Diagnosis
Migraine FAQs
Amaal Starling, M.D., a neurologist at Mayo Clinic, answers the important questions you may have about migraine.
Hi, I'm Dr. Amaal Starling, a neurologist at Mayo Clinic. And I'm here to answer some of the important questions that you might have about migraine.
Why doesn't migraine show up on MRI?
Migraine is a disease of abnormal function within the setting of normal brain structure. An MRI of the brain solely tells you about the structure of the brain but tells you very little about the function of the brain. And that is why migraine doesn't show up on an MRI. Because it's abnormal function in the setting of normal structure.
How can this much pain be just migraine?
Migraine is highly disabling for some individuals. In fact, it is the second leading cause of disability worldwide. Disabling symptoms are not just the pain, but also the sensitivity to light and sound, as well as the nausea and vomiting.
Do I need daily treatment if I don’t have daily attacks?
There is a wide range of disease severity in migraine. There are some people who only need a rescue or an acute treatment for migraine because they have infrequent migraine attacks. But there are other people who are having frequent migraine attacks, maybe two or three times a week. If they used rescue treatments for every attack, it could potentially lead to other complications. Those individuals need a preventive treatment regimen to reduce the frequency and severity of attacks. Those preventive treatments might be daily medications. They might be once a month injections or other injectable medications delivered once every three months.
What should I do on the days I can’t take my rescue medication?
This is why preventive treatment is so crucial. With preventive treatment, we can reduce the frequency as well as the severity of attacks so that you're not having attacks more than two times per week. However, for some individuals, despite preventive treatment, they may still have migraine symptoms more frequently throughout the week. For them, there are non-medication options for treating pain, such as biofeedback, relaxation techniques, cognitive behavioral therapy, as well as a number of devices that are non-medication options for treating migraine pain.
Should I consider neurotoxin injections for migraine?
Yes, that is an option for the preventive treatment of chronic migraine. These onabotulinum toxin A injections are administered by your doctor once every 12 weeks to reduce the frequency and severity of migraine attacks. However, there are many different preventive treatment options. And it is important for you to speak with your doctor about which option is best for you.
How can I be the best partner to my medical team?
The best way to partner with your medical team is to, number one, get a medical team. Many people living with migraine have not even talked to a doctor about their symptoms. If you have headaches where you have to rest in a dark room, where you might get sick to your stomach. Please talk to your healthcare professional about your symptoms. You might have migraine and we can treat migraine. Migraine is a chronic disease. And to best manage this disease, patients need to understand the disease. This is why I prescribe advocacy to all of my patients. Learn about migraine, join patient advocacy organizations, share your journey with others, and become empowered through advocacy and efforts to shatter the stigma of migraine. And together, the patient and the medical team can manage the disease of migraine. Never hesitate to ask your medical team any questions or concerns that you have. Being informed makes all the difference. Thanks for your time and we wish you well.
Migraines can be diagnosed by a specialist trained in treating headaches, known as a neurologist. The diagnosis is based on your medical history, symptoms, and a physical and neurological exam.
If your condition is complex or suddenly becomes serious, tests to rule out other causes of your pain might include:
- An MRI scan. A magnetic resonance imaging scan, also known as an MRI scan, uses a powerful magnetic field and radio waves to produce detailed images of the brain and blood vessels. MRI scans help diagnose tumors, strokes, bleeding in the brain, infections, and other brain and nervous system conditions.
- A CT scan. A computerized tomography scan, also called a CT scan, uses a series of X-rays to create detailed cross-sectional images of the brain. This helps diagnose tumors, infections, brain damage, bleeding in the brain and other medical conditions that can cause headaches.
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Treatment
Migraine treatment is aimed at stopping symptoms and preventing future attacks.
Medicines
Many medicines have been designed to treat migraines. They fall into two broad categories:
- Pain-relieving medicines. Also known as acute or abortive treatments, these medicines are taken during migraine attacks and are designed to stop symptoms.
- Preventive medicines. These medicines are taken regularly, often daily, to reduce migraine symptoms.
Your treatment choices depend on how often you have headaches and how painful they are. Your treatment also depends on whether you have nausea and vomiting, whether your headaches are disabling, and whether you have other medical conditions.
Pain-relieving medicines
Medicines used to relieve migraine pain work best when taken as soon as symptoms begin. These medicines include:
- Pain relievers. Pain relievers that you can get with or without a prescription include aspirin and ibuprofen (Advil, Motrin IB, others). Medicines that combine caffeine, aspirin and acetaminophen (Excedrin Migraine) may be helpful, but usually only against mild migraine pain. But be sure to talk with your healthcare professional about how often it's safe to take these medicines. When taken too long, they can cause medication overuse headaches and possibly ulcers and bleeding in the gastrointestinal tract.
- Triptans. These prescription medicines can relieve many symptoms of migraine by blocking pain pathways in the brain. Triptans are taken as pills, shots, nasal sprays, nasal powders and disintegrating tablets. They include sumatriptan (Imitrex, Tosymra, others), rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan, almotriptan, eletriptan (Relpax) and frovatriptan (Frova). They might not be safe to take if you're at risk of a stroke or heart attack.
- Dihydroergotamine (Migranal, Trudhesa). Available as a nasal spray, this medicine is most effective when taken shortly after the start of symptoms for migraines that tend to last longer than 24 hours. Side effects can include worsening of migraine-related vomiting and nausea. People with coronary artery disease, high blood pressure, or kidney or liver disease should avoid dihydroergotamine.
- Lasmiditan (Reyvow). This is an oral medicine approved for the treatment of migraines with or without aura. In studies, lasmiditan significantly improved headache pain. Lasmiditan can make you sleepy and cause dizziness, so don't drive or operate machinery for at least eight hours after taking it.
- Oral calcitonin gene-related peptides antagonists, also known as gepants. Ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) are oral gepants approved for the treatment of migraines in adults. In clinical trials, medicines from this class were more effective than placebo at relieving pain two hours after taking them. They also were effective at treating migraine symptoms such as nausea and sensitivity to light and sound. Common side effects include dry mouth, nausea and too much sleepiness. Ubrogepant and rimegepant should not be taken with strong CYP3A4 inhibitor medicines such as some medicines used to treat cancer.
- Intranasal zavegepant (Zavzpret). This nasal spray is a gepant that can relieve migraine pain within two hours and for up to 48 hours. It also can improve other symptoms, such as nausea and sensitivity to light and sound. Side effects of zavegepant include a change in your sense of taste, nasal discomfort and throat irritation.
- Antinausea medicines. These are usually taken with pain medicines and can help if you have nausea and vomiting with your migraines. Medicines include chlorpromazine, metoclopramide (Gimoti, Reglan) and prochlorperazine (Compro).
- Opioid and barbiturate medicines. Opioids or barbiturates may help if you can't take other migraine medicines. However, they're usually avoided due to better and more effective options. Because they can be highly addictive, these medicines are used only if no other treatments are effective.
Some migraine medicines are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medicines without first talking with your healthcare professional.
Preventive medicines
Medicines can help prevent frequent migraines. Your healthcare professional might recommend these medicines if you have long-lasting, very bad headaches that happen often and don't respond well to treatment.
Preventive medicine can reduce how often you get a migraine, how painful the attacks are and how long they last. Options include:
- Blood pressure-lowering medicines. These include beta blockers such as propranolol (Inderal LA, InnoPran XL) and metoprolol (Lopressor, Toprol-XL). Calcium channel blockers such as verapamil (Verelan) can be helpful in preventing migraines with aura.
- Antidepressants. Tricyclic antidepressants, such as amitriptyline and nortriptyline, are the most commonly used medicines to prevent migraine. These medicines have side effects that include dry mouth and sleepiness, and they may interact with other medicines. For these reasons, another antidepressant with fewer side effects or interactions, such as venlafaxine (Effexor XR), might be prescribed instead.
- Antiseizure medicines. Valproate and topiramate (Topamax, Qudexy XR, others) might help if you have less frequent migraines. These medicines can cause side effects such as dizziness, weight changes, nausea and others. They're also not recommended in people who are pregnant or who are trying to get pregnant.
- Botox injections. Shots of onabotulinumtoxinA (Botox) about every 12 weeks help prevent migraines in some adults.
- Calcitonin gene-related peptide, also called CGRP, monoclonal antibodies. These medicines help prevent migraines by blocking the chemical messenger CGRP. Medicines include erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), galcanezumab-gnlm (Emgality) and eptinezumab-jjmr (Vyepti). They're given monthly or once every three months by injection. The most common side effect is a reaction at the injection site.
- Atogepant (Qulipta). This medicine is a gepant that helps prevent migraines. It's a tablet taken by mouth daily. Potential side effects of the medicine include nausea, constipation and fatigue.
- Rimegepant (Nurtec ODT). This medicine is unique in that it's a gepant that helps prevent migraines in addition to treating migraines after they begin.
Ask your healthcare professional if these medicines are right for you. Some are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medicines without first talking with your healthcare professional.
Neuromodulation therapy
Devices that stimulate nerves, known as neuromodulation devices, can reduce the number of migraines you have or make them less painful. The devices are noninvasive and work by stimulating a peripheral or cranial nerve to change the brain's response to pain. Therapies include transcutaneous supraorbital nerve stimulation, external vagal nerve stimulation and distal transcutaneous electrical stimulation. Combined occipital and trigeminal neurostimulation is another option.
Another therapy called single-pulse transcranial magnetic stimulation treats the brain to relieve migraine pain. For this therapy, you place the device on the back of your head.
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Clinical trials
Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.
Lifestyle and home remedies
When symptoms of migraine start, try heading to a quiet, darkened room. Close your eyes and rest or take a nap. Place a cool cloth or ice pack wrapped in a towel or cloth on your forehead and drink lots of water.
To help soothe migraine pain, you also might want to:
- Try relaxation techniques. Breathing exercises and other forms of relaxation training teach you ways to deal with stressful situations, which might help reduce the number of migraines you have.
- Develop a sleeping and eating routine. Don't sleep too much or too little. Set and follow a consistent sleep and wake schedule daily. Try to eat meals at the same time every day.
- Drink plenty of fluids. Staying hydrated, particularly with water, might help.
- Keep a headache diary. Recording your symptoms in a headache diary can help you learn more about what triggers your migraines and what treatment is most effective. It also can help your healthcare professional diagnose your condition and track your progress between visits.
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Exercise regularly. Regular aerobic exercise reduces tension and can help prevent a migraine. If your healthcare professional agrees, choose aerobic activities you enjoy, such as walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches.
Regular exercise also can help you lose weight or maintain a healthy body weight. Obesity is thought to be a factor in migraines.
Alternative medicine
Nontraditional therapies might help with 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.
- 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.
- Meditation and yoga. Meditation may relieve stress, which is a known trigger of migraines. Done on a regular basis, yoga may reduce the number of migraines you have or how long they last.
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Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur might prevent migraines or reduce their severity, though study results are mixed. Butterbur isn't recommended because of safety concerns.
A high dose of riboflavin, also called vitamin B-2, may reduce the number of migraines you have and how painful they are. Coenzyme Q10 supplements might decrease the frequency of migraines, but larger studies are needed.
Magnesium supplements have been used to treat migraines, but with mixed results.
Ask your healthcare professional if these treatments are right for you. If you're pregnant, talk with your healthcare professional before trying any of these treatments.
Preparing for your appointment
You'll probably first see your primary healthcare professional, who might then refer you to a doctor trained in evaluating and treating headaches, called a neurologist.
What you can do
- Keep track of your symptoms. Keep a headache diary by writing a description of each incident of visual disturbances or unusual sensations. Include when your headaches occurred, how long they lasted and what triggered them. This information can help diagnose your condition.
- Write down key personal information, including major stresses or recent life changes.
- Make a list of all medicines, vitamins and supplements you take, including doses. It's particularly important to list all medicines you've used to treat your headaches.
- Write down questions to ask your healthcare professional.
Take a family member or friend along, if possible, to help you remember the information you receive.
For migraines, questions to ask your healthcare professional include:
- What is likely triggering my migraines?
- Are there other possible causes for my migraine symptoms?
- What tests do I need?
- Are my migraines likely short-term or long lasting?
- 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 other health conditions. How can I best manage them together?
- Are there printed materials you can give me? What websites do you recommend?
Don't hesitate to ask other questions.
What to expect from your doctor
Your healthcare professional is likely to ask you a number of questions, including:
- How often do your headaches occur?
- How bad are your symptoms?
- What, if anything, seems to make your symptoms better?
- What, if anything, appears to worsen your symptoms?
- Does anyone else in your family have migraines?