Types

Migraines are classified according to the symptoms they produce. The two most common types are migraine with aura and migraine without aura. Less common types include the following:

• Basilar artery migraine

• Carotidynia

• Headache-free migraine

• Ophthalmoplegic migraine

• Status migraine

Some women experience migraine headaches just prior to or during menstruation. These headaches, which are called menstrual migraines, may be related to hormonal changes and often do not occur during pregnancy. Other women develop migraines for the first time during pregnancy or after menopause.

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Incidence and Prevalence

Migraines afflict about 30 million people in the United States. They may occur at any age, but usually begin between the ages of 10 and 40 and diminish after age 50. Some people experience several migraines a month, while others have only a few migraines throughout their lifetime. Approximately 75% of migraine sufferers are women.

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Causes

The cause of migraine is unknown. The condition may result from a series of reactions in the central nervous system caused by changes in the body or in the environment. There is often a family history of the disorder, suggesting that migraine sufferers may inherit sensitivity to triggers that produce inflammation in the blood vessels and nerves around the brain, causing pain.

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Triggers

A trigger is any stimulus that initiates a process or reaction. Commonly identified migraine triggers include the following:

• Alcohol (e.g., red wine)

• Environmental factors (e.g., weather, altitude, time zone changes)

• Foods that contain caffeine (e.g., coffee, chocolate), monosodium glutamate (MSG; found in Chinese food), and nitrates (e.g., processed foods, hot dogs)

• Glare

• Hormonal changes in women

• Hunger

• Lack of sleep

• Medications (over-the-counter and prescription)

• Perfume

• Stress

Signs and Symptoms

Migraine pain is often described as throbbing or pulsating pain that is intensified by routine physical activity, coughing, straining, or lowering the head. The headache is often so severe that it interferes with daily activity and may awaken the person. The attack is debilitating, and migraine sufferers are often left feeling tired and weak once the headache has passed.

A migraine typically begins in a specific area on one side of the head, then spreads and builds in intensity over 1 to 2 hours and then gradually subsides. It can last up to 24 hours, and in some cases, several days.

There may be accompanying symptoms such as nausea, vomiting, sensitivity to light (photophobia), or sensitivity to sound (phonophobia). Hands and feet may feel cold and sweaty and unusual odors may be intolerable.

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Different Types of Migraines

Migraine with aura is characterized by a neurological phenomenon (aura) that is experienced 10 to 30 minutes before the headache. Most auras are visual and are described as bright shimmering lights around objects or at the edges of the field of vision (called scintillating scotomas) or zigzag lines, wavy images, or hallucinations. Others experience temporary vision loss.

Nonvisual auras include motor weakness, speech or language abnormalities, dizziness, vertigo, and tingling or numbness (parasthesia) of the face, tongue, or extremities.

Migraine without aura is the most prevalent type and may occur on one or both sides (bilateral) of the head. Tiredness or mood changes may be experienced the day before the headache. Nausea, vomiting, and sensitivity to light (photophobia) often accompany migraine without aura.

Basilar artery migraine involves a disturbance of the basilar artery in the brainstem. Symptoms include severe headache, vertigo, double vision, slurred speech, and poor muscle coordination. This type occurs primarily in young people.

Carotidynia, also called lower-half headache or facial migraine, produces deep, dull, aching, and sometimes piercing pain in the jaw or neck. There is usually tenderness and swelling over the carotid artery in the neck. Episodes can occur several times weekly and last a few minutes to hours. This type occurs more commonly in older people.

Headache-free migraine is characterized by the presence of aura without headache. This occurs in patients with a history of migraine with aura.

Ophthalmoplegic migraine begins with a headache felt in the eye and is accompanied by vomiting. As the headache progresses, the eyelid droops (ptosis) and nerves responsible for eye movement become paralyzed. Ptosis may persist for days or weeks.

Status migraine is a rare type involving intense pain that usually lasts longer than 72 hours. The patient may require hospitalization.

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Diagnosis

Diagnosis of migraine is based on the history of symptoms, physical examination, and neurological tests. The tests are performed to rule out other neurological and cerebrovascular conditions, including the following:

• Bleeding within the skull (intracranial hemorrhage)

• Blood clot within the membrane that covers the brain (cerebral venous sinus thrombosis)

• Cerebral stroke (infarct)

• Dilated blood vessel in the brain (cerebral aneurysm)

• Excess cerebrospinal fluid in the brain (hydrocephalus)

• Inflammation of the membranes of the brain or spinal cord (meningitis)

• Low level of cerebral spinal fluid (CSF)

• Nasal sinus blockage

• Postictal headache, which occurs after a stroke or seizure

• Tumor

Laboratory Tests

Computed tomography (CT scan) is performed to rule out an underlying brain abnormality when migraines are new or when there is a change in their character or frequency. CT scan involves injecting contrast dye and then taking a series of x-rays.

Electroencephalography (EEG) records electrical signal within the brain using electrodes placed on the scalp. This test is used to detect malfunctions in brain activity (e.g., seizures).

Spinal tap (lumbar puncture) is performed to detect infection and determine levels of white blood cells, glucose, and protein in the cerebrospinal fluid. This test involves withdrawing a small amount of fluid and examining it under a microscope.

Magnetic resonance imaging (MRI scan) and magnetic resonance angiography (MRA) may be performed for a more complete evaluation. MRI produces clear images of the brain using electromagnetic energy. MRA produces images of blood vessels in the brain and is used to detect aneurysms and other vascular abnormalities.

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Treatment

The physician analyzes the patient’s migraine history to devise an appropriate treatment program. The goals of treatment are to prevent or reduce the number of migraines (called prophylactic treatment) and to alleviate symptoms and shorten the duration of the migraine (called abortive treatment).

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Prophylactic Treatment
Preventative medication may be prescribed for patients who have frequent headaches (3 or more a month) that do not respond to abortive treatment. Studies have shown that as many as 40% of these patients may benefit from preventative treatment.

Using one medication (monotherapy) is tried first, but a combination of medicines may be necessary. Many of these medications have adverse side effects. If migraines become controlled, the dosage is often reduced or the drug discontinued.

Beta blockers (e.g., propranolol [Inderal®], atenolol [Tenormin®]) are the preferred medications. These drugs produce an effect on heart rate. They should not be taken by patients with asthma and should be used with caution in patients with diabetes.

Side effects include gastrointestinal upset, insomnia, low blood pressure (hypotension), slowed heart rate (bradycardia), and sexual dysfunction. Some beta blockers pass into breast milk and may cause problems in nursing infants.

Antiseizure drugs such as valproic acid (Depakote®), topiramate (Topamax®), and gabapentin (Neurontin®) may be used to treat migraine.

Side effects include nausea, gastrointestinal upset, sedation, liver damage, and tremors.

Calcium channel blockers (e.g., verapamil, amlodipine [Norvasc®]) inhibit artery dilation and block the release of serotonin. They should not be taken by patients with heart failure or heart block.

Side effects include constipation, flushing, low blood pressure, rash, and nausea.

Tricyclic antidepressants (TCAs; e.g., amitryptaline [Elavil®], nortryptaline [Pamelor®], desipramine [Norpramin®]) block serotonin reabsorption and take 2–3 weeks be effective.

Side effects include the following:

• Constipation

• Dry mouth

• Low blood pressure (hypotension)

• Increased heart rate (tachycardia)

• Urinary retention

• Sexual dysfunction

• Weight gain

High doses of TCAs have been implicated in seizures, stroke, and heart attack. Abrupt discontinuation of these medications may cause headache, nausea, and malaise, and may intensify side effects.

Selective serotonin reuptake inhibitors (SSRIs; e.g., paroxetine [Paxil®], fluoxetine [Prozac®], sertraline [Zoloft®]) are usually better tolerated than TCAs, but may not be as effective.

Side effects include nausea, insomnia, sexual dysfunction, and loss of appetite.

Methysergide maleate (e.g., Deseril®, Sansert®) may be prescribed for patients with frequent, severe migraines.

Side effects include insomnia, drowsiness, lightheadedness, and hair loss. This drug should not be used by patients with coronary artery disease and must be discontinued for 3–4 weeks after 4–6 months of use because it can cause retroperitoneal fibrosis, a condition in which the blood vessels in the abdomen thicken, which reduces blood flow to organs.

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Abortive Treatment
Mild, infrequent migraines may be relieved using over-the-counter medication. Severe headaches with accompanying symptoms may require prescription medication.

During a migraine, people often prefer to rest or sleep alone in a dark, quiet room. Applying cold packs to the head or pressing on the bulging artery in front of the ear on the painful side of the head may provide temporary pain relief.

Analgesics (e.g., aspirin, ibuprofen, acetaminophen) provide symptomatic relief from headache pain and should be taken at the first sign of a migraine. They are most effective for infrequent migraines (less than 3 a month) and breakthrough headaches (i.e., headaches that occur despite using prophylactic medications).

Frequent use of analgesics (i.e., more than 4 times a week) can cause rebound headaches and may interfere with prophylactic treatment. Acetaminophen is sometimes combined with other drugs to form an analgesic compound (e.g., Midrin®).

Side effects caused by aspirin and ibuprofen (e.g., Advil®, Motrin®) include gastrointestinal upset and bleeding. These drugs should be taken with food and used with caution. Ibuprofen is available in suppository form, which can be useful if the migraine is accompanied by severe nausea and vomiting.

Serotonin receptors (e.g., Imitrex®, Amerge®, Axert®, Zomig®), are fast-acting, usually well- tolerated medications commonly used to treat migraines. They are available in oral, injectable, and nasal spray forms and can be taken any time during the headache.

Side effects include dizziness, drowsiness, flushing, discomfort, tingling, and nausea.

Ergots (e.g., Cafergot®, Mioranal®) may be administered orally or as a suppository and is often combined with antinausea drugs, such as prochlorperazine (Compazine®). This medication should be taken at the first sign of a migraine and may not be effective if the headache has moved into the throbbing stage.

Side effects include gastrointestinal upset, dizziness, stroke, and high blood pressure (hypertension). Ergots should not be taken by patients with heart, vascular, liver, or kidney disease.

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Prevention

Avoiding triggers, managing stress, and taking prophylactic medications can help prevent migraines. Keeping a migraine journal can help identify triggers and gauge the effectiveness of preventive measures. Patients should monitor the following:

• Activities

• Emotional factors (e.g. stressful situations)

• Environmental factors (e.g., weather, altitude changes)

• Foods and beverages

• Medications (over-the-counter and prescription)

• Migraine characteristics (e.g., severity, length)

• Physical factors (e.g., illness, fatigue)

• Sleep patterns

Stress management techniques (e.g., biofeedback, hypnosis) and stress-reducing activities (e.g., meditation, yoga, exercise) may help prevent migraines.

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Naturopathic Treatment

Migraines are caused by excessive dilation of the cerebral blood vessels, though scientists do not fully understand what causes the dilation in the first place. Blood vessels don't just dilate spontaneously - they are presumably responding to chemical changes that are occurring in the body.

A naturopathic physician or holistic medical doctor will want to take a complete medical, family, menstrual, and diet history before considering the cause of migraine. Some of the illnesses to be ruled out are bowel problems, mold allergies, vitamin deficiencies, hypertension, TMJ misalignment, food allergies or intolerances, dehydration, spinal subluxations, coffee/caffeine intoxication, and aspartame (Nutrasweet, Equal) toxicity among others. All of these problems can cause migraine symptoms and usually can be treated very easily without the use of drugs.

Paradoxical as it may seem, a surprising percentage of migraine headaches may be caused by migraine medication. The "rebound effect" of analgesic and ergotomine compounds has been implicated as a contributing factor for sufferers of daily headaches. Discuss this phenomenon with your prescribing doctor if you are taking more than 30 analgesic tablets a month or if you regularly use ergotamine derivatives. Withdrawal from these products can temporarily make headaches worse, but eliminating these products altogether may ultimately mean no more headaches -- ever.

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How & What You Eat Can Give You Migraines
When exploring the causes of headaches, the easiest, cheapest place to start is diet. Food reactions are a significant contributor to headaches and some improvement in symptoms, if not complete remission, can always be achieved by eliminating problematic dietary items. The elimination/challenge trial described below is a good way to identify food reactions that may be causing your headaches.

Foods that most commonly induce migraines:

• cow's milk

• wheat

• chocolate

• egg

• orange

• benzoic acid

• cheese

• tomato

• tartrazine (yellow food dye)

• rye

Foods like cheese, beer, and wine induce migraines in some people because they contain histamines and/or vasoactive compounds that cause blood vessels to expand. Women tend to react to histamine-containing foods more frequently than men do, on account of a deficiency in an enzyme (diamine oxidase) that breaks histamine down. Taking supplemental B6 may be helpful in these situations, as it can increase diamine oxidase activity.

Nitrites, which are common ingredients in lunch meats and smoked/cured meats, dilate blood vessels, and may trigger migraine.

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The Elimination/Challenge Trial
This traditional naturopathic procedure has been accurately diagnosing food-related symptoms for many years and continues to be the standard for identifying food sensitivities.

There are two ways to approach an elimination/challenge trial. The first and more difficult but more effective route is outlined as option #1 below. It involves eliminating all the major suspects that usually cause problems and then slowly, over time, adding them back into the diet one by one. It provides clear insight into what foods are impacting you in what ways. (The added bonus of this approach is that you may find that there are other foods that, while they are not causing RA, are giving you headaches or insomnia or another health problem).

The second option is reserved for those who already have a good idea about what foods are problematic for them. The suspected food group is eliminated until symptoms clear and then added back into the diet in order to experience the response or return of symptoms.

Symptoms associated with food challenges may not be the same as the symptoms you were experiencing before you began the elimination process. For example, while you may have experienced chronic sinus pain prior to embarking on your elimination/challenge, you might find that upon challenging the suspected food that your stomach hurts. This doesn't mean the food group being challenged is not causing your sinus pain, rather your body and immune system may react a bit differently when re- introduced to the offending agent.

Some symptoms that can occur on a food challenge include: headache (may be brief or prolonged), nausea, sleepiness, irritability, depression, anxiety, excitability - feeling "hyper" or "buzzed, stomach ache, sharp abdominal pain, sore throat, stuffy nose, runny nose, itchy nose or eyes, tightness in the chest, skin rash or itching, facial flushing, red ears, muscle twitching or humming or aching, insomnia, fatigue, and apathy. Of course, there are as many ways of manifesting sensitivities as there are people who suffer from them, so be observant.

Elimination/challenge is the most effective way of determining food intolerance. It also provides you with an excellent opportunity to explore and understand your relationship with food more directly.

Option#1
Option #1 involves an elimination that lasts from 2 to 6 weeks, followed by a challenge.

The elimination involves managing your diet based on the following criteria.

Eliminate all suspect foods:

• wheat products - pasta, breads, processed foods, faux meat

• dairy products - milk, cheese, yogurt, cream, etc.

• corn products - tortilla, chips, polenta, cornstarch/thickeners

• peanuts - peanut butter, peanut oil

• soy products - tofu, tempeh, soy milk, soy protein powder, faux food, soy oil

• glutinous grains - rye, barley, oats, spelt, kamut, seitan, hops

• beef - this is usually more a problem with additives than with the protein itself

• chocolate

• sugar

• nutrasweet/aspartame

• food colorings/dyes

• pesticides and chemical spoilage retardants (especially sulfites)

Maintain a diet based on:

• FRESH fruits

• vegetables

• potatoes

• yams

• animal protein (fish, poultry, lamb)

• nonglutinous grains (millet, buckwheat, rice, amaranth)

If you have a choice, always choose organic. Otherwise, you could be ingesting pesticides, herbicides, fungicides, and/or formaldehydes.

Avoid sulfite-containing foods, which most commonly include canned vegetables and fruits, wine, and canned tuna (albacore).

Read labels. Know that "vegetable protein" is either wheat or soy; thickening agents and stabilizers are either wheat or corn; and food starch is usually wheat or corn. It is much easier to avoid processed food and faux food while on the diet than to figure out all the additives in prepared foods.

After 2 to 6 weeks of maintaining a strict elimination diet, you should experience relief from symptoms. You may also lose some weight.

Challenge
Begin your challenge with the food group you feel is the least likely culprit. Eat several servings from that food group throughout the day. For example, if you are challenging dairy, have milk with breakfast; include cheese, cream, and yogurt in your lunch and dinner menus; drink milk at meals; and snack on dairy items. Then wait. DO NOT continue to add that food group to your diet. You only challenge for one day, then wait for at least 48 hours. Return to eating ONLY your elimination diet foods. If you do not experience a return of symptoms after 48 hours, go on to the next suspected food group. Continue this process until you find the problematic food group. In most cases you will experience a return of symptoms within 48 hours. Rarely do symptoms appear several days or weeks later. If, however, you want to wait more than 48 hours, feel free to do so, as this will only increase the accuracy of this type of diagnosis. A week between food group challenges is optimal. Only challenge one food group at a time.

Option #2
Maintain your regular diet, eliminating only the food group that you believe to be causing your symptoms. Eliminate ALL items in that food group for at least one month. If your symptoms disappear before the one-month deadline, continue to abstain from that food group for one more week after symptom relief. If, for example, you find yourself symptom-free after just a few days of avoidance, you must still continue to avoid that food group for another week before you can effectively challenge. When you challenge, follow the guidelines stated above: eat several servings of the suspected food group during a 24-hour period then return to the elimination diet and wait. More often than not you will get immediate information about how your body is interacting with a problem food group.

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Nutritional supplements for the relief of migraines

• Wobenzyme: 5 tablets 3 times a day between meals; or, if this dose causes loose stools, 3 tablets 5 times a day

• Magnesium citrate: 250mg to 500mg 3 times a day with meals

• Vitamin B6: 25mg 3 times a day with meals; vitamin B6 supports the enzymatic breakdown of histamine.

• 5-HTP (5- Hydroxytryptophan): 100mg to 200mg 3 times a day; 5-HTP increases seritonin and endorphin levels in the brain and has been shown to be as effective as commonly used migraine drugs and with none of the side effects.

Physical medicine

• Submerge the feet in a bucket of very hot water while applying an ice compress to the back of the neck. This actually draws the blood down to the feet away from the head. Reduction of pain coincides with the duration of application.

• Acupressure can be helpful. See a trained acupressure therapist for instructions on procedures to do at home.

• Chiropractic adjustments and maintaining correct spinal alignment can be very supportive in the prevention of headaches that are triggered by muscle stress and spasm.

Miscellaneous treatment options

• Intravenous magnesium: IV magnesium can be very helpful for migraine patients who have low-grade magnesium deficiencies. Physician monitoring is needed for this procedure.

• Biofeedback therapy: Look for a certified biofeedback practitioner to learn how to reduce pain with a relaxation response that is as effective as Inderol without the side effects.

• TENS Unit: Electrical nerve stimulation units can reduce muscle spasm in patients with tension and migraine headaches. A health care practitioner's prescription is needed for insurance coverage of these units, which should be available through medical supply companies. Some chiropractors and physical therapists loan these devices out to patients for a small deposit.

• Acupuncture: Acupuncture can balance underlying hormonal deficiencies, tone the gastrointestinal system, and calm reactive blood vessels.

  A word of caution: When selecting an acupuncturist, be very careful to research the training and qualifications of your practitioner. Medical doctors can take weekend courses in acupuncture and call themselves certified acupuncturists. A weekend course is NOT enough to time to understand the complex philosophy or practice of Chinese medicine. These doctors can do harm, so be careful.

  Choose a practitioner who holds a full doctorate degree in Chinese medicine, an O.M.D. (Oriental Medicine Doctor), or Lic.Ac (licensed acupuncturist). These practitioners are required to complete several years of training and often have completed internships in China, Japan, or Korea. The letters TCM (Traditional Chinese Medicine) after the name means that the doctor has additional training in prescribing Chinese herbs. The more knowledge a practitioner has about Chinese medicine and its supporting philosophy, the more able they are to diagnose and treat your symptoms. Also, as with all health care practitioners, check their practice's reputation in the community.

Migraines & Your Environment

Migraines can be agonizing, debilitating, and scary. The inclination to "make the pain go away now" can, ironically, be an obstacle to curing the pain. Migraines do not just happen -- they are not a random occurrence. They are your body interacting with its environment. Explore your environment to determine what is upsetting your internal balance, and you can learn how to control your headaches and prevent them from ever recurring.

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Locate a Neurologist

The Neurology Channel offers a service to help you find a Neurologist. Please visit the following link: http://wo.mdlocator.com/cgi-bin/WebObjects/MDLocator.woa/1/wa/DirectAction?location=neurologychannel

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Organizations

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Related Publications and Information from NINDS

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Page updated on: 12/04/05

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