely temporary or chronic?
  • What is the best course of action?
  • What are the alternatives to the primary approach that you're suggesting?
  • What changes to my lifestyle or diet do you suggest I make?
  • I have these other health conditions. How can I best manage them together?
  • Is there a generic alternative to the medicine you're prescribing for me?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, so be ready to answer them to save time for your questions. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
  • Has anyone in your family experienced migraines?

What you can do in the meantime

  • Keep a headache diary. A diary can help spot your migraine triggers. Note when your headaches start, how long they last and anything that provides relief.

    Be sure to record your response to any headache medications you take. Also note the foods you ate in the 24 hours preceding attacks, any unusual stress, and how you feel and what you're doing when headaches strike.

  • Reduce stress. Because stress triggers migraines for many people, try to avoid overly stressful situations, or use stress-reduction techniques such as meditation.
  • Get enough sleep. Aim for a regular sleep schedule and get an adequate amount of sleep.

Migraine care at Mayo Clinic