Migraine
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Authors: Harshika Satyarthi, MD, MPH; Aliya Frederick, MD, PhD
University of California San Diego

Reviewed: June 2021

SUMMARY

Migraine is a type of headache caused directly by a disorder of brain function. It is not caused by another medical problem, such as a brain injury or infection.  

Migraine disorder affects individual of all ages. Migraines are most common in those between the ages of 15-49 years, but can occur in young children as well. It is more common in women than men, especially after puberty. There are different types of migraine attacks. Treatment focuses on both acute relief from symptoms and long-term prevention of attacks. Diagnosis is made based on symptom history and clinical exam. Imaging is not required for diagnosis.  

Individuals can experience the pain and disability of migraine disorder over the course of their lives, however, with variation in frequency and severity. Overall, the outcome is good with treatment. There is no impact on mortality. 

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Disorder Overview

DESCRIPTION 

Common characteristics of migraine attacks include: 

Severity

Moderate to severe pain.

Location

Front, top or sides of head. Pain is usually on one side, but can occur on both sides in children.

Quality of pain

 Pounding, throbbing or pulsating.

Duration

Attacks can last 4 to 72 hours in adults. They are often shorter in length in young children, but can last more than 2 hours. 

Other symptoms

Migraines can involve either light and sound sensitivity and/or nausea, vomiting, and not wanting to eat. Children may have facial pallor in association with their migraines.  This symptom may occur prior to any complaints of headache pain. 

Migraine attacks are usually improved by rest and worsened by physical activity.  

Migraine attacks can be further divided into the following categories: 

Migraine without aura

Headache pain without other neurological symptoms. 

Migraine with aura

An aura is a reversible neurologic symptom that develops gradually over minutes. It is sensory, visual, motor, or speech-related symptom. It can begin before or at the start of the headache. Migraine with aura is possibly associated with aincreased risk of stroke

Hemiplegic migraine

A specific type of migraine with aura. This migraine can look like a stroke. It presents with one-sided weakness and/or numbness. It also presents with confusion and headache. However, unlike with stroke, the symptoms develop over minutes or hours. They do not begin all of a sudden. The family history is often significant for other family members having hemiplegic migraines. There are identified genes associated with hemiplegic migraines. 

Episodic migraine

Headaches that happen on fewer than 15 days per month. 

Chronic migraine

Headaches that happen on 15 or more days per month for more than 3 months. These headaches must have features of migraine for at least 8 of those headache days per month. 

Status migrainosus

A migraine headache that lasts for 72 hours or longer.

SIGNS AND SYMPTOMS

Phases of Migraine Headache 

A migraine attack starts gradually, over minutes to hours and can last for hours if untreated. It never happens suddenly. Usually, there are three phases that can be identified. The first is the pre-headache phase. The second is the headache phase. The third is the post-headache phase. If an aura is present, it usually takes place between the first and second phases. A useful chart of the phases of migraine can be found on the American Migraine Foundation website. 

1. Pre-headache (prodrome) phase.This phase can start almost 72 hours prior to the headache attackThis phase may be hard to recognizeSymptoms may carry through an aura phase and beyond. Most common symptoms include:

    • Changes in mood
    • Restlessness 
    • Fatigue 
    • Yawning Sensitivity to sound

2. Headache phase. Time during which actual head pain happens, with or without other symptoms.  

3. Post-headache (postdrome) phase: During the post-headache phase, individuals can feel tired, have trouble concentrating, or feel changes in mood. 

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Symptoms of Migraine Attacks 

Common symptoms experienced by persons with migraine disorder during an attack include: 

  • Pain in the head, behind the eyes, or in the neck 
  • Sensitivity to light 
  • Sensitivity to sound 
  • Nausea and/or vomiting 
  • Vision changes 
  • Dizziness 
  • Lightheadedness 
  • Scalp tenderness 
  • Difficulty concentrating 

 Individuals who experience migraine with aura can experience additional symptoms.

Migraine with aura symptoms can include: 

  • Weakness 
  • Numbness or tingling 
  • Speech difficulties 
  • Slurred speech 
  • Visual distortions 

Migraine can be diagnosed by a medical professional based on a history of symptoms and an exam. 

CAUSES

Migraine is one of the most common disorders in the world. It is also one of the most underdiagnosed disorders. Migraine disorder can affect people of all ages. However, it usually starts in the early teenage years. Some migraine attacks begin in young children. They may be briefer in duration and not associated with as many signs or symptoms as are typically seen.  

Migraine disorder often runs in families. The genes that cause inherited hemiplegic migraine have been identified. However, no other specific genes have been associated with migraines at this time. The underlying cause of migraines is still unclear.  

Environmental factors play a role. There are various aspects of a person’s daily life that can worsen headaches. These things can affect the frequency and duration of headaches. These factors are called migraine triggers.  

Below are common migraine attack triggers and how to avoid them: 

Sleep

It is important to get enough quality sleepRegular sleep-wake cycles can help. Regular bedtimes and waking times will help establish a good pattern. It is important to maintain these cycles even on the weekend. For children and teenagersaround 8 or 9 hours is usually needed. 

Hydration

Maintaining good hydration is important. Aim to drink plenty of water during the daytime. Increase water intake if active or sweating. A good general rule is to drink enough to need the restroom at least every 2 to 3 hours.

Food

It is important to eat regular meals every day. This includes breakfast, lunch, dinner, and snacks. Missing meals can trigger headaches for some people. Some are able to identify particular food triggers for headaches. Commonly reported food triggers include bananas, strawberries, chocolate, red wine, strongly flavored cheeses, processed meats, and foods with MSG. It is best to eat healthy food. Limit sugary foods and beverages.

Stress

Everyone has stress in life. It is a very common trigger. Learning to identify and manage stress is crucial. There are many ways to manage stress. They include:  

  • Time management 
  • Exercise 
  • Talking about stressors 
  • Breathing exercises 
  • Visualization 
  • Relaxation techniques 
  • Yoga 
  • Counseling 

Caffeine

Using caffeine on a regular basis can increase your risk for severe headaches when you don’t use it. This is due to your body becoming used to it. Try to avoid caffeine in general. However, the occasional soda or beverage with caffeine will not be harmful. For some people, caffeine can be helpful at the start of a headache. 

Posture

Poor posture can lead to more headaches. Good posture will help avoid excessive strain on many musclesIt can reduce strain on the neck, shoulders, and upper back. Be sure to avoid looking down too long. Screens, smart phones, and tablets can cause a person to look down too much. When using screens, reading, or doing homework, try to use a comfortable posture and take regular breaks.

Exercise

People who get regular exercise get fewer headaches. Aim to get at least 30 minutes of physical activity on at least three days per week. Find something that is active but enjoyable.

Heat and Sunlight

Hot weather can be a headache trigger for some people. Try to avoid long periods in hot weather. For some, bright lights or sunlight can bring on headaches. Wearing sunglasses and a hat with a brim can help. 

Migraine 1

LABORATORY INVESTIGATIONS 

Imaging and lab tests are rarely needed to diagnose migraine. However, these tests are sometimes still done. They can help ensure that headaches are not caused by another medical problem. 

A physical exam is typically normal for those with migraine. The exception is in some cases of migraine with aura. With aura, an exam may find temporary neurologic symptoms before or during a headache attack.   

TREATMENT AND THERAPIES 

There are many daily habits and lifestyle factors that can strongly influence headache burden. A child or teen, and their family, can work to manage these things. Many of them are listed above as headache attack triggers. Often, improving these areas alone can have a significant benefit. 

The type and duration of treatment is variable and depends on the needs of each person. Sometimes there is some trial and error to determine which treatments will work.   

Treatments for migraine attacks can be divided into three categories. The first is acute treatments. The second is preventative treatments. The third is treatments that may be used for both.  

Acute Treatments 

These are treatments that can stop a headache once it has already started.  

Medication Treatments

Medications work best when used at the start of the headache attack.

Over-the-counter medications should not be used more than twice in one week. If used too often, these medications can worsen headaches over time.

They include: 

  • Acetaminophen (without codeine preferred) 
  • Ibuprofen 
  • Naproxen 
  • Diclofenac 

Triptans are prescription medications used to treat migraine attacks. 

The most commonly prescribed for under 18 years of age are: 

  • Sumatriptan 
  • Rizatriptan 

Non-Medication Treatments

Non-medication techniques can be used in combination with medications. 

Options include: 

  • Rest 
  • Relaxation 
  • Distraction 
  • Application of a cool compress to area of discomfort 

Preventative Treatments 

These are medications or other therapies used on a regular schedule to prevent headache attacks and reduce the overall burden of headache. 

Preventative treatment options include the following: 

  • Natural supplements, such as riboflavin, magnesium, and coenzyme Q 
  • Antidepressants, such as amitriptyline and nortriptyline 
  • Anticonvulsants, such as topiramate and valproic acid 
  • Antihistamines, such as cyproheptadine 
  • Beta-blockers, such as propranolol 
  • Calcium channel blockers, such as verapamil 
  • Injectable calcitonin gene-related peptide (CGRP) inhibitors, such as eptinezumab, galcanezumab, fremanezumab, and erenumab 
  • Injections of onabotulinumtoxinA 

Other Treatments 

Treatments listed below can be used for both acute symptoms and prevention: 

  • Gepants, a class of medications which are CGRP inhibitors 
  • FDA-approved nerve stimulation devices 
  • Special nerve blockers called trigger point injections 

OUTLOOK

Migraine headache disorder does not result in death. However, migraine attacks can negatively impact quality of life. This is especially true for children or teens who experience frequent or severe migraines. Migraines can affect their work or school performance, mood, behavior, and relationships.

A study by the World Health Organization lists migraine as the third leading cause of disability in 15- to 49-year-olds. Headache accounts for more disability time in years than all other neurological disorders combined.

With proper support and treatment, a child with migraine disorder should have no difficulty performing well in school. Migraines do not affect development. They do not affect the ability to learn. If a child has frequent attacks, then it might be helpful to inform the school or teacher. This can help minimize triggers during the school day. For instance:

  • Allowing a child to carry a water and use the restroom frequently can prevent a dehydration trigger. 
  • Allowing the child to wear sunglasses while outside for recess can prevent a light trigger. 
  • Allowing a child to stay indoors on a very hot day can prevent a heat trigger. 
  • Allowing a child with migraines to access to timely treatment in the nurse’s office is important. 
  • Rest breaks can also help prevent migraine.  

It is entirely possible to function independently as an adult with migraine disorder. Some people with migraines do outgrow them as adults. However, there is always a risk that a migraine attack could be triggered in the right circumstances.

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Resources 

ORGANIZATIONS/GROUPS 

American Migraine Foundation
Working alongside the American Headache Society, the American Migraine Foundation’s mission is to mobilize a community for patient support and advocacy, as well as drive and support impactful research that translates into treatment advances for patients with migraine and other disabling diseases that cause severe head pain. The website includes a Pediatric Migraine Resources section which includes videos, articles, and podcasts.

AMF also hosts a private Facebook group, Move Against Migraine, with over 28,000 members.

Miles for Migraine
The mission of Miles for Migraine is to improve the lives of people with migraine and other headache disorders, and their families, by raising public awareness about this disease, and helping to find a cure. Miles for Migraine produces fun walk/run events, typically a 2-mile walk and 5K and 10K races to raise money for migraine research. They also host parent support programsteen supportyouth eventsand educational events for kids and teens impacted by migraine and other headache disorders. Miles for Migraine has a private Facebook group for parents or caregivers of a child with migraine or headache disorder.  

Coalition for Headache and Migraine Patients

The mission of the Coalition for Headache and Migraine Patients (CHAMP) is to improve the lives of people with migraine, cluster, and other headache diseases by aligning coalition organizations and empowering patient voices. Exploring treatment, navigating insurance options, and connecting with others can all be found on their website. For students, parents, and teachers learn about resources through the Migraine at School program.

National Headache Foundation
The mission of the National Headache Foundation is to further awareness of headache and migraine as legitimate neurobiological diseases. In support of that mission, the NHF looks to achieve these key goals:

  • Advocacy – Represent people living with headache disorders in efforts with the public, insurance providers, and governmental agencies.
  • Awareness – Increase public awareness regarding headache disorders and its impact on the individual, their families, and society.
  • Education – Serve as the premiere resource by providing information to patients, health care professionals, and the media.
  • Research – Support research into the potential causes of headache disorders and treatments.

Please see the Children’s Headache Disorders page and Pediatric Headache for information specific to children. The Migraine University page includes information for the causes of headache disorders in college students.

Danielle Byron Henry Migraine Foundation
The mission of Danielle Byron Henry Migraine Foundation is to raise awareness and provide support and access to treatment for those living with migraine disease, especially young adults and children. A new program, Migraine at School, is a collection of the best resources for students, parents, and educators.

Childhood Stroke 1

Child Neurology Foundation (CNF) solicits resources from the community to be included on this webpage through an application process. CNF reserves the right to remove entities at any time if information is deemed inappropriate or inconsistent with the mission, vision, and values of CNF. 

Research 

ClincalTrials.gov for migraine in children and adolescents are clinical trials that are recruiting or will be recruiting. Updates are made daily, so you are encouraged to check back frequently.  

ClinicalTrials.gov is a database of privately and publicly funded clinical studies conducted around the world. This is a resource provided by the U.S. National Library of Medicine (NLM), which is an institute within the National Institutes of Health (NIH). Listing a study does not mean it has been evaluated by the U.S. Federal Government. Please read the NLM disclaimer for details.  

Before participating in a study, you are encouraged to talk to your health care provider and learn about the risks and potential benefits. 

Family Stories 

Miles for Migraines shares advocacy stories from adults and children living with migraine on their blog pages. 

The information in the CNF Child Neurology Disorder Directory is not intended to provide diagnosis, treatment, or medical advice and should not be considered a substitute for advice from a healthcare professional. Content provided is for informational purposes only.  CNF is not responsible for actions taken based on the information included on this webpage. Please consult with a physician or other healthcare professional regarding any medical or health related diagnosis or treatment options. 

References

Migraine [Internet]. ICHD. 2019 [cited 2021Apr24]. Available from: https://ichd-3.org/1-migraine/  

Arruda MA, Arruda R, Guidetti V, Bigal ME. Psychosocial adjustment of children with migraine and tension-type headache: A nationwide study. Headache. 2015 Feb;55 Suppl 1:39-50. PMID: 25659227. https://doi.org/10.1111/head.12510  

GBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019 May;18(5):459-480. PMID: 30879893; PMCID: PMC6459001; https://doi.org/10.1016/s1474-4422(18)30499-x  

Goadsby PJ, Holland PR, Martins-Oliveira M, Hoffmann J, Schankin C, Akerman S. Pathophysiology of migraine: A disorder of sensory processing. Physiological Reviews. 2017;97(2):553–622. https://doi.org/10.1152/physrev.00034.2015  

Mohanty D, Lippmann S. CGRP Inhibitors for migraine. Innov Clin Neurosci. 2020 Apr 1;17(4-6):39-40. PMID: 32802591; PMCID: PMC7413335. 

Powers SW, Patton SR, Hommel KA, Hershey AD. Quality of life in childhood migraines: clinical impact and comparison to other chronic illnesses. Pediatrics. 2003 Jul;112: e1-5. PMID: 12837897; https://doi.org/10.1542/peds.112.1.e1  

Saylor D, Steiner TJ. The global burden of headache. Semin Neurol. 2018 Apr;38(2):182-190. PMID: 29791944; https://doi.org/10.1055/s-0038-1646946  

Scher AI, Launer LJ. Migraine: migraine with aura increases the risk of stroke. Nat Rev Neurol. 2010 Mar;6(3):128-9. PMID: 20212428; PMCID: PMC4540227; https://doi.org/10.1038/nrneurol.2010.14  

Spector JT, Kahn SR, Jones MR, Jayakumar M, Dalal D, Nazarian S. Migraine headache and ischemic stroke risk: An updated meta-analysis. The American Journal of Medicine. 2010;123(7):612–24. PMID: 20493462 PMCID: PMC2900472; https://doi.org/10.1016/j.amjmed.2009.12.021  

Steiner TJ, Stovner LJ, Vos T. GBD 2015: Migraine is the third cause of disability in under 50s. J Headache Pain. 2016 Dec;17(1):104. PMID: 27844455; PMCID: PMC5108738; https://doi.org/10.1186/s10194-016-0699-5  

Victor TW, Hu X, Campbell JC, Buse DC, Lipton RB. Migraine prevalence by age and sex in the United States: A life-span study. Cephalalgia. 2010 Sep;30(9):1065-72. PMID: 20713557; https://doi.org/10.1177/0333102409355601  

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