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.
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.
If your condition is unusual, complex or suddenly becomes severe, tests to rule out other causes for your pain might include:
- Magnetic resonance imaging (MRI). An MRI scan 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.
Migraine treatment is aimed at stopping symptoms and preventing future attacks.
Many medications have been designed to treat 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 daily, to reduce the severity or frequency of migraines.
Your treatment choices depend on the frequency and severity of your headaches, whether you have nausea and vomiting with your headaches, how disabling your headaches are, and other medical conditions you have.
Medications for relief
Medications used to relieve migraine pain work best when taken at the first sign of an oncoming migraine — as soon as signs and symptoms of a migraine begin. Medications that can be used to treat it include:
Pain relievers. These over-the-counter or prescription pain relievers include aspirin or ibuprofen (Advil, Motrin IB, others). When taken too long, these might cause medication-overuse headaches, and possibly ulcers and bleeding in the gastrointestinal tract.
Migraine relief medications that combine caffeine, aspirin and acetaminophen (Excedrin Migraine) may be helpful, but usually only against mild migraine pain.
- Triptans. Prescription drugs such as sumatriptan (Imitrex, Tosymra) and rizatriptan (Maxalt, Maxalt-MLT) are used to treat migraine because they block pain pathways in the brain. Taken as pills, shots or nasal sprays, they can relieve many symptoms of migraine. They might not be safe for those at risk of a stroke or heart attack.
Dihydroergotamine (D.H.E. 45, Migranal). Available as a nasal spray or injection, this drug is most effective when taken shortly after the start of migraine 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 newer oral tablet is approved for the treatment of migraine with or without aura. In drug trials, lasmiditan significantly improved headache pain. Lasmiditan can have a sedative effect and cause dizziness, so people taking it are advised not to drive or operate machinery for at least eight hours.
- Ubrogepant (Ubrelvy). This oral calcitonin gene-related peptide receptor antagonist is approved for the treatment of acute migraine with or without aura in adults. It's the first drug of this type approved for migraine treatment. In drug trials, ubrogepant was more effective than placebo in relieving pain and other migraine symptoms such as nausea and sensitivity to light and sound two hours after taking it. Common side effects include dry mouth, nausea and excessive sleepiness. Ubrogepant should not be taken with strong CYP3A4 inhibitor drugs.
- CGRP antagonists. Ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) are oral CGRP antagonists recently approved for the treatment of acute migraine with or without aura in adults. In drug trials, drugs from this class were more effective than placebo in relieving pain and other migraine symptoms such as nausea and sensitivity to light and sound two hours after taking it. Common side effects include dry mouth, nausea and excessive sleepiness. Ubrogepant and rimegepant should not be taken with strong CYP3A4 inhibitor drugs.
- Opioid medications. For people who can't take other migraine medications, narcotic opioid medications might help. Because they can be highly addictive, these are usually used only if no other treatments are effective.
- Anti-nausea drugs. These can help if your migraine with aura is accompanied by nausea and vomiting. Anti-nausea drugs include chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro). These are usually taken with pain medications.
Some of these medications are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medications without first talking with your doctor.
Medications can help prevent frequent migraines. Your doctor might recommend preventive medications if you have frequent, long-lasting or severe headaches that don't respond well to treatment.
Preventive medication is aimed at reducing how often you get a migraine, how severe the attacks are and how long they last. Options include:
- Blood pressure-lowering medications. These include beta blockers such as propranolol (Inderal, InnoPran XL, others) and metoprolol tartrate (Lopressor). Calcium channel blockers such as verapamil (Verelan) can be helpful in preventing migraines with aura.
- Antidepressants. A tricyclic antidepressant (amitriptyline) can prevent migraines. Because of the side effects of amitriptyline, such as sleepiness, other antidepressants might be prescribed instead.
- Anti-seizure drugs. Valproate and topiramate (Topamax, Qudexy XR, others) might help if you have less frequent migraines, but can cause side effects such as dizziness, weight changes, nausea and more. These medications are not recommended for pregnant women or women trying to get pregnant.
- Botox injections. Injections of onabotulinumtoxinA (Botox) about every 12 weeks help prevent migraines in some adults.
- CGRP monoclonal antibodies. Erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), galcanezumab-gnlm (Emgality), and eptinezumab-jjmr (Vyepti) are newer drugs approved by the Food and Drug Administration to treat migraines. They're given monthly or quarterly by injection. The most common side effect is a reaction at the injection site.
Ask your doctor if these medications are right for you. Some of these medications are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medications without first talking with your doctor.
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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.
These practices might also soothe migraine pain:
- Try relaxation techniques. Biofeedback 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 will help you learn more about what triggers your migraines and what treatment is most effective. It will also help your doctor diagnose your condition and track your progress in between visits.
Exercise regularly. Regular aerobic exercise reduces tension and can help prevent a migraine. If your doctor agrees, choose aerobic activity you enjoy, such as walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches.
Regular exercise can also help you lose weight or maintain a healthy body weight, and obesity is thought to be a factor in migraines.
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 frequency and duration of migraines.
- 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 (vitamin B-2) may reduce the frequency and severity of headaches. 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 doctor if these treatments are right for you. If you're pregnant, don't use any of these treatments without first talking with your doctor.
Preparing for your appointment
You'll probably first see a primary care provider, who might then refer you to a doctor trained in evaluating and treating headaches (neurologist).
Here's some information to help you get ready for your appointment.
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, including when they occurred, how long they lasted and what triggered them. A headache diary can help your doctor diagnose your condition.
- Write down key personal information, including major stresses or recent life changes.
- Make a list of all medications, vitamins or supplements you take, including doses. It's particularly important to list all medications you've used to treat your headaches.
- Write down questions to ask your doctor.
Take a family member or friend along, if possible, to help you remember the information you receive.
For migraines, questions to ask your doctor 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 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?
- 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 doctor is likely to ask you a number of questions, including:
- How often do your headaches occur?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
- Does anyone else in your family have migraines?