Patient education: Migraines in adults (Beyond the Basics)

MIGRAINE OVERVIEW — Migraines are a common type of headache, affecting up to 12 percent of adults.

Most headaches fall into one of three categories, all of which have different characteristics (table 1):

●Migraine

●Tension-type headaches

●Cluster headaches

While headaches can be severe in some cases, the vast majority are not due to life-threatening disorders.

This article discusses migraines in adults. Migraines are thought to have a genetic component, meaning that they tend to run in families, although environmental factors also play a role. They occur about three times more commonly in females than in males.

Other types of headaches are discussed separately. (See "Patient education: Headache causes and diagnosis in adults (Beyond the Basics)" and "Patient education: Headache treatment in adults (Beyond the Basics)".)

MIGRAINE SYMPTOMS — A typical migraine "attack" involves four phases: the prodrome, the aura, the headache (which may be accompanied by other symptoms), and the postdrome. The exact progression and symptoms differ from person to person.

Prodrome — Many people start having symptoms 24 to 48 hours before a migraine headache comes on. These may include increased yawning, a feeling of euphoria, depression, irritability, food cravings, constipation, and neck stiffness.

Aura — About 25 percent of people with migraines experience an "aura" before the headache. Aura symptoms may include flashing lights or bright spots, zigzag lines, changes in vision, or numbness or tingling in the fingers of one hand, lips, tongue, or lower face. You may have one or more of these aura symptoms.

Auras may also involve other senses and can occasionally cause temporary muscle weakness or changes in speech; these symptoms can be frightening.

Aura symptoms typically last five to 20 minutes and rarely last more than 60 minutes. The headache typically occurs soon after the aura stops, although some people experience aura without a headache. Muscle-related auras may last longer.

Headache — The pain of a migraine headache usually begins gradually, intensifies over one to several hours, and resolves gradually at the end of the attack. It frequently affects only one side of the head. The headache is typically dull, and steady when mild to moderate in severity; it becomes throbbing or pulsatile when more severe.

Migraine headaches may be aggravated by light, sneezing, straining, constant motion, moving the head rapidly, or physical activity. Many people try to get relief by lying down in a darkened, quiet room. 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. Some people also feel very sensitive to touch, and may find normal activities (such as brushing the hair, shaving, or putting in contact lenses) painful.

Recognizing a more serious headache — The symptoms of a typical migraine attack may be severe and alarming, but in most cases there are no lasting health effects when the attack ends.

However, a change in the pattern of headache (such as an increase in attack frequency or severity) or onset of a different kind of headache can be a "red flag," meaning it could be a sign of a more serious underlying condition. Red flags include headaches that occur with infection (which may be accompanied by fever, chills, night sweats, or muscle pain) or new headaches that develop in the setting of cancer, weight loss, or pregnancy. Other concerning symptoms include headaches associated with confusion, double vision, ringing in the ears, a stiff neck, or weakness on one side of the body. If you have any of these "red flags," tell your health care provider right away or seek emergency care.

MIGRAINE TRIGGERS — Migraines can be triggered by many different things, including stress, physical exertion, fatigue, lack of sleep, hunger, odors, chemicals, and certain medications and substances (table 2). In females, migraines can be triggered by the normal decrease in estrogen levels that occurs before the menstrual period each month. (See 'Menstrual migraines' below.)

If you think a medication you are taking may be triggering migraines, talk to your health care provider. They may be able to suggest a different medication instead.

Headache diary — People who have frequent or severe headaches may benefit from keeping a "headache diary" over the course of one month. In a diary, you keep track of your headaches, and record information about how long each lasts, the location and intensity, what you did and ate before it came on, and whether it responded to treatment. This can be used to determine what triggers the migraines and what makes them better.

MIGRAINE TREATMENT — Treatment depends upon the frequency, severity, and symptoms of your migraines. Many people who experience regular migraines need both acute and preventive treatment:

●Acute treatment refers to medicines you can take when you have a migraine to relieve the pain immediately.

●Preventive treatment refers to medicines you can take on a regular (usually daily) basis to prevent migraines in the future.

Acute treatment — The pain of migraines can be tough to get rid of. Treatment is most likely to work if you take it at the first sign of an attack.

Some people consistently experience an aura before the migraine headache (see 'Aura' above). Therefore, an aura can serve as a reliable warning that a migraine headache is on the way, and should be the signal to take migraine medication. If you do not get an aura, it's best to take medication as soon as possible once the migraine headache begins.

Pain relievers — Mild migraine attacks may respond to pain relievers, some of which are available without a prescription. These include:

●Aspirin

●Acetaminophen (sample brand name: Tylenol)

●Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (sample brand names: Advil, Motrin), or naproxen (sample brand names: Aleve, Naprosyn)

One NSAID, indomethacin, is also available by prescription as a rectal suppository. This may be useful for people who have nausea during their migraines and cannot take oral medication.

Some pain relievers are also available in combination with caffeine, which makes them more effective against migraines. As an example, some pain relievers contain a combination of acetaminophen, aspirin, and caffeine (sample brand name: Excedrin).

Pain relievers are often recommended first for mild to moderate migraine attacks. However, they should not be used too often, as this can lead to medication-overuse headaches or chronic daily headaches. If your pain responds to a pain reliever, you can continue taking it with each attack, as long as you do not take it more than once or twice per week. (See 'Avoiding medication overuse headache' below.)

People with gastritis (inflammation of the stomach), ulcers, kidney disease, and bleeding conditions should not take products containing aspirin or NSAIDs.

Triptans — If a pain reliever does not control your headache, most health care providers will recommend a treatment that is migraine-specific (meaning it disrupts the mechanism through which migraines develop, rather than just targeting pain). This includes a class of medications called triptans. Examples include sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and frovatriptan.

Triptans can be prescribed for use at home, work, or school, and are all available in an oral (pill) form. Sumatriptan and zolmitriptan are also available as nasal sprays, and sumatriptan is available as an injection. Your health care provider can help you decide which medication and formulation is best for your situation. Triptans are typically limited to no more than nine days of use per month in order to avoid medication overuse headache. (See 'Avoiding medication overuse headache' below.)

People with certain health conditions should not take triptans in most cases. This includes pregnant people and people with hemiplegic migraine (a rare disorder in which headache is accompanied by muscle weakness on one side of the body), basilar migraine (another rare form of migraine), uncontrolled high blood pressure, or history of certain heart problems or stroke.

Common side effects of injectable sumatriptan include pain at the injection site, dizziness, a feeling of warmth, and tingling in the arms or legs. Most of these reactions occur soon after the injection and resolve within 30 minutes.

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.

A tablet that contains a combination of sumatriptan and naproxen (an NSAID) appears to be more effective than either medication taken alone.

Anti-nausea medications — If you have nausea and vomiting with a migraine, you may get an anti-nausea medication intravenously (through an IV) or by injection. These include metoclopramide and prochlorperazine. These are given in a hospital or clinic setting. Antinausea medications may also be taken by mouth and are usually used in combination with other medications to treat acute migraine.

CGRP antagonists — These medications aim to block the transmission of pain. Ubrogepant (brand name: Ubrelvy), rimegepant (brand name: Nurtec), and zavegepant (brand name: Zavzpret) are approved for the treatment of acute migraine. Side effects may include nausea, sleepiness, and dry mouth.

Other CGRP antagonists are sometimes used for preventing migraines. (See 'Preventive treatment' below.)

Lasmiditan — Lasmiditan (brand name: Reyvow) is a newer medication for migraine. It comes in tablet form. It may be an option for people who cannot take triptans (for example, because they have a history of heart disease or stroke). Side effects may include dizziness, tingling in the arms of legs, fatigue, and nausea. If you take lasmiditan, you should avoid driving (or operating other heavy machinery) for at least eight hours after each dose.

Ergots — Ergots are migraine-specific drugs, similar to triptans. They include:

●Dihydroergotamine – This medication can be taken as a nasal spray for mild or moderate migraine attacks. It can also be given intravenously (by IV) or as an injection for severe attacks. It is often given along with an anti-nausea medication. (See 'Anti-nausea medications' above.)

●Ergotamine – This medication is used less frequently, but is occasionally recommended for people with prolonged migraines (lasting more than 48 hours). It is available as a pill or rectal suppository, and is often combined with caffeine.

Ergots are not usually as effective as triptans and are more likely to cause side effects. People with high blood pressure, coronary artery disease, or kidney or liver disease should not use ergots. Ergots should not be used along with triptans or within 24 hours of using a triptan.

Dexamethasone — Dexamethasone is a glucocorticoid (steroid) medication that, when given along with another acute migraine treatment, can reduce the risk of recurrence. Dexamethasone may be given by IV or injection in a hospital or clinic.

Neuromodulation — Neuromodulation refers to devices that stimulate the brain and nervous system using magnetic waves or electric currents. They may be an option for people who prefer to avoid medication, cannot take medication, or have symptoms that do not respond to medication.

Several different neuromodulation devices are available by prescription for treating migraines. Some can be used at home, while others require going to a hospital or clinic.

Preventive treatment — Preventive treatment helps to reduce the frequency and severity of migraines in most people, although the benefits may not be evident for several weeks. Usually, your health care provider will start you off at a low dose and increase it gradually until you notice an effect.

Preventive treatment is typically recommended for people who have frequent, long-lasting, or very severe migraines. In some cases, both acute treatment and preventive treatment are necessary to adequately control migraines.

Lifestyle changes — It may help to change certain behaviors. For example, you can:

●Practice good "sleep hygiene" (set consistent bedtimes and wake times; sleep only as long as you need to feel rested; avoid caffeine, alcohol, and smoking before bed; do not look at your phone or other devices right before bed)

●Eat healthy meals around the same time each day

●Get regular exercise

●Avoid things that may trigger a migraine (see 'Migraine triggers' above)

Beta blockers — Beta blockers were originally developed to treat high blood pressure. In addition, beta blockers have been found to be effective in preventing migraines. Commonly used beta blockers include metoprolol, propranolol, and timolol. Beta blockers may cause depression in some people or impotence in males.

Antidepressant medications — Tricyclic antidepressants (TCAs) and certain other antidepressant medications are often recommended for migraine prevention. These include amitriptyline, nortriptyline, and doxepin. Of these, amitriptyline has proven benefit for migraine prevention, while there are less data for the other medications in this class.

Side effects are common with tricyclic antidepressants. Most of these medications 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 can include dry mouth, constipation, palpitations, weight gain, blurred vision, and urinary retention. Confusion can occur, particularly in older adults.

Anti-seizure medications — The anti-seizure (anticonvulsant) medications valproate (also called divalproex) and topiramate have been found to be effective in preventing migraines.

Both of these medications have side effects. Valproate can cause weight gain and hair loss. Topiramate can cause mild to moderate side effects that may include abnormal sensations (often tingling), fatigue, nausea, changes in taste, loss of appetite, diarrhea, and weight loss. More severe side effects can occur, including difficulty with thinking and concentration.

Anyone who is pregnant or could become pregnant should not take valproate or topiramate, as they can cause birth defects.

CGRP antagonists — These medications aim to block the transmission of pain; they are generally used in people who don't improve with standard preventive migraine medications such as beta-blockers, antidepressants, and anti-seizure medications. They include erenumab, fremanezumab, galcanezumab, and eptinezumab, which are all given by injection. Common side effects include a reaction at the injection site. Erenumab may also cause constipation, and eptinezumab may cause a stuffy nose or scratchy throat.

Rimegepant and atogepant are other examples of CGRP antagonists; these are oral (pill) medications.

Calcium channel blockers — Calcium channel blockers were developed to treat high blood pressure. Calcium channel blockers are widely used for migraine prevention. Examples of calcium channel blockers include verapamil and nifedipine extended release. 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.

Herbal therapies — Different herbs have been evaluated for the treatment of migraine, 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 and safety are still unproven. Neither treatment is recommended.

Botulinum toxin — Botulinum toxin type A (brand name: Botox) is a toxin produced by a bacteria that temporarily paralyzes muscles. There is some evidence that it may be helpful as a treatment for chronic migraine (usually defined as symptoms that happen for 15 days or more each month). However, other medications are typically used first in this situation. Botox has not been proven effective for acute migraines, nor as a preventive therapy for people who have less frequent migraines.

Avoiding medication overuse headache — It is essential to use anti-migraine medications according to your prescription and your provider's instructions. Overuse of certain medications for migraine, including over-the-counter drugs such as acetaminophen and NSAIDs, or prescription drugs such as triptans, can lead to medication-overuse headaches (also called rebound headaches). This is a repeating pattern of frequent headaches that require increasing quantities of drugs for relief. (See "Patient education: Headache treatment in adults (Beyond the Basics)".)

Let your health care provider know if your migraine treatment does not relieve your headaches or if you are having bothersome medication side effects. Switching to another medication or switching from acute treatment to preventive treatment may be helpful.

MENSTRUAL MIGRAINES — Menstrual migraines are migraines that occur around the beginning of the menstrual period (usually two days before to three days after the period begins). They 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.

People 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 an aura accompanies migraine at other times.

Treatment — Initial treatment of acute menstrual migraine is the same as treatment for migraine occurring at any other time. (See 'Acute treatment' above.)

Preventive therapies for menstrual migraine can be either nonspecific (those that do not address the hormonal trigger) or specific (hormone-based treatments).

With nonspecific strategies, success is dependent on being able to reliably predict; people with irregular menstrual cycles are not good candidates for these options. Coexisting issues, such as irregular periods, endometriosis, and birth control needs may influence choice of preventive therapy.

A preventive treatment may be useful for people who have menstrual migraines on a predictable schedule. Options include:

●Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen or naproxen (see 'Pain relievers' above)

●Triptans such as frovatriptan, sumatriptan, or naratriptan (see 'Triptans' above)

Hormonal treatments may be recommended to prevent menstrual migraines. One approach is to use estrogen-progestin birth control pills in an extended cycle; another choice is supplemental estrogen taken just before and during menstruation. These treatments work by preventing a rapid decline in the level of estrogen in the body before the menstrual period, which is believed to trigger the migraine.

If you get menstrual migraines, or migraines that otherwise seem triggered by hormonal changes, talk to your health care provider about your options for treatment and prevention.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Migraines in adults (The Basics)
Patient education: Headaches in adults (The Basics)
Patient education: Headaches in children (The Basics)
Patient education: Migraines in children (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Headache causes and diagnosis in adults (Beyond the Basics)
Patient education: Headache treatment in adults (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Acute treatment of migraine in adults
Migraine with brainstem aura
Chronic migraine
Estrogen-associated migraine headache, including menstrual migraine
Evaluation of headache in adults
Migraine-associated stroke: risk factors, diagnosis, and prevention
Preventive treatment of episodic migraine in adults

The following organizations also provide reliable health information.

●National Library of Medicine

     (https://medlineplus.gov/migraine.html, available in Spanish)

●National Institute of Neurological Disorders and Stroke

     (https://www.ninds.nih.gov/Disorders/All-Disorders/Migraine-Information-Page)

●American Headache Society

     (https://americanheadachesociety.org)

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ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Zahid H Bajwa, MD and R Joshua Wootton, MDiv, PhD, who contributed to earlier versions of this topic review.