Health

What Causes a Migraine, and What Relieves the Pain?

June National Migraine & Headache Awareness Month. Dr. Baxter Allen, focuses this article on the symptoms of, and treatment for, that severe form of headache, the migraine.—Ed

 

Dear Dr. Allen,

I am 45 years old and am having an increase in headaches. I’ve always had premenstrual headaches, but my periods are now closer together and unusual, so I seem to have a headache more often than not.

I used to be able to take Advil and lie down and the headaches would get better. Now I find that I know when the headache is coming, because I get an odd sensation of numbness on the left side of my tongue and face.  My GP thought I might be having an unusual seizure, or even a stroke, and sent me to a neurologist, who told me that I was having migraine aura.  It was a relief to know that nothing serious was going on, but I don’t understand why these headaches are becoming more frequent, are lasting longer, and are more severe.

I have two children in middle school and work 40 hours a week in a stressful job. I get only six hours of sleep, since I have to help the kids with homework, cook, clean, and do laundry at night.  I like having a glass of wine with dinner to decrease the stress, but even that seems to cause a headache.  I am taking so much Advil now that I have stomach pain.

What are migraines, anyway?  What causes the migraine?  Is this change in my periods— the perimenopause I’ve read about—causing the increase in headaches?  My girlfriend said that I should learn to meditate to decrease my stress, but I don’t have time for that.

I don’t like taking prescription medication, but I am ready to try something before I miss too much work and lose my job.  What drugs usually work?  If hormone change is really the cause of these headaches, will the headaches get better when I am in menopause?

Lisa

 

Dr. Allen Responds:

Dear Lisa:

Unfortunately, migraine headaches are one of the most common conditions in the world, and their ability to cause disabling symptoms is frequently overlooked. In the U.S. alone there are roughly 36 million diagnosed with a migraine syndrome—roughly 10 percent of the population, 18 percent of women, and 6 percent of men. The disability from these headaches leads to a loss of over 100 million work days per year in the United States, and costs the economy over $13 billion a year.

What Is a Migraine?

As you have experienced, a migraine is much more than just a bad headache. It is a debilitating collection of several symptoms, most frequently:

  • A severe, one-sided, throbbing headache
  • Visual disturbances—blurry vision or difficulty focusing
  • Gastrointestinal symptoms—nausea, vomiting, poor appetite
  • Fatigue
  • Dizziness or vertigo
  • Sensory sensitivity—a worsening of symptoms with exposure to lights, sounds, touch, or smell
  • Sensory changes—numbness or tingling in a part of the face or an extremity

Approximately one fifth of migraineurs (people who have migraines) experience an aura prior to the onset of headache pain. An aura is typically a visual disturbance consisting of an enlarged blind spot, wavy lines, dots, or flashing lights that begin roughly 20 to 60 minutes prior to the start of the migraine itself. Other auras include tingling in the face or arm or mild difficulty speaking. These symptoms typically start slowly and expand over several minutes, lasting between 5 and 60 minutes. While it was previously thought to be due to constriction of small blood vessels supplying specific areas of the brain, current research has shown instead that an aura is from short-term changes in specific nerve cells.

Less often, auras can last longer—from hours to days, and even be associated with scarier, more severe symptoms. These auras, previously called “complicated” or “complex” migraine variants, are associated with significant neurologic symptoms that include stroke-like weakness on one side of the body, a reduced ability to form or comprehend words, extreme incoordination or difficulty walking, visual loss, or weakness of one or more muscles that move an eye. If an aura lasts for a prolonged time, or if you experience new or unusual symptoms, you should immediately seek medical attention. After you have been diagnosed with a specific migraine syndrome, you should talk with your neurologist about what to do if the same set of symptoms occurs again. While migraine aura is rarely associated with stroke, there is a reported increase in the risk of stroke in women who suffer from migraine with aura.

 

What Happens During a Migraine?

The migraine process starts with some sort of trigger. Triggers vary from person to person, but common ones include changes in sleep patterns (too much or too little); environment (weather, bright lights, odors, or pollution); stress; diet (skipping meals, specific foods, medications); alcohol (especially red wine, beer, and sherry); caffeine; and hormonal changes—mostly fluctuations in estrogen levels.

Once the migraine is triggered, people will generally have a sense that a migraine is coming on, sometimes up to 24 hours prior to the start of the headache. This period is called the “prodrome.” The prodrome is likely caused by some aberrant electrical firing in the brain, producing the vague sense that something is off. These prodromes generally do not change: one person may experience significant hunger; another may feel extremely fatigued or even just have a premonition that a headache is about to start.

This aberrant firing leads to the spread of electrical activity to other regions of the brain (figure 1.1). The spreading electrical activity can be experienced as an aura, as described above, or simply an intensification of the prodromic sensations (figure 1.2).

 

MigrainePathway(Source: www.interactive-biology.com)

As this electrical activity spreads, the brain releases chemicals that lead to the dilation of blood vessels in the meninges, a membranous covering that surrounds the brain (figure 1.3). With the increased blood flow, nerve fibers in the meninges that branch off of the trigeminal nerve (the nerve responsible for sensation in the face and scalp) are activated and pain signals travel back through the trigeminal system (figure 1.4). Over-stimulating the nerves responsible for relaying touch from the face (e.g. brushing the hair, touching the face) can lead to additional pain.

Without intervention, these painful attacks can last from 4 to 72 hours, and occasionally even longer.

 

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  • Andrea Rosenhaft June 17, 2019 at 7:51 am

    I’ve had severe and chronic migraines for about 9 years. I’m 58 years old and 6 years post-menopausal. Amovig (140 mg) has been a life-changing medication for me, especially since I can no longer use triptans as I had a stroke in 2018. I’m seen at a major headache center in the Bronx, NY. In addition to the Amovig, I get Botox injections every 3 months and nerve block/trigger point injections every 2 weeks. I take Topiramate as a preventive medication. My mother also had migraines and became addicted to Fiorcet as there was not much available to help her. I’ve become aware of my triggers – the first being a drop in barometric pressure, which I can’t control and the second, stress, and the third, being missing a meal and/or a snack. Those are the top three. Recently I had extensive oral surgery on my lower jaw and that triggered a migraine for as long as it took my jaw to heal which was more than a week. Unless a person has actually experienced the excruciating pain of one, they don’t understand and tend to downplay it as “just a headache.”

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