Migraine

A migraine is usually a moderate or severe headache felt as a throbbing pain on one side of the head.

Many people also have symptoms such as nausea, vomiting and increased sensitivity to light or sound.

Migraine is a common health condition, affecting around one in every five women and around one in every 15 men. They usually begin in early adulthood.

There are several types of migraine, including:

• migraine with aura – where there are specific warning signs just before the migraine begins, such as seeing flashing lights
• migraine without aura – the most common type, where the migraine occurs without the specific warning signs
• migraine aura without headache, also known as silent migraine – where an aura or other migraine symptoms are experienced, but a headache doesn't develop

Some people have migraines frequently, up to several times a week. Other people only have a migraine occasionally. It's possible for years to pass between migraine attacks.

Read more about the symptoms of migraine

When to seek medical advice

You should see your GP if you have frequent or severe migraine symptoms.

Simple painkillers such as paracetamol or ibuprofen can be effective for migraine. However, be careful not to take too many painkillers as this could make it harder to treat headaches over time.

You should also make an appointment to see your GP if you have frequent migraines (on more than five days a month), even if they can be controlled with medication, as you may benefit from preventative treatment.

You should call 999 for an ambulance immediately if you or someone you're with experiences:

• paralysis or weakness in one or both arms and/or one side of the face
• slurred or garbled speech
• a sudden agonising headache resulting in a blinding pain unlike anything experienced before
• headache along with a high temperature (fever), stiff neck, mental confusion, seizures, double vision and a rash

These symptoms may be a sign of a more serious condition, such as a stroke or meningitis, and should be assessed by a doctor as soon as possible.

Read more about diagnosing migraines

Causes of migraines

The exact cause of migraines is unknown, although they're thought to be the result of temporary changes in the chemicals, nerves and blood vessels in the brain.

Around half of all people who experience migraines also have a close relative with the condition, suggesting that genes may play a role.

Some people find migraine attacks are associated with certain triggers, which can include:

• starting their period
• stress
• tiredness
• certain foods or drinks

Read more about the causes of migraines

Treating migraines

There's no cure for migraines, but a number of treatments are available to help reduce the symptoms.

These include:

• painkillers – including over-the-counter medications such as paracetamol and ibuprofen
• triptans – medications that can help reverse the changes in the brain that may cause migraines
• anti-emetics – medications often used to reduce nausea and vomiting

During an attack, many people find that sleeping or lying in a darkened room can also help.

Read more about treating migraines

Preventing migraines

If you suspect a specific trigger is causing your migraines, such as stress or a certain type of food, avoiding this trigger may help reduce your risk of experiencing migraines.

It may also help to maintain a generally healthy lifestyle, including regular exercise, sleep and meals, as well as ensuring you stay well hydrated and limiting your intake of caffeine and alcohol.

If your migraines are severe or you've tried avoiding possible triggers and are still experiencing symptoms, your GP may prescribe medication to help prevent further attacks.

Medications used to prevent migraines include the anti-seizure medication topiramate and a medication called propranolol that's usually used to treat high blood pressure. It may take several weeks before your migraine symptoms begin to improve.

Read more about preventing migraines

Outlook

Migraines can severely affect your quality of life and stop you carrying out your normal daily activities. Some people find they need to stay in bed for days at a time.

However, a number of effective treatments are available to reduce the symptoms and prevent further attacks.

Migraine attacks can sometimes get worse over time, but they tend to gradually improve over many years for most people.

The main symptom of a migraine is usually an intense headache on one side of the head.

The pain is usually a moderate or severe throbbing sensation that gets worse when you move and prevents you from carrying out normal activities.

In some cases, the pain can occur on both sides of your head and may affect your face or neck.

Additional symptoms

Other symptoms commonly associated with a migraine include:

• nausea
• vomiting
• increased sensitivity to light and sound – which is why many people with a migraine want to rest in a quiet, dark room

Some people also occasionally experience other symptoms, including:

• sweating
• poor concentration,
• feeling very hot or very cold
• abdominal (tummy) pain
• diarrhoea

Not everyone with a migraine experiences these additional symptoms and some people may experience them without having a headache.

The symptoms of a migraine usually last between four hours and three days, although you may feel very tired for up to a week afterwards.

Symptoms of aura

About one in three people with migraines have temporary warning symptoms, known as aura, before a migraine. These include:

• visual problems – such as seeing flashing lights, zig-zag patterns or blind spots
• numbness or a tingling sensation like pins and needles – which usually starts in one hand and moves up your arm before affecting your face, lips and tongue
• feeling dizzy or off balance
• difficulty speaking
• loss of consciousness – although this is unusual

Aura symptoms typically develop over the course of about five minutes and last for up to an hour. Some people may experience aura followed by only a mild headache or no headache at all.

When to seek medical advice

You should see your GP if you have frequent or severe migraine symptoms that can't be managed with occasional use of over-the-counter painkillers, such as paracetamol.

However, be careful not to take too many painkillers as this could make it harder to treat headaches over time.

You should also make an appointment to see your GP if you have frequent migraines (on more than five days a month), even if they can be controlled with medication, as you may benefit from preventative treatment.

You should call 999 for an ambulance immediately if you or someone you're with experiences:

• paralysis or weakness in one or both arms and/or one side of the face
• slurred or garbled speech
• a sudden agonising headache resulting in a blinding pain unlike anything experienced before
• headache along with a high temperature (fever), stiff neck, mental confusion, seizures, double vision, and a rash

These symptoms may be a sign of a more serious condition, such as a stroke or meningitis, and should be assessed by a doctor as soon as possible.

Read more about diagnosing migraines

The exact cause of migraines is unknown, but they're thought to be the result of abnormal brain activity temporarily affecting nerve signals, chemicals and blood vessels in the brain.

It's not clear what causes this change in brain activity, but it's possible that your genes make you more likely to experience migraines as a result of a specific trigger.

Migraine triggers

Many possible migraine triggers have been suggested, including hormonal, emotional, physical, dietary, environmental and medicinal factors.

These triggers are very individual but it may help to keep a diary to see if you can identify a consistent trigger. It can also sometimes be difficult to tell if something is really a trigger or if what you're experiencing is an early symptom of a migraine attack.

Hormonal changes

Some women experience migraines around the time of their period, possibly because of changes in the levels of hormones such as oestrogen around this time.

These type of migraines usually occur between two days before the start of your period to three days after. Some women only experience migraines around this time, which is known as pure menstrual migraine. However, most women experience them at other times too and this is called menstrual related migraine.

Many women find their migraines improve after the menopause, although the menopause can trigger migraines or make them worse in some women.

Emotional triggers:

• stress
• anxiety
• tension
• shock
• depression
• excitement

Physical triggers:

• tiredness
• poor quality sleep
• shift work
• poor posture
• neck or shoulder tension
• jet lag
• low blood sugar (hypoglycaemia)
• strenuous exercise, if you're not used to it

Dietary triggers:

• missed, delayed or irregular meals
• dehydration
• alcohol
• the food additive tyramine
• caffeine products, such as tea and coffee
• specific foods such as chocolate, citrus fruit and cheese

Environmental triggers:

• bright lights
• flickering screens, such as a television or computer screen
• smoking (or smoky rooms)
• loud noises
• changes in climate, such as changes in humidity or very cold temperatures
• strong smells
• a stuffy atmosphere

Medication:

• some types of sleeping tablets
• the combined contraceptive pill
• hormone replacement therapy (HRT), which is sometimes used to relieve symptoms associated with the menopause 

There's no specific test to diagnose migraines. For an accurate diagnosis to be made, your GP must identify a pattern of recurring headaches along with the associated symptoms.

Migraines can be unpredictable, sometimes occurring without the other symptoms. Obtaining an accurate diagnosis can sometimes take time.

Seeing your GP

On your first visit, your GP may carry out a physical examination and check your vision, co-ordination, reflexes and sensations. These will help rule out some other possible underlying causes of your symptoms.

Your GP may ask if your headaches are:

• on one side of the head
• a pulsating pain
• severe enough to prevent you carrying out daily activities
• made worse by physical activity or moving about
• accompanied by nausea and vomiting
• accompanied by sensitivity to light and noise

Migraine diary

To help with the diagnosis, it can be useful to keep a diary of your migraine attacks for a few weeks. Note down details including:

• the date
• time
• what you were doing when the migraine began
• how long the attack lasted
• what symptoms you experienced
• what medication you took (if any)

Taking too many painkillers is an important reason why migraines can become difficult to treat. This is called analgesic overuse headache.

It will be very helpful to keep a record of what painkillers you take and how often you take them. You shouldn't take painkillers on more than 10 days every month in the long-term.

It may also be helpful for women to make a note when they start their period, as this can help your GP identify potential triggers.

Read more about keeping a migraine diary on The Migraine Trust website

Referral to a specialist

Your GP may decide to refer you to a neurologist (a specialist in conditions affecting the brain and nervous system) for further assessment and treatment if: 

• a diagnosis is unclear
• you experience migraines on 15 days or more per month (chronic migraine)
• treatment isn't helping to control your symptoms

There's currently no cure for migraines, although a number of treatments are available to help ease the symptoms.

It may take time to work out the best treatment for you. You may need to try different types or combinations of medicines before you find the most effective ones.

If you find you can't manage your migraines using over-the-counter medicines, your GP may prescribe something stronger.

During an attack

Most people find that sleeping or lying in a darkened room is the best thing to do when having a migraine attack.

Others find that eating something helps, or they start to feel better once they've been sick.

Painkillers

Many people who have migraines find that over-the-counter painkillers, such as paracetamol, aspirin and ibuprofen, can help to reduce their symptoms.

They tend to be most effective if taken at the first signs of a migraine attack, as this gives them time to absorb into your bloodstream and ease your symptoms.

It's not advisable to wait until the headache worsens before taking painkillers as it's often too late for the medication to work. Soluble painkillers (tablets you dissolve in a glass of water) are a good alternative because they're absorbed quickly by your body.

If you can't swallow painkillers because of nausea or vomiting, suppositories may be a better option. These are capsules that are inserted into the anus (back passage).

Cautions

When taking over-the-counter painkillers, always make sure you read the instructions on the packaging and follow the dosage recommendations.

Children under 16 shouldn't take aspirin unless it's under the guidance of a healthcare professional. Aspirin and ibuprofen are also not recommended for adults who have a history of stomach problems, such as stomach ulcers, liver problems or kidney problems.

Taking any form of painkiller frequently can make migraines worse. This is sometimes called "medication overuse headache" or "painkiller headache".

Speak to your GP if you find yourself needing to use painkillers repeatedly or if over-the-counter painkillers aren't effective. Your GP may prescribe stronger painkillers or recommend using painkillers along with triptans (see below). If they suspect the frequent use of painkillers may be contributing your headaches, they may recommended that you stop using them.

Triptans

If ordinary painkillers aren't helping to relieve your migraine symptoms, you should make an appointment to see your GP. They may recommend taking painkillers in addition to a type of medication called a triptan and possibly anti-sickness medication (see below).

Triptan medicines are a specific painkiller for migraine headaches. They're thought to work by reversing the changes in the brain that may cause migraine headaches.

They cause the blood vessels around the brain to contract (narrow). This reverses the dilating (widening) of blood vessels that's believed to be part of the migraine process.

Triptans are available as tablets, injections and nasal sprays.

Common side effects of triptans include:

• warm-sensations
• tightness
• tingling
• flushing
• feelings of heaviness in the face, limbs or chest

Some people also experience nausea, dry mouth and drowsiness. These side effects are usually mild and improve on their own.

As with other painkillers, taking too many triptans can lead to medication overuse headache.

Your GP will usually recommend having a follow-up appointment once you've finished your first course of treatment with triptans. This is so you can discuss their effectiveness and whether you had any side effects.

If the medication was helpful, treatment will usually be continued. If they weren't effective or caused unpleasant side effects, your GP may try prescribing a different type of triptan since responses can be highly variable.

Anti-sickness medicines

Anti-sickness medicines, known as anti-emetics, can successfully treat migraine in some people even if you don't experience nausea or vomiting. These are prescribed by your GP and can be taken alongside painkillers and triptans.

As with painkillers, anti-sickness medicines work better if taken as soon as your migraine symptoms begin. They usually come in the form of a tablet, but are also available as a suppository.

Side effects of anti-emetics include drowsiness and diarrhoea.

Combination medicines

You can buy a number of combination medicines for migraine without a prescription at your local pharmacy. These medicines contain both painkillers and anti-sickness medicines. If you're not sure which one is best for you, ask your pharmacist.

It can also be very effective to combine a triptan with another painkiller, such as ibuprofen.

Many people find combination medicines convenient. However, the dose of painkillers or anti-sickness medicine may not be high enough to relieve your symptoms. If this is the case, it may be better to take painkillers and anti-sickness medicines separately. This allows you to easily control the doses of each.

Seeing a specialist

If the treatments above aren't effectively controlling your migraines, your GP may refer you to a specialist migraine clinic for further investigation and treatment.

In addition to the medications mentioned above, a specialist may recommend other treatments such as transcranial magnetic stimulation.

Transcranial magnetic stimulation

In January 2014, the National Institute for Health and Care Excellence (NICE) approved the use of a treatment called transcranial magnetic stimulation (TMS) for the treatment and prevention of migraines.

TMS involves holding a small electrical device to your head that delivers magnetic pulses through your skin. It's not clear exactly how TMS works in treating migraines, but studies have shown that using it at the start of a migraine can reduce its severity. It can also be used in combination with the medications mentioned above without interfering with them.

However, TMS isn't a cure for migraines and it doesn’t work for everyone. The evidence for its effectiveness isn't strong and is limited to people who have migraine with aura.

There's also little evidence about the potential long-term effects of the treatment, although studies into the treatment have so far only reported minor and temporary side effects, including:

• slight dizziness
• drowsiness and tiredness
• a muscle tremor that can make it difficult to stand
• irritability

NICE recommends that TMS should only be provided by headache specialists in specialist centres, because of the uncertainty about the potential long-term side effects. The specialist will keep a record of your experiences using the treatment.

Treatment for pregnant and breastfeeding women

In general, migraine treatment with medicines should be limited as much as possible when you're pregnant or breastfeeding. Instead, trying to identify and avoid potential migraine triggers is often recommended.

If medication is essential, then your GP may prescribe you a low-dose painkiller, such as paracetamol. In some cases, anti-inflammatory drugs or triptans may be prescribed. Speak to your GP or midwife before taking medication when you are pregnant or breastfeeding.

Migraines are associated with a small increased risk of ischaemic strokes, and a very small increased risk of mental health problems.

Stroke

An ischaemic stroke occurs when the blood supply to the brain is blocked by a blood clot or fatty material in the arteries.

Studies have shown that people who experience migraines (particularly migraine with aura) have about twice the risk of having an ischaemic stroke at some point compared to people without migraines. However, this risk is still small.

It is unclear why ischaemic strokes are linked to migraine.

Contraceptive pill

The risk of having an ischaemic stroke is increased by the use of the combined contraceptive pill. Medical professionals generally advise women who experience migraine with aura not to use the combined contraceptive pill.

Women who have migraine without aura can usually take the combined contraceptive pill safely, unless they have other stroke risk factors such as high blood pressure or a family history of cardiovascular disease.

If you take the combined contraceptive pill and you experience aura symptoms, talk to your GP about alternative forms of contraception.

Mental health problems

Migraine is associated with a very small increased risk of mental health problems, including:

• depression
• bipolar disorder
• anxiety disorder
• panic disorder

There are a number of ways you can reduce your chances of experiencing migraines.

Identifying and avoiding triggers

One of the best ways of preventing migraines is recognising the things that trigger an attack and trying to avoid them. 

You may find you tend to have a migraine after eating certain foods or when you're stressed and by avoiding this trigger, you can prevent a migraine. Read more about possible migraine triggers.

Keeping a migraine diary can help you identify possible triggers and monitor how well any medication you're taking is working.

In your migraine diary, try to record:

• the date of the attack
• the time of day the attack began
• any warning signs
• your symptoms (including the presence or absence of aura)
• what medication you took
• when the attack ended

Medication and supplements

Medication is also available to help prevent migraines. These medicines are usually used if you've tried avoiding possible triggers but you're still experiencing migraines.

You may also be prescribed these medicines if you experience very severe migraine attacks, or if your attacks happen frequently.

Some of the main medications used to prevent migraines are outlined below.

Topiramate

Topiramate is a type of medication originally developed to prevent seizures in people with epilepsy, but is now much more commonly used in migraine. It's been shown to help prevent migraines and is usually taken every day in tablet form.

Topiramate should be used with caution in people with kidney or liver problems. It can also harm an unborn baby if taken during pregnancy and can reduce the effectiveness of hormonal contraceptives, so your GP should discuss alternative methods of contraception with women who are prescribed topiramate.

Side effects of topiramate can include:

• decreased appetite
• nausea
• vomiting,
• constipation or diarrhoea
• dizziness
• drowsiness
• problems sleeping

Propranolol

Propranolol is a medication traditionally used to treat angina and high blood pressure, but it's also been shown to effectively prevent migraines. It's usually taken every day in tablet form.

Propranolol is unsuitable for people with asthma, chronic obstructive pulmonary disease (COPD) and some heart problems. It should be used with caution in people with diabetes.

Side effects of propranolol can include:

• cold hands and feet
• pins and needles
• problems sleeping
• tiredness

Botulinum toxin type A

In June 2012, NICE recommended the use of a medication called botulinum toxin type A by headache specialists to prevent headaches in some adults with chronic (long-term) migraine.

Botulinum toxin type A is a type of neurotoxin (nerve toxin) that paralyses muscles. It's not exactly clear why this treatment can be effective for migraine.

NICE recommends that this treatment can be considered as an option for people who have chronic migraine (headaches on at least 15 days of every month, at least eight days of which are migraine) that hasn't responded to at least three previous preventative medical treatments.

Under the NICE guidelines, botulinum toxin type A should be given by injection to between 31 and 39 sites around the head and back of the neck. A new course of treatment can be administered every 12 weeks.

Preventing menstrual-related migraines

Menstrual-related migraines usually occur between two days before the start of your period to three days after. As these migraines are relatively predictable, it may be possible to prevent them using either non-hormonal or hormonal treatments.

Non-hormonal treatments

The non-hormonal treatments that are recommended are:

• non-steroidal anti-inflammatory drugs (NSAIDs) – a common type of painkiller
• triptans – medicines that reverse the widening (dilation) of blood vessels, which is thought to be a contributory factor in migraines

These medications are taken as tablets two to four times a day from either the start of your period or two days before, until the last day of bleeding.

Hormonal treatments

Hormonal treatments that may be recommended include:

• combined hormonal contraceptives, such as the combined contraceptive pill, patch or vaginal ring
• progesterone-only contraceptives, such as progesterone-only pills, implants or injections
• oestrogen patches or gels, which can be used from three days before the start of your period and continued for seven days

Hormonal contraceptives aren't usually used to prevent menstrual-related migraines in women who experience aura symptoms because this can increase your risk of having a stroke. Read about the complications of migraines for more information about this.

Acupuncture

If medication is unsuitable, or it doesn't help to prevent migraines, you may want to consider acupuncture.

NICE states that a course of up to 10 sessions over a five to eight week period may be beneficial.