What is migraine?

Migraine is a complex neurological disorder that usually manifests as a throbbing or pulsing feeling on one side of the head with periodic, piercing pain. Other migraine symptoms besides headaches often include: 

• Nausea 
• Dizziness
• Fatigue
• Increased sensitivity to external stimuli like light or sound
• Increased pain with physical activity or strong smells

Migraines are extremely disruptive to one’s daily life and often come in the way of one’s financial, emotional, and physical well-being. Migraine triggers make it harder to be in certain environments, for example, a loud concert or restaurant, or to indulge in certain foods or drinks, like chocolate or caffeine. In some instances, migraines even result in speech difficulties. There are multiple migraine treatments one might consider to tackle different types of migraines. 

Migraine headaches: the difference between headaches and migraines?

While some use “headache” and “migraine” interchangeably, or even refer to attacks as “migraine headaches”,  they are not the same. Headaches are just one symptom of migraines and one can have headaches of various types without being a migraine patient. Though someone experiencing headaches might not have migraines, someone with migraines almost always experiences headaches. You can distinguish headaches and migraines mainly by noting the range of symptoms you experience before, during, and after a headache. This, primarily, is the difference between migraines vs. headaches. 

What are the types of migraine?

There are various types of migraine with the two most common being classic migraines and common migraines. Classic migraines are those with auras whereas common migraines are those without. An aura refers to sensory disturbances, like dots or sparks in one’s vision, usually 30 to 60 minutes before the onset of migraine pain. Auras might even persist through a migraine in some cases. 

Other migraine types include: 

• Menstrual migraine: This type of migraine usually starts 2 days before one’s period and can persist up to 3 days after. One is unlikely to experience aura in menstrual migraines. 
• Abdominal migraine: Characterised by stomach pain, nausea, and vomiting, this type of migraine is more likely in children. 
• Chronic migraine: Migraines that occur daily or for long periods, with symptoms that change frequently. 
• Silent migraine: Also referred to as acephalgic migraines, this type comes with aura symptoms but no headache. 
• Hemiplegic migraine: Accompanied by paralysis or a feeling of weakness in one side of the body. One might also experience dizziness, numbness, or anomalies in vision. 
• Retinal migraine: Causes partial or total loss of vision temporarily in one eye, with an ache behind the eye. 
• Status migrainosus: A migraine attack that lasts over 72 hours with intense symptoms like excruciating head pain, nausea and/or vomiting. 

 These various types of migraines need different treatments. 

Migraine in India 

According to research, approximately 15% of the Indian population suffers from migraines. Women are more likely to suffer from migraines in India than men.  

What are the 4 phases of migraine?

Migraine is known to occur in four stages or phases. These are: 

• Prodrome phase: Usually occurs 24 to 48 hours before the onset of a headache. Symptoms include mood fluctuations, lethargy, stiffness in the neck, increased sensitivity to light, and more. 
• Aura phase: Lasts less than 60 minutes and is marked by sensory, verbal, and motor difficulties that usually occur before a headache, though some experience auras alongside headaches. People most commonly experience visual auras. Not everyone experiences auras.
• Headache phase: Can last from several hours up to a few days. Starts with a throbbing or pulsing feeling that increases in intensity as this phase develops. Other symptoms one might experience in this phase include nausea, vomiting, sensitivity to light or sound, and a runny nose. One might find relief in a dark room as sleep alleviates the pain. 
• Postdrome phase: Comes after the headache phase with movement-related pain in the previous site of the headache. One might feel exhausted, dizzy, euphoric, or easily distracted in this phase.

Since people might experience the different phases of migraine with varying intensity and typology of symptoms, it is crucial to consult an expert on how to treat your specific case. 

What are the main reasons and causes of migraine? 

It is still not fully understood how migraines are caused. However, studies show that reasons might include dysfunction of pain modulatory pathways, central sensitisation, structural brain changes, and dysfunction in neurotransmitters.

Other migraine causes might also have to do with the activation of nerve fibres within brain blood vessel walls. Genetics might play a big part in who is likely to suffer from migraines as well. Other conditions, like depression, anxiety, or bipolar disorder, are likely to result in migraines, though further research is required on this front.

Considering women are more likely to suffer from migraines, it is suspected that there’s a hormonal aspect to migraines as well, with the onset usually at the start of one’s first menstrual cycle. Most women find relief from migraines after menopause.

What are various migraine symptoms I could experience?

Symptoms of migraines usually correlate to the four phases of a migraine. There are some common symptoms people face with varying severity. Most people report a headache, throbbing, or pulsing sensation in one part of the head that might move around to the other side over time. Others might experience pain in various parts of their face, like behind an eye, on the jaw, or in the temples. 

Even though not everyone struggles with motor, speech, or sensory symptoms, these are traits to look out for. Most symptoms broadly have positive features and negative features. Positive features feel like a sense is being stimulated, like bright spots, whereas negative features feel like a sense is not working optimally or is taken away, like blind spots. Below are examples of positive and negative symptoms someone with migraines could face:

Positive visual symptoms: 

• Flickering lights
• Spots
• Lines

Negative visual symptoms: 

• Loss of vision
• Blind spots
• Inability to see colours

While a majority of migraine patients tend to experience visual auras, one might experience other negative and positive symptoms as well. For example, positive features in sensory symptoms include pins and needles while negative features include numbness. Some people also face migraines with hypothalamic symptoms, or in simpler terms, increased hunger, thirst, fatigue, irritability, or even elation. 

Migraine frequency: How often do migraines appear? 

The frequency of migraines varies from person to person, with some saying they experience migraines several times a week while others say they experience it once a year. It can be considered chronic or too frequent if you experience headaches for over 15 days in a month with 8 days of migraine symptoms, for 3 months or more. Migraines most commonly appear in the mornings. Women might expect them before menstruation. The good news is that most people find relief from migraines as they get older. 

What can trigger or worsen my migraines? 

The multiple migraine triggers that exist can be categorised into internal and external factors. 

Internal migraine triggers include: 

• Stress or anxiety
• Hormones
• Hunger/fasting
• Fatigue or lack of sleep

External migraine triggers include: 

• Light
• Sound
• Odours
• Weather conditions
• Foods & beverages – cheese, chocolate, beans, food additives, etc. 
• Stimulants – coffee, tobacco, alcohol, etc.
• Physical activity – exercise or sexual intercourse

Given there is a wide range of things that might trigger migraines, it is important to work with an expert to become aware of your specific triggers. Treating migraines requires an understanding of how your body reacts to different internal and external triggers. 

What are the risk factors for migraines? 

Migraines have shown strong signs of being hereditary, with multiple people in a family line suffering from the condition. There are various migraine risk factors and people who are more likely to get migraines include: 

• Sex: Women are three times more likely to experience migraines than men. 
• Age: Higher chances of experiencing migraines below the age of 45 years. 
• Hormonal imbalance: People with higher instances of fluctuating hormone levels are more likely to suffer from migraines.
• Substance use: Alcohol and smoking are amongst the top triggers for migraines, putting people with substance use disorders at higher risk of migraines. 
• Medication: Overuse of common over-the-counter medication might lead to higher instances or intensity of migraines. 

How do you diagnose a migraine? 

A doctor examines a patient’s medical history and symptoms to determine whether they should be diagnosed with migraines. Doctors often ask the following questions to make a diagnosis: 

• Does anyone else in your family suffer from migraines? 
• How long do headaches last on average? 
• Did anything trigger your headache or symptoms?
• What symptoms do you feel before and after the onset of the headache?
• How often do you face these symptoms in a week/month/year?

Doctors might ask patients to maintain a headache diary as a diagnostic aid. A patient might be asked to record things like: 

• Pattern or length of headaches
• Frequency of headaches
• What medications you use
• Accompanying symptoms – Nausea, vomiting, sensitivity to light, etc.

Various types of migraines have different criteria that need to be met in order to be deemed a migraine. For example, someone can only be diagnosed with chronic migraine disorder if they suffer from headaches for over 15 days a month, with 8 of those days presenting migraine symptoms, continuously for at least 3 months. On the other hand, a migraine without aura can only be diagnosed as such if someone has at least five untreated headache attacks that last from 4-72 hours. 

A doctor might even conduct a physical or neurological exam to understand your symptoms better. A range of tests, like blood tests or neuroimaging, help doctors rule out other conditions that might have shared symptoms with migraines. 

Who should I meet to diagnose migraines? 

Start by speaking to your family doctor as they are most likely to understand your medical history best. If you require further assistance, contact a general physician (GP). A GP might turn to a neurologist or headache specialist to diagnose the condition more accurately and for expert advice on treatment.

What are treatment options for migraines? 

While there is no cure for migraines, there are many ways to treat migraine symptoms. Some involve immediate solutions for symptomatic relief while others involve preventative measures to reduce frequency of attacks. There exist alternative therapies as well with little to no side effects to manage and prevent migraines.

Migraine symptom relief treatments: 

• Analgesics (pain medication): These are usually people’s first choice for mild to moderate migraine. Analgesic medications include aspirin, paracetamol, ibuprofen, naproxen, diclofenac, phenazone and tolfenamic acid. These medications come with side effects and should be consumed carefully, as overuse might in fact cause further headaches amongst other adverse effects. If you or a loved one chooses analgesics to treat migraines, be sure to use analgesics as infrequently as possible.
• Triptans: Considered to be great for symptom relief in migraine patients, most people turn to triptans when analgesics prove ineffective. There are 7 triptans used for migraines: sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and frovatriptan. Consuming triptans might harm people who are suffering from arterial hypertension, coronary heart disease, Raynaud's disease, a history of ischaemic stroke, and severe liver or renal failure. Triptans might also be harmful to people who are pregnant or lactating. To avoid major side effects, consume triptans less than 10 days a month. 
• Ergot derivatives: While people might choose ergot derivatives to combat symptoms of migraines, efficacy is yet to be established. Triptans have been found to work better for symptom relief than ergot derivatives, with ergotamine tartrate and dihydroergotamine (DHE) being the two most efficacious compounds for migraines. The main side effects of using ergot derivatives are nausea, vomiting, and pins and needles. Ergot derivatives might pose a risk to people suffering from cardiovascular and cerebrovascular diseases, Raynaud's disease, arterial hypertension, and renal failure. Women who are pregnant or lactating are at risk too. 
• Ditans: Ditans, particularly Lasmiditan, are prescribed for acute migraines when triptans are ineffective or when a patient cannot consume triptans due to various risks. Ditans are known to be effective for migraines with or without auras and help with symptoms like headache pain, sensitivity to light or sound, and nausea. 
• Gepants: A calcitonin gene-related peptide (CGRP) antagonist, gepants have shown lesser efficacy in treating migraines than triptans but also come with fewer side effects. While the long-term effects of gepants for migraine patients are yet to be evaluated, doctors might prescribe gepants if other medications are ineffective in treating chronic or acute migraines. 

Preventative treatments for migraines: 

• Antiepileptic drugs: The most common antiepileptic, or antiseizure drugs used to prevent migraines are gabapentin, valproic acid, lamotrigine, and topiramate.
• Beta-blockers: Most widely used in the prevention of migraines. Propranolol and metoprolol have shown consistent efficacy but atenolol, bisoprolol, nadolol, and timolol might also be effective. 
• Antidepressant medication: Effective for various kinds of chronic pain, including migraines, how antidepressants work is still not fully understood. The most common antidepressants used to prevent migraines are tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). 
• Other preventative treatments: Other preventative treatments for migraines include calcium channel blockers, angiotensin-converting enzyme inhibitors, histamines, antihistamines, leukotriene receptor antagonists, aspirin and other NSAIDs, herbs, and vitamins. 

Alternative treatments for migraines: 

These are some effective migraine treatments:

• Acupuncture
• Botulinum toxin A injections (Botox)
• Massage therapy
• Yoga
• Aerobic exercises
• Biofeedback
• Cognitive-behavioural therapy
• Meditation
• Ginger and other herbal remedies
• Cannabinoid medicine

How do I avoid migraine triggers? 

The first step to avoiding a migraine is identifying one’s triggers. Speak with a doctor for help in pointing out what might be setting off migraines in your case. Doctors might ask you to maintain a headache or migraine diary to help aid them. There are apps that can help you log migraine entries as well. Along with details like frequency and length of migraines, you will have to also record details about the things you’ve eaten or drank or activities you have taken part in. Once a doctor has identified your triggers, avoiding them becomes a lot easier. While it might not always be possible to avoid migraine triggers entirely, you can take steps to reduce your exposure to them over time. 

What migraine treatments are available during pregnancy?

While most women facing menstrual migraines experience a period of relief during pregnancy, there are cases where women suffer from migraines for the first time during pregnancy. Some medications, like triptans and ergot derivatives, pose a risk to pregnant women with migraines. For this reason, pregnant women should try non-drug interventions first, like: 

• Relaxation
• Sleep
• Massage therapy
• Biofeedback
• Ice packs

The good news is there are options for pregnant women to help them tackle their migraines in the form of medication as well. Here are some medicines pregnant women with migraines might consider:  

• Paracetamol – as a suppository
• Aspirin or ibuprofen – risk is minimised when consumed episodically (to be avoided in the last trimester of pregnancy)
• Prochlorperazine – for symptom relief from nausea
• Metoclopramide – works when used in the second and third trimesters of pregnancy
• Metoprolol and propranolol – the only safe beta-blockers during pregnancy 

What do I do for instant migraine relief during the onset or development of an attack? 

Migraines do not always require an elaborate plan to get some relief from. Here are some things you can do to alleviate migraine pain: 

• Close yourself off in a dark, cool room 
• Move to a quieter environment 
• Gently massage the sides of your head, temples, and scalp
• Take a few deep breaths or practice relaxation exercises

How do I stop getting or prevent migraines? 

Migraines can’t be entirely prevented or stopped. Although, with the right preventative measures and medications, it is possible to work with your doctor to reduce your migraine's frequency, duration, and intensity. 

Also read: Effective Migraine Home Remedies

What should I keep in mind when dealing with migraines? 

While migraines do not have a cure, it is possible to manage and experience relief from symptoms to enable a better quality of life. People living with migraines can avoid triggers and reduce their overall impact with the correct therapeutic interventions and lifestyle changes. It is important to recognise worsening or improvements in symptoms so your doctor can help you treat migraines effectively. 

What can I do to ensure my migraines don’t get worse? 

It is crucial to work closely with a doctor. In addition to steps you can take, like sitting in a dark room or practising calming exercises, remember to contact your doctor if: 

• You experience new symptoms that you previously did not
• You experience worsening symptoms 
• You experience side effects from any medications to treat migraines

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