Migraine
Patient information: Migraine headaches in adults
Author
Zahid H Bajwa, MD
R Joshua Wootton, MDiv, PhD Section Editor
Jerry W Swanson, MD Deputy Editor
Leah K Moynihan, RNC, MSN
John F Dashe, MD, PhD
MIGRAINE HEADACHE OVERVIEW — Headache is one of the most common medical complaints. Headaches can be quite debilitating, although the vast majority are not due to life threatening disorders. Approximately 90 percent of headaches are caused by one of three syndromes (show table 1):
Migraine headache
Tension-type headaches
Cluster headaches
This article discusses migraine headaches in adults. Other types of headaches are discussed separately. (See “Patient information: Headache causes and diagnosis in adults” and see “Patient information: Headache treatment in adults”).
MIGRAINE HEADACHE SYMPTOMS — Between 12 and 16 percent of people in the United States experience migraine headaches, making it the second most common type of headache. Migraines have well-defined periods of head pain and other symptoms, separated by periods during which there are no symptoms. Migraine attacks frequently begin in the morning, but can occur at any time.
Pain — The pain of a migraine headache usually begins gradually, intensifies over minutes to one or more hours, and resolves gradually at the end of the attack. The headache is typically dull, deep, and steady when mild to moderate in severity; it becomes throbbing or pulsatile when severe.
Migraine headaches are worsened by moving the head rapidly, light, sneezing, straining, constant motion, or physical activity; many migraine sufferers try to get relief by lying down in a darkened, quiet room. In 60 to 70 percent of people, the pain occurs on only one side of the head. In adults, a migraine headache usually lasts a few hours, although it can last from four to 72 hours.
Other symptoms — Migraine headaches are often accompanied by nausea and vomiting, as well as sensitivity to light and noise. Between 10 and 20 percent of people with migraines also experience nasal stuffiness and runny nose, teary eyes, or changes in skin tone or body temperature.
The symptoms of a migraine attack may be severe and alarming, but in most cases there are no lasting health effects when the attack ends.
Aura — About 20 percent of people with migraines experience visual or other neurologic symptoms before the headache; this is called an aura. The aura may include flashing lights or bright spots, zigzag lines, loss of part of the field of vision, numbness or tingling in the fingers of one hand, lips, tongue, or lower face. A person can have several types of aura symptoms that vary with the headache attack.
Aura symptoms typically last five to 20 minutes and rarely last more than 60 minutes with the headache occurring soon after the aura stops. Muscle-related auras may last longer.
Auras may also involve other senses and can occasionally cause temporary muscle weakness or changes in speech; these symptoms can be frightening because they mimic a stroke or transient ischemic attack (TIA). (See “Patient information: Transient ischemic attack”).
MIGRAINE HEADACHE TRIGGERS — Many conditions are potential triggers of migraine headaches. A partial list appears in the table (show table 2).
Migraines can be triggered by stress, worry, menstrual periods, birth control pills, physical exertion, fatigue, lack of sleep, hunger, head trauma, and certain foods or drinks that contain chemicals such as nitrites, glutamate, aspartate, tyramine. The specific factors that trigger attacks differ from one person to another.
Certain medications and chemicals can also trigger a migraine, including nitroglycerin (used to treat chest pain), estrogens, hydralazine (used to treat high blood pressure), perfumes, smoke, and organic solvents with a strong odor.
Headache diary — People who have frequent or severe headaches may benefit from keeping a headache diary over the course of one month. This can be used to determine the characteristics of the headaches, what triggers them, and what makes them better. A sample diary is included here (show figure 1).
MIGRAINE HEADACHE VARIANTS — Some types of migraine headaches have specific symptoms that distinguish them from a typical migraine.
Hemiplegic migraine is characterized by inability to move and loss of sensation on one half of the body; this usually last longer than the headache itself. Complete recovery may take weeks; permanent weakness can occur after multiple attacks. There is a form of hemiplegic migraine, familial hemiplegic migraine (FHM), that is inherited, although this condition is rare.
Basilar-type migraine predominantly affects young women and children. Symptoms may include any combination of double vision, vertigo (sensation of movement or spinning), difficulty hearing, pain in the toes or fingers, double vision, ringing ears, difficulty with balance, and altered consciousness (show table 3). (See “Basilar-type migraine”).
Migraine aura without headache is characterized by migraine aura that occurs without headache. It may be confused with a stroke or transient ischemic attack (TIA), especially in older persons (see “Aura” above). In one study, 38 percent of people had migraines with aura as well as migraine aura without a headache.
Migrainous vertigo is the term used to describe vertigo (a sense of spinning or dizziness) that accompanies a migraine headache. (See “Migrainous vertigo”).
MIGRAINE HEADACHE TREATMENT TYPES — Migraine headache treatment depends upon the frequency, severity, and symptoms of an individual’s headache.
Acute treatment (also called abortive or symptomatic treatment) refers to the use of medications to end or lessen the severity of a headache once it begins. This treatment is appropriate for people who have infrequent headaches (for example, fewer than four headaches per month) that last less than 12 hours. These treatments are available in several easy-to-use forms. (See “Acute treatment” below).
Preventive treatment (also called prophylactic treatment) refers to the regular (usually daily) use of medication to reduce the frequency and severity of migrain headaches. Preventive treatment is usually recommended if migraines are frequent, long lasting, or interfere with your ability to function. (See “Preventive treatment” below).
Acute treatment — The initial (acute) treatment of migraines is most effective when taken at the first sign of an attack (eg, the onset of aura if one occurs, or at the onset of pain). In some people (about one out of five), an aura occurs before the migraine. Therefore, an aura can serve as a reliable warning for some that a migraine headache is on the way, and should be the signal to take migraine medication. (See “Acute treatment of migraine in adults”).
Mild analgesics — Mild migraine attacks may respond to mild analgesics (pain medication), some of which are available without a prescription. These drugs include aspirin, acetaminophen, and nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (eg, Motrin or Advil), indomethacin, or naproxen (eg, Naprosyn or Aleve). Indomethacin comes in a rectal suppository, which makes it particularly useful for people who experience nausea during their headaches. Mild analgesics are also available in combination with caffeine, which enhances their antimigraine effect. As an example, Excedrin® contains a combination of acetaminophen, aspirin, and caffeine.
Mild analgesics are often recommended first for mild to moderate migraine attacks. However, they should not be used regularly (especially acetaminophen) because overuse can lead to medication-overuse headaches or chronic daily headaches. People who tend to respond to mild analgesics should continue taking these with each attack, as long as they are not being used more than once or at most twice per week.
People with gastritis (inflammation of the stomach), ulcers, kidney disease, and bleeding conditions should not take products containing aspirin or NSAIDs.
Anti-nausea medications — If nausea and vomiting occur with a migraine, an anti-nausea can be taken by injection or rectal suppository. In some cases, antimigraine drugs can be taken in combination with drugs that alleviate nausea and vomiting, such as metoclopramide (Reglan®), chlorpromazine (Thorazine®), and prochlorperazine (Compazine®). Anti-nausea medications are not usually used alone to treat acute migraine.
Triptans — If a mild analgesic does not effectively control migraines, most healthcare providers will recommend a treatment that is migraine-specific. This includes a class of medications called triptans. Examples of triptans are sumatriptan (Imitrex®), zolmitriptan (Zomig®), naratriptan (Amerge®), rizatriptan (Maxalt®), almotriptan (Axert®), eletriptan (Relpax®) and frovatriptan (Frova®).
Triptans can be used at home or work/school, and are all available in an oral (pill) form. Sumatriptan and zolmitriptan are available as nasal sprays. In general, naratriptan and frovatriptan are not as effective as the other medications in this group. Nevertheless, some individuals prefer them. All of the oral triptans are effective and well tolerated.
Older adults and people with high blood pressure, vascular disease (including coronary artery disease), and kidney or liver disease should not take triptans in most cases.
Sumatriptan — Sumatriptan is available in many different formulas, including tablet, nasal spray, and injectable formulas. Over 70 percent of people experience migraine headache relief within one hour of injecting sumatriptan; by two hours, 90 percent of people notice improvement.
The injection may be repeated after 60 minutes if symptoms improve with the first injection but do not completely resolve. However, a second injection is not recommended if there was no improvement in headache symptoms after the first injection. Unlike other triptans that can be taken at the first sign of aura, injectable sumatriptan should not be used until migraine pain is present.
Sumatriptan nasal spray begins to work faster than the pill form and has fewer side effects than the injection. The most common side effect of the nasal spray is an unpleasant taste.
Common side effects of injectable sumatriptan include redness around the injection site, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, a feeling of warmth, and tingling in the extremities. Most of these reactions occur soon after the injection and resolve within 30 minutes. There have been rare serious side effects associated with injection of triptans, but these drugs are generally considered safe for most patients.
A tablet that contains a combination of sumatriptan and naproxen (Treximet®) appears to be more effective for migraines than either medication taken alone. It is not known if taking the two medications separately would be as effective as the combination tablet.
Dexamethasone — Dexamethasone is a glucocorticoid (steroid) medication that can be given by injection, along with another acute treatment, to reduce the risk of early migraine headache recurrence. Dexamethasone injections may be given in an emergency department or clinic. However, frequent use of dexamethasone for migraines can have side effects and is not recommended.
Ergots — Ergotamine is an older, migraine-specific drug. It is often combined with caffeine (Cafergot®, Wigraine®). Ergots are not usually as effective as triptans and are more likely to cause side effects. They are usually recommended for people with migraines of a long duration (greater than 48 hours) or that frequently recur. People with high blood pressure, coronary artery disease, or kidney or liver disease should not use ergotamines.
Dihydroergotamine is related to ergotamine, and can be taken by nasal spray (Migrainol®) for mild or moderate attacks or can be given by injection (DHE 45) for severe attacks. Both drugs are effective; within four hours, nasal dihydroergotamine relieves migraine headaches in 70 percent of people. Injections of dihydroergotamine relieves migraine symptoms in about 86 percent of people.
Other medications — Other medications for migraine are not as well studied or are less effective. A small percentage of patients with migraine headaches do not respond to routine acute treatments and may require additional treatment for pain. Benzodiazepines, opioids (narcotics), and barbiturates are all options, although these medications should not be used on a long-term basis since they are habit-forming and can increase the risk of medication-overuse headaches and chronic daily headaches.
Preventive treatment — Preventive treatment effectively controls migraine headaches in most people, although the benefits of this treatment may not be evident for three to four weeks. In some cases, both acute treatment and preventive treatment are necessary to adequately control migraines. The choice of drug should be tailored to each individual, and it is often based upon side effects and underlying medical conditions. (See “Preventive treatment of migraine in adults”).
Beta blockers — These reduce the frequency of migraine attacks in 60 to 80 percent of people. Commonly used beta blockers include propranolol, nadolol, timolol, atenolol, and metoprolol. Beta blockers may cause depression or impotence in some people.
Tricyclics — Tricyclic antidepressants (TCAs) and certain other antidepressant medications are often recommended for migraine prevention. These include amitriptyline, nortriptyline, doxepin, and protriptyline. Of these, amitriptyline has proven benefit for migraine prevention, while there is less data for the other tricyclics.
Side effects are common with tricyclic antidepressants. Most of these drugs cause drowsiness, particularly amitriptyline and doxepin. Therefore, these drugs are usually taken at bedtime and started at a low dose. Additional side effects of tricyclics include dry mouth, constipation, rapid heart beat (tachycardia), palpitations, blood pressure decrease when standing up after sitting or lying (called orthostatic hypotension), weight gain, blurred vision, and urinary retention. Confusion can occur, particularly in older adults.
Valproate — Valproate (Depacon®) is an antiepileptic drug that appears to be at least as effective as beta blockers for preventing migraine, and may be better tolerated. However, valproate can cause weight gain and hair loss. Women who are pregnant or sexually active and not using effective contraception should not take valproate.
Topiramate — Topiramate (Topamax®) is an antiepileptic drug that can help to prevent migraine. It typically has mild to moderate side effects that may include paresthesia (abnormal sensations, often tingling), fatigue, nausea, alterations in taste, loss of appetite, diarrhea, and weight loss. More severe side effects can occur, including language problems and difficulty with concentration.
Calcium channel blockers — Calcium channel blockers are widely used for migraine prevention and aura treatment, and include verapamil, nifedipine, and nimodipine. Verapamil is frequently used as a first choice for preventive migraine therapy because it is easy to use and has few side effects. Calcium channel blockers may lose their effectiveness over time, but this can sometimes be remedied by taking a higher dose of the drug or switching to a similar drug.
Other medications — Other medications that may be helpful in preventing migraines include the angiotensin converting enzyme (ACE) inhibitor lisinopril (Zestril®), the angiotensin II receptor blocker (ARB) candesartan (Atacand®), coenzyme Q10, methysergide, nonsteroidal anti-inflammatory drugs (NSAIDs), and riboflavin. More clinical studies are needed before these medications are generally recommended for migraine prevention.
Herbal therapies — Herbal therapies have been evaluated for the treatment of migraine headache, including feverfew and butterbur. Of these, feverfew has been the most widely studied. Some studies have found it to be effective for migraine prevention, although most experts agree that the benefits are still unproven. Neither treatment is recommended.
Avoiding medication overuse — It is essential to use antimigraine medications according to the prescription and clinician’s instructions. Overuse of these medications, including over-the-counter drugs such as acetaminophen or NSAIDs, can lead to medication-overuse headaches (also called rebound headaches) and to a pattern of daily headaches that require increasing quantities of drugs for relief.
A vicious cycle occurs when frequent headaches cause people to chronically take medications, which then cause rebound headaches as the medications wear off, causing more medication use, and so on. (See “Patient information: Headache treatment in adults”).
Speak with a healthcare provider if a treatment is not adequately relieving migraines or is causing unpleasant side effects. Switching to another drug or switching from acute treatment to preventive treatment may be helpful.
MIGRAINE HEADACHES IN WOMEN — Migraines occur about three times more commonly in women than in men. Estrogen has a variable effect on the frequency and severity of a woman’s migraines; some women who take oral contraceptives (which contain estrogen) or hormone replacement therapy experience worsening headaches, while others improve. Similarly, some women have an increasing headache pattern during pregnancy while others have diminished headache intensity. (See “Estrogen-associated migraine”).
Menstrual migraines are migraine headaches that occur around the beginning of a woman’s menstrual period (usually two days before to three days after the period begins). Women with menstrual migraine may also have migraines at other times during the month. Most often, there is no migraine aura associated with menstrual migraines, even if the woman usually has aura at other times.
Menstrual migraines are thought to be triggered by the normal decrease in estrogen levels that occurs before the menstrual period begins. Menstrual migraines tend to be longer lasting, more severe, and more resistant to treatment than other types of migraine.
Treatment — Menstrual migraines are usually treated with the measures described above. (See “Acute treatment” above).
A preventive treatment may be useful for women who have menstrual migraines on a predictable schedule. This treatment strategy is called “mini-prophylaxis”, and usually includes a preventive medication that is started one or two days before the headache is expected and then continued for one to three days.
Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen or naproxen are first-line therapy for mini-prophylaxis of menstrual migraine. Naproxen sodium 550 mg twice daily during the perimenstrual period is one commonly used regimen. Women who have coronary artery disease should speak with a healthcare provider about the risks and benefits of NSAIDs before taking this treatment. (See “Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)”).
Triptans are not well studied for prevention of menstrual migraines, although a few studies have shown benefit. If a woman cannot take or does not respond to NSAIDs, frovatriptan (Frova® 2.5 mg once or twice daily), sumatriptan 25 mg three times daily, or naratriptan 1 mg twice daily for six days may be recommended. Triptans are not approved for this use in the United States, although some clinicians have found them helpful.
Hormonal treatments, such as birth control pills, may be recommended to prevent menstrual migraines. The pill may be taken continuously (eg, by skipping the last week of pills in the pack and starting a new pack) or in combination with a low-dose estrogen pill (taken only during the fourth week of the cycle, when the menstrual period is expected). This treatment works by preventing a rapid decline in the level of estrogen in the body before the menstrual period, which is believed to trigger the migraine.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.
National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
American Council for Headache Education (ACHE)
(856) 423-0258
(800) 255-2243
(www.achenet.org)
American Headache Society
Phone: (856) 423.0043
(www.ahsnet.org)
The Mayo Clinic
(www.mayoclinic.com)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement .
REFERENCES
1 Silberstein, SD, for the US Headache Consortium. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review). Neurology 2000; 55:754.
2 Linde, K, Rossnagel, K. Propranolol for migraine prophylaxis. Cochrane Database Syst Rev 2004; :CD003225.
3 Goadsby, PJ, Lipton, RB, Ferrari, MD. Migraine–current understanding and treatment. N Engl J Med 2002; 346:257.
4 Silberstein, SD, Rosenberg, J.Multispecialty consensus on diagnosis and treatment of headache. Neurology 2000; 54:1553.
©2009 UpToDate® • customerservice@uptodate.com
www.uptodate.com