Symptoms and causes

Symptoms

Migraines often begin in childhood, adolescence or early adulthood. Migraines may progress through four stages: prodrome, aura, headache and post-drome, though you may not experience all stages.

Prodrome

One or two days before a migraine, you may notice subtle changes that warn of an upcoming migraine, including:

  • Constipation
  • Mood changes, from depression to euphoria
  • Food cravings
  • Neck stiffness
  • Increased thirst and urination
  • Frequent yawning

Aura

Aura may occur before or during migraines. Most people experience migraines without aura.

Auras are symptoms of the nervous system. They are usually visual disturbances, such as flashes of light or wavy, zigzag vision.

Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Your muscles may get weak, or you may feel as though someone is touching you.

Each of these symptoms usually begins gradually, builds up over several minutes and lasts for 20 to 60 minutes. Examples of migraine aura include:

  • Visual phenomena, such as seeing various shapes, bright spots or flashes of light
  • Vision loss
  • Pins and needles sensations in an arm or leg
  • Weakness or numbness in the face or one side of the body
  • Difficulty speaking
  • Hearing noises or music
  • Uncontrollable jerking or other movements

Sometimes, a migraine with aura may be associated with limb weakness (hemiplegic migraine).

Attack

A migraine usually lasts from four to 72 hours if untreated. The frequency with which headaches occur varies from person to person. Migraines may be rare, or strike several times a month. During a migraine, you may experience:

  • Pain on one side or both sides of your head
  • Pain that feels throbbing or pulsing
  • Sensitivity to light, sounds, and sometimes smells and touch
  • Nausea and vomiting
  • Blurred vision
  • Lightheadedness, sometimes followed by fainting

Post-drome

The final phase, known as post-drome, occurs after a migraine attack. You may feel drained and washed out, while some people feel elated. For about 24 hours, you may also experience:

  • Confusion
  • Moodiness
  • Dizziness
  • Weakness
  • Sensitivity to light and sound

When to see a doctor

Migraines are often undiagnosed and untreated. If you regularly experience signs and symptoms of migraine attacks, keep a record of your attacks and how you treated them. Then make an appointment with your doctor to discuss your headaches.

Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.

See your doctor immediately or go to the emergency room if you have any of the following signs and symptoms, which may indicate a more serious medical problem:

  • An abrupt, severe headache like a thunderclap
  • Headache with fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or trouble speaking
  • Headache after a head injury, especially if the headache gets worse
  • A chronic headache that is worse after coughing, exertion, straining or a sudden movement
  • New headache pain if you're older than 50

Causes

Though migraine causes aren't understood, genetics and environmental factors appear to play a role.

Migraines may be caused by changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway.

Imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system — also may be involved. Researchers are still studying the role of serotonin in migraines.

Serotonin levels drop during migraine attacks. This may cause your trigeminal nerve to release substances called neuropeptides, which travel to your brain's outer covering (meninges). The result is migraine pain. Other neurotransmitters play a role in the pain of migraine, including calcitonin gene-related peptide (CGRP).

Migraine triggers

A number of factors may trigger migraines, including:

  • Hormonal changes in women. Fluctuations in estrogen seem to trigger headaches in many women. Women with a history of migraines often report headaches immediately before or during their periods, when they have a major drop in estrogen.

    Others have an increased tendency to develop migraines during pregnancy or menopause.

    Hormonal medications, such as oral contraceptives and hormone replacement therapy, also may worsen migraines. Some women, however, find their migraines occur less often when taking these medications.

  • Foods. Aged cheeses, salty foods and processed foods may trigger migraines. Skipping meals or fasting also can trigger attacks.
  • Food additives. The sweetener aspartame and the preservative monosodium glutamate (MSG), found in many foods, may trigger migraines.
  • Drinks. Alcohol, especially wine, and highly caffeinated beverages may trigger migraines.
  • Stress. Stress at work or home can cause migraines.
  • Sensory stimuli. Bright lights and sun glare can induce migraines, as can loud sounds. Strong smells — including perfume, paint thinner, secondhand smoke and others — can trigger migraines in some people.
  • Changes in wake-sleep pattern. Missing sleep or getting too much sleep may trigger migraines in some people, as can jet lag.
  • Physical factors. Intense physical exertion, including sexual activity, may provoke migraines.
  • Changes in the environment. A change of weather or barometric pressure can prompt a migraine.
  • Medications. Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines.

Risk factors

Several factors make you more prone to having migraines, including:

  • Family history. If you have a family member with migraines, then you have a good chance of developing them too.
  • Age. Migraines can begin at any age, though the first often occurs during adolescence. Migraines tend to peak during your 30s, and gradually become less severe and less frequent in the following decades.
  • Sex. Women are three times more likely to have migraines. Headaches tend to affect boys more than girls during childhood, but by the time of puberty and beyond, more girls are affected.
  • Hormonal changes. If you are a woman who has migraines, you may find that your headaches begin just before or shortly after onset of menstruation.

    They may also change during pregnancy or menopause. Migraines generally improve after menopause.

    Some women report that migraine attacks begin during pregnancy, or their attacks worsen. For many, the attacks improved or didn't occur during later stages in the pregnancy. Migraines often return during the postpartum period.

Complications

Sometimes your efforts to control your migraine pain cause problems, such as:

  • Abdominal problems. Certain pain relievers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others), may cause abdominal pain, bleeding, ulcers and other complications, especially if taken in large doses or for a long period of time.
  • Medication-overuse headaches. Taking over-the-counter or prescription headache medications more than 10 days a month for three months or in high doses may trigger serious medication-overuse headaches.

    Medication-overuse headaches occur when medications stop relieving pain and begin to cause headaches. You then use more pain medication, which continues the cycle.

  • Serotonin syndrome. Serotonin syndrome is a rare, potentially life-threatening condition that occurs when your body has too much of the nervous system chemical called serotonin.

    While the risk is considered extremely low, taking migraine medications called triptans and antidepressants known as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) may increase the risk of serotonin syndrome. These medications naturally raise serotonin levels, and it is possible that combining them could cause levels that are too high.

    Triptans and SSRIs or SNRIs may be used together, but it's important to watch out for possible symptoms of serotonin syndrome such as changes in cognition, behavior and muscle control (such as involuntary jerking).

    Triptans include medications such as sumatriptan (Imitrex) or zolmitriptan (Zomig). Some common SSRIs include sertraline (Zoloft), fluoxetine (Sarafem, Prozac) and paroxetine (Paxil). SNRIs include duloxetine (Cymbalta) and venlafaxine (Effexor XR).

Also, some people experience complications from migraines such as:

  • Chronic migraine. If your migraine lasts for 15 or more days a month for more than three months, you have chronic migraine.
  • Status migrainosus. People with this complication have severe migraine attacks that last for longer than three days.
  • Persistent aura without infarction. Usually an aura goes away after the migraine attack, but sometimes aura lasts for more than one week afterward. A persistent aura may have similar symptoms to bleeding in the brain (stroke), but without signs of bleeding in the brain, tissue damage or other problems.
  • Migrainous infarction. Aura symptoms that last longer than one hour can signal a loss of blood supply to an area of the brain (stroke), and should be evaluated. Doctors can conduct neuroimaging tests to identify bleeding in the brain.
June 17, 2016
References
  1. NINDS migraine information page. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/migraine/migraine.htm. Accessed Feb. 29, 2016.
  2. Headache: Hope through research. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/headache/detail_headache.htm. Accessed Feb. 29, 2016.
  3. Cutrer FM, et al. Pathophysiology, clinical manifestations and diagnosis of migraine in adults. http://www.uptodate.com/home. Accessed Feb. 29, 2016.
  4. Daroff RB, et al. Headache and other craniofacial pain. In: Bradley's Neurology in Clinical Practice. 6th ed. Philadelphia, Pa.: Saunders Elsevier; 2012. https://www.clinicalkey.com. Accessed Feb. 29, 2016.
  5. Bajwa ZH, et al. Acute treatment of migraine in adults. http://www.uptodate.com/home. Accessed Feb. 26, 2016.
  6. Calhoun AH. Estrogen-associated migraine. http://www.uptodate.com/home. Accessed Feb. 29, 2016.
  7. Martin KA, et al. Risks and side effects associated with estrogen-progestin contraceptives. http://www.uptodate.com/home. Accessed Feb. 29, 2016.
  8. Solomon DH. Nonselective NSAIDs: Overview of adverse effects. http://www.uptodate.com/home. Accessed Feb. 29, 2016.
  9. Bajwa ZH, et al. Preventive treatment of migraine in adults. http://www.uptodate.com/home. Accessed Feb. 29, 2016.
  10. Neurological diagnostic tests and procedures. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/misc/diagnostic_tests.htm. Accessed Feb. 29, 2016.
  11. Headaches and complementary health approaches. National Center for Complementary and Alternative Medicine. http://nccam.nih.gov/health/pain/headachefacts.htm?nav=gsa. Accessed Feb. 29, 2016.
  12. Ramzan M, et al. Headache, migraine and stroke. http://www.uptodate.com/home. Accessed Feb. 29, 2016.
  13. Cruse RP. Management of migraine headache in children. http://www.uptodate.com/home. Accessed Feb. 29, 2016.
  14. Ask Mayo Expert. Migraine. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2013.
  15. Tintinalli JE, et al. Atypical and serotonergic antidepressants. In: Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: The McGraw-Hill Companies; 2011. http://www.accessmedicine.com. Accessed April 26, 2013.
  16. Swanson JW (expert opinion). Mayo Clinic, Rochester, Minn. March 3, 2016.
  17. Cognitive-Behavioral Therapy (CBT). American Chronic Pain Association. https://theacpa.org/treatment/cognitive-behavioral-therapy-cbt. Accessed March 3, 2016.
  18. FDA allows marketing of first medical device to prevent migraine headaches. U.S. Food and Drug Administration, http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm388765.htm. Accessed March 9, 2016.