Migraine Headaches

Migraines are the second most common cause of primary headaches, affecting over 12% of the American population, predominantly females. The symptoms can range from moderate to severe and can have a significant impact on the quality of life, making them one of the leading disabling conditions in the world.

What Causes Migraines?

Migraines are caused by interactions in genetic, anatomical, and environmental factors. It is considered to be a heritable disease, as a family history of migraines is a significant risk factor. Through imaging studies, scientists have found differences in how the brain looks and works in people who suffer from migraines compared with those who do not.  The pathological process behind this disorder is complex and has not yet been fully described. There are several mechanisms suggested by the current research that seem to result in the activation of the pain pathways of the brain and the neurovascular system of the fifth cranial nerve (trigeminal nerve). Increased levels of Calcitonin Gene-Related Peptide (CGRP), a protein that is involved in the transmission of pain signals, have also been found.

Migraines headaches may be triggered by increased stress, irregular sleep patterns, weather changes, fluctuations of hormones during menstruation, as well as consumption of red wine, cheese, and MSG.



Less common forms of migraines include:

Ocular or retinal migraines that are characterized by pain in the back of the eye during the migraine.

Vestibular migraines, which include dizziness and loss of balance.

Hemiplegic migraine, a rare but serious type of migraine that mimics symptoms of a stroke in addition to the usual symptoms of migraines, with weakness of one side of the body, trouble speaking, or confusion.

Migraines with brainstem aura are also rare and can include symptoms of dizziness, double vision, problems with, hearing, understanding what is being said to them, speaking clearly, or movement.

Treatment of Migraines

Acute treatment, also known as abortive therapy, can be used to bring quick relief from the headache and any associated symptoms.

  • NSAIDs, such as ibuprofen and naproxen, may be used to reduce the inflammation in the brain and relieve the pain. Overuse of pain medications may worsen the headache or lead to medication-overuse headaches.

  • Triptans, such as sumatriptan, work by binding to the receptors of one of the brain’s signaling protein, serotonin, to deactivate the pain pathways. If taken too often, triptans may cause medication-overuse headaches. Triptans lead to constriction of blood vessels and should not be used by pregnant women and may rarely cause cardiac symptoms in those with ischemic heart disease.

  • Ergots, such as dihydroergotamine, also bind to serotonin receptors but are less effective and have a higher risk of side effects.

  • Lasmiditan is a newer migraine drug that targets a specific type of serotonin receptor. Unlike triptans, lasmiditan does not cause vasoconstriction. Side effects may include dizziness, fatigue, and nausea.

  • CGRP antagonists, such as ubrogepant, are a new class of migraine medications that target the CGRP in the brain and block the transmission of pain signals. Side effects include nausea, sleepiness, and dry mouth.

  • Anti-nausea medications, such as prochlorperazine, and IV fluids may be given to ease the symptoms of nausea and vomiting.

  • Dexamethasone, a steroid, reduces the inflammation in the brain and may be given to decrease the rate of headache recurrence.

  • Non-pharmacologic options include the use of neuromodulation devices that stimulate the nervous system using electric currents, and self-care strategies, such as resting in a dark room.

Preventative treatment may be used if you have frequent, long-lasting, or severe migraines. It may take time to notice the effects.

    • Beta-blockers, such as propranolol, work by decreasing the dilation of blood vessels in the brain. Side effects may include depression and impotence in males.

    • Anticonvulsants, such as topiramate, that are used in the treatment of seizure disorder have also shown evidence of preventing migraines, likely through the modulation of neurotransmitters in the brain. Side effects of topiramate include fatigue, nausea, loss of appetite, and difficulty in concentration.

    • Antidepressants can decrease the frequency of migraines. The mechanism by which they do so is not fully understood. Amitriptyline has the most evidence in preventing migraines compared with other antidepressants. Side effects of amitriptyline include drowsiness, dry mouth, and constipation.

    • CGRP antagonists also prevent the development of migraines by blocking the transmission of pain signals.

    • Botox injections are useful in people with chronic migraines, occurring 15 days or more in a month.

    • Lifestyle changes, such as good sleep hygiene, regular exercise, and avoidance of triggers, may significantly reduce the frequency of migraine attacks. Tracking food, weather, emotional state, and your menstrual cycle in a headache diary can help identify potential triggers.