What are Migraines?

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A migraine is much more than a bad headache: It is a complex brain disorder involving nerve pathways, chemicals, and/or blood vessels. 

 

Types of Migraines

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• Migraine Without Aura - The most frequent type, presenting as a throbbing headache without any preceding warning signs, often accompanied by nausea, sensitivity to light, and sound.

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• Migraine With Aura - Also involves neurological symptoms (auras) such as visual disturbances (flashing lights, blind spots), tingling in the hands or face, or speech difficulties.

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• Chronic Migraine - Defined as having headaches 15 or more days per month for at least three months, with at least 8 of those days meeting the criteria for a migraine attack.

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• Vestibular Migraine: Primarily causes episodes of vertigo, dizziness, and balance issues, sometimes with little or no head pain.

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• Menstrual Migraine - attacks occurring on days -2 to +3 of the menstruation cycle, and sometimes on other days too, and in at least 2 of 3 menstrual cycles.

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• Migraine with brainstem aura - vertigo, slurred speech, and double vision without weakness during the aura phase

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• Hemiplegic Migraine - temporary paralysis or weakness on one side of the body during the aura phase

 

Diagnostic Criteria

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According to the International Classification of Headache Disorders (ICHD-3):

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Migraine Without Aura

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• 1)  At least 5 attacks fulfilling criteria 2 through 4.

• 2) Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated).

• 3) Headache has at least two of the following characteristics:

  • One-sided location

  • Pulsating/throbbing quality

  • Moderate or severe pain intensity

  • Aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)

• 4) During the headache, at least one of the following occurs:

  • Nausea and/or vomiting

  • Sensitivity to light (photophobia) and sound (phonophobia)

• 5) Not better accounted for by another diagnosis.

 

Migraine With Aura

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• 1)  At least two attacks fulfilling criteria 2 and 3.

• 2) One or more of the following fully reversible aura symptoms:

  • Visual

  • Sensory

  • Speech and/or language

  • Motor

  • Brainstem

  • Retinal

• 3) At least three of the following six characteristics:

  • At least one aura symptom spreads gradually over at least 5 minutes.

  • Two or more aura symptoms occur in succession.

  • Each individual aura symptom lasts 5-60 minutes (note: motor symptoms can last longer).

  • At least one aura symptom is unilateral.

  • At least one aura symptom is positive/extra sensory (e.g., flashing lights, twitches, pins and needles).

  • The aura is accompanied, or followed within 60 minutes, by headache.

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Causes

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Primary Migraine risk factors include an inherited polygenic susceptibility plus general factors including:

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• Female sex

• Common Triggers:

  • Stress

  • Hormonal changes during puberty, menstruation, pregnancy, or menopause

  • Dietary factors (aged cheeses, alcohol—especially red wine, processed foods, caffeine or caffeine withdrawal, skipping meals)

  • Sensory stimuli (bright lights, loud sounds, strong smells)

  • Sleep changes (lack of sleep or too much sleep)

  • Weather changes or barometric pressure shifts

 

Secondary causes and mimickers:

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• Medication overuse headache

• Withdrawal

• Infections

• Post-traumatic headache

• Cervicogenic headache

• Severe high blood pressure

• Giant cell arteritis

• Unruptured vascular malformations, aneurysms

• Stroke or transient ischemic attack (TIA)

• Cervicocephalic arterial dissections

• Hydrocephalus

• Idiopathic Intracranial Hypertension

• Spontaneous intracranial hypotension

• Reversible Cerebral Vasoconstriction Syndrome (RCVS)

• Focal Seizures - Occipital seizures frequently manifest with elementary visual hallucinations (e.g., brief, unformed colored spots or circles) that can resemble visual migraine aura. However, epileptic visual symptoms are typically very brief (seconds to a couple of minutes), evolve instantly, and may be followed by post-ictal confusion or motor activity.

• Cluster headaches

• Pheochromocytoma

• Cerebral Venous Sinus Thrombosis (CVST)

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Treatments

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Lifestyle Management

• Migraine Diary: Track your habits, diet, stress, and headaches to identify triggers.

• Establish Routine: Maintain a consistent sleep schedule, stay well-hydrated, and avoid skipping meals.

• Stress Management

Medication

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                                                                          Medications

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1. Abortive Medications

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• Triptans - Sumatriptan, Rizatriptan (FDA-approved)

• CGRP Inhibitors - Ubrogepant, Rimegepant (FDA-approved)

• Pain Relievers - Ketorolac, Ibuprofen, Naproxen, or Acetaminophen, sometimes with Caffeine. 

• Antiemetics- Metoclopramide, Ondansetron, Promethazine

• Corticosteroids

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2. Preventative Medications

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• Beta-blockers -  Propranolol, Metoprolol 

• Antidepressants - Amitriptyline, Venlafaxine

• Anticonvulsants - Topiramate, Valproate

• CGRP Monoclonal Antibodies - Erenumab, Fremanezumab: Monthly or quarterly injections 

• Botox Injections - every 12 weeks.

• Continuous estrogen-containing contraception (off-label) - for menstrual migraines, NOT in those with auras

• Magnesium glycinate or magnesium citrate (off-label) - especially for migraine w/ aura

 

*Atogepant (Qulipta): Taken as a once-daily oral tablet specifically approved for the preventive treatment of both episodic and chronic migraines.

*Rimegepant (Nurtec ODT): An orally disintegrating tablet that can be used for acute treatment as well as taken on a schedule of once every other day for migraine prevention.

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• Beware of Medication Overuse Headaches (MOH):  Taking acute pain relievers, triptans, or combination analgesics too many days a month can paradoxically cause daily or near-daily "rebound" headaches. If a patient is overusing acute treatments, a preventive reset is often necessary. To officially be diagnosed with Medication-Overuse Headache (MOH) as a chronic disorder, the patient must experience headaches on 15 or more days per month with regular medication use for more than 3 months. The Medication Days (The 10 vs. 15 rule): The overuse itself is defined by how many days a month the acute medication is taken, which varies by drug class: 10 or more days per month for triptans, opioids, ergots, or combination analgesics and 15 or more days per month for NSAIDs or acetaminophen.

• The Triptan Contraindication Rule: Triptans constrict blood vessels and are generally contraindicated in patients with a history of ischemic stroke, coronary artery disease, uncontrolled hypertension, or hemiplegic or basilar migraine. For these patients, CGRP inhibitors are preferred.

• Botox Requires Patience: maximum clinical efficacy may take 6 to 9 months

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                                                                         References & Guidelines

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• International Headache Society (IHS). International Classification of Headache Disorders, 3rd Edition (ICHD-3).

• American Headache Society (AHS). Clinical Practice Guidelines and Position Statements.

• American Headache Society (AHS). Calcitonin Gene-Related Peptide-Targeting Therapies Are a First-Line Option for the Prevention of Migraine: Position Statement Update.

• American Headache Society (AHS). Evidence Assessment of Acute Migraine Pharmacotherapies.

• American Migraine Foundation (AMF). Migraine treatment and triptan guidance.