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Top 10 Questions About Migraine Headache – JournalFeed Health

Written by Clay Smith

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Migraine headache is a common and disabling neurological condition.  This post will help you better understand what a migraine is, why it happens, and how you can best treat a migraine headache at home and prevent migraines from happening altogether.

What is migraine headache?

Migraine headache is a specific type of headache syndrome that is usually one-sided, throbbing, and made worse with physical activity, even something as minor as walking up a flight of stairs.  Migraines are often accompanied by nausea, vomiting, light and sound sensitivity. Migraine headaches are second only to tension headache as the most common neurological disorder.  They are three times more common in females than males.  Migraines tend to peak between the ages of 35-39 years and usually improve after age 50. There is often a family history of migraine headache. Up to 7% of school-age children have migraine. Migraine is common, with up to 15% of the population affected; that’s 1 billion people worldwide1!

Why do migraine headaches happen?

The trigeminal nerve (the fifth cranial nerve) is largely a sensory nerve.  The sense of touch or pain on the face is transmitted via the trigeminal nerve.  It also provides sensation for the linings of the brain (meninges) and the blood vessels in the brain. It is not known exactly what triggers migraines, but when the trigeminal nerve pain fibers are stimulated, there is a complex release of chemical messengers that causes blood vessel dilation and promotes inflammation.  Researchers have learned what some of these vasoactive peptides are and have been able to design custom medications to block some of these pain pathways.

What about migraine triggers?

Many people seem to have migraine triggers, such as poor sleep, stress, fasting, heat, exercise, or certain trigger-foods.  However, when 27 patients who reported bright light stimulation and exercise as triggers, just 3 of them had migraine when intentional exposed to their reported trigger2.  Much attention has been focused on certain foods or drinks as migraine triggers, but a recent rigorous meta-analysis did not find high-quality evidence (randomized controlled trials) to support or refute potential trigger foods or drinks3. Although some patients may find that consistent triggers exist for them, the link between migraine triggers and onset of migraine headaches is less clear than was previously thought.

What is a migraine aura?

Some people have migraine with aura.  The aura may manifest as visual symptoms (lights or shapes that may be sparkling or scintillating), numbness or tingling of a part of the body, trouble speaking or understanding speech (that could even mimic stroke), vertigo (spinning sensation), or spots out of the vision of one eye (scotoma).  The aura is not present in all migraine sufferers.  It seems to occur because of a wave of neuronal firing across the cortex of the brain followed by decreased blood flow in those areas1.  Sometimes an aura will precede a migraine, but not every aura is always followed by a migraine headache.  A word of caution, some migraine aura symptoms can be indistinguishable from stoke.  If you develop these symptoms, do not delay seeking emergency care.

What are some red flags that might indicate other, more serious headache conditions?

Sudden onset, severe, near maximal-onset headache, also called “thunderclap headache,” could indicate a very serious headache syndrome. In addition, the presence of fever, confusion, stiff neck, seizure, disorientation, excessive irritability or sleepiness are all concerning and may indicate more dangerous headache syndromes. If you have any question about your headache, please talk to your doctor or seek immediate medical care.

What are the best medications to treat adults with acute migraine headaches?

A 2024 meta-analysis included a huge number of studies, 137 randomized controlled trials, with a total of almost 90,000 adult patients.  They found that when the “triptan” drugs were compared head-to-head, eletriptan was the most effective drug for pain relief at two hours. Then in descending order: rizatriptan, sumatriptan, and zolmitriptan were also effective. For sustained pain relief at 24 hours, eletriptan and ibuprofen were the best4. In general, most people will have relief with either triptans or non-steroidal anti-inflammatory drugs (NSAIDs) – like ibuprofen or naproxen.  Patients who cannot use NSAIDs can use acetaminophen, but it is not as effective for migraine-related pain.  There are two newer drug classes that were custom designed to combat the complex mix of chemical messengers released in migraine.  The first is calcitonin gene-related peptide (CGRP) receptor antagonists, a group of drugs called the gepants; next are the 5-hydroxytryptamine type 1F (5-HT1F) receptor agonists, called ditans. Example drugs are rimegepant, ubrogepant, and lasmiditan. These are second-line after triptans and NSAIDs, as they are less effective. However, in patients who cannot take triptans or NSAIDs, such as patients with poorly controlled hypertension, heart disease, prior stroke, or other health issues that would make NSAIDs unsafe, the gepants of ditans are an option.  Lasmiditan can be sedating or cause a feeling of dizziness, so driving or operating machinery is not advised1,4.

What are the best medications to treat children or adolescents with acute migraine headaches?

Ibuprofen (10mg/kg; maximum dose 600mg) is first line for children and adolescents. Next are oral triptans or a combination of sumatriptan plus naproxen1,5. Talk to your child’s pediatrician or primary care physician.

What are the best preventive migraine headache treatments for children and adolescents?

For some children or adolescents with frequent migraine (variably defined but more than 2-4 migraine episodes per month), preventive medication may be an option to reduce the frequency, intensity, or duration of headaches.  Several randomized controlled trials have shown inconclusive benefit for preventive medication in children. However, a recent compilation of trials found two drugs were effective for prevention in reducing headache frequency: topiramate and pregabalin6. Other single trials have found benefit for various medications to prevent migraine, but more research is needed to make firmer recommendations. There are some additional, common-sense recommendations for children and teens in another systematic review as well, such as modifying lifestyle to ensure adequate sleep, hydration, and nutrition and avoidance of medication overuse, especially over-the-counter medications for pain7.

What are the best preventive migraine headache treatments for adults?

For adult patients with frequent migraine, prevention may also be helpful. The best evidence favors use of topiramate or other medications, like beta-blockers, amitriptyline, valproate, and – less so – gabapentin8.  All of these may help but are often poorly tolerated due to side effects, such as sedation. A newer class of drugs, monoclonal antibodies against the CGRP receptor or against CGRP (erenumab, fremanezumab, galcanezumab, and eptinezumab) has been shown to be effective, with fewer side effects.  The gepants can also be used in a preventive role1,8.  With all these medications, patient must weigh side effects and cost. Other treatments, such as occipital nerve blocks or botulinum-toxin may also be used alone or in combination with other therapies. Several of the listed medications may be associated with very high out-of-pocket cost, and this should be discussed with your physician or other healthcare provider. Special care must be taken in pregnant women, as some of these agents are associated with an increased risk of birth defects9.  So, preventive medication in pregnancy must be discussed with your healthcare provider.

What are the non-pharmacologic migraine headache treatment options?

It’s not only medication that can prevent or treat migraine. There are a host of migraine hacks that can be found with an internet search, most of which have only anecdotal evidence for their use.  The non-drug treatments which have been rigorously studied – and are effective – are listed here.

  • Exercise: Moderate intensity exercise reduces migraine duration and frequency in a meta-analysis of 28 different studies 10.  Another large meta-analysis of 21 clinical trials found that strength training and high-intensity exercise were the most effective for reducing migraine frequency11.
  • Yoga: A meta-analysis of six randomized controlled trials among patients with mixed headache type – tension headache or migraine headache – found yoga reduced headache frequency, duration, and intensity12.  Also, yoga was included as one of the exercise regimens mentioned above that specifically reduced migraine headache frequency and intensity10.
  • Acupuncture: For acute migraine, there is very low-certainty evidence that acupuncture, compared to sham acupuncture, reduces pain – but it does not appear to reduce pain more than medication13. For migraine prevention, there is good evidence that acupuncture reduced headache frequency better than no treatment, better than sham acupuncture, and better than preventive medication14.  Although different from acupuncture, dry needling was not found to be effective for migraine, though for other headache types, there was weak, low-quality evidence that it may improve short-term disability15.
  • Spinal Manipulation: There was significant improvement in pain and reduction in number of migraine days in patients who received spinal manipulation. However, most studies were are higher risk of bias, as the primary outcome was self-reported via headache diary, and patients cannot be blinded to the intervention16.  In addition, cervical spine manipulation is not without risk of arterial dissection17, and only two included studies explicitly reported on adverse events16.
  • Coenzyme Q10: Although a supplement may be considered as a pharmacological agent, we will consider it here as an alternative therapy. Coenzyme Q10 reduced the duration and frequency of migraine attacks compared to placebo in this meta-analysis of six randomized controlled trials, with no increase in adverse effects18.

Wrap Up

Migraine headache is common and negatively impacts quality of life.  Those who regularly exercise, get adequate sleep, and eat a healthy diet usually have fewer migraine episodes. When migraines happen, there are effective treatments to improve the acute pain for children and adults.  Some, with more frequent migraine episodes, may benefit from preventive medication.  However, there are a growing number of non-pharmacologic options, with good evidence for their use, that can reduce the burden of migraine headaches.

Works Cited

  1. Ashina M. Migraine. Ropper AH, editor. New England Journal of Medicine [Internet]. 2020 Nov 5;383(19):1866–1876. Available from: http://www.nejm.org/doi/10.1056/NEJMra1915327
  2. Hougaard A, Amin F, Hauge AW, Ashina M, Olesen J. Provocation of migraine with aura using natural trigger factors. Neurology [Internet]. Neurology; 2013 Jan 29 [cited 2024 Nov 17];80(5):428–431. Available from: https://pubmed.ncbi.nlm.nih.gov/23345632/ PMID: 23345632
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  4. Karlsson WK, Ostinelli EG, Zhuang ZA, Kokoti L, Christensen RH, Al-Khazali HM, Deligianni CI, Tomlinson A, Ashina H, Ruiz de la Torre E, Diener HC, Cipriani A, Ashina M. Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis. BMJ [Internet]. 2024 Sep 18;e080107. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj-2024-080107
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  8. Lampl C, MaassenVanDenBrink A, Deligianni CI, Gil-Gouveia R, Jassal T, Sanchez-del-Rio M, Reuter U, Uluduz D, Versijpt J, Zeraatkar D, Sacco S. The comparative effectiveness of migraine preventive drugs: a systematic review and network meta-analysis. Journal of Headache and Pain. BioMed Central Ltd; 2023 Dec 1;24(1). PMID: 37208596
  9. Puledda F, Sacco S, Diener HC, Ashina M, Al-Khazali HM, Ashina S, Burstein R, Liebler E, Cipriani A, Chu MK, Cocores A, Dodd-Glover F, Ekizoğlu E, Garcia-Azorin D, Göbel CH, Goicochea MT, Hassan A, Hirata K, Hoffmann J, Jenkins B, Kamm K, Lee MJ, Ling YH, Lisicki M, Martinelli D, Monteith TS, Ornello R, Özge A, Peres MFP, Pozo-Rosich P, Romanenko V, Schwedt TJ, Souza MNP, Takizawa T, Terwindt GM, Thuraiaiyah J, Togha M, Vandenbussche N, Wang SJ, Yu S, Tassorelli C. International Headache Society Global Practice Recommendations for Preventive Pharmacological Treatment of Migraine. Cephalalgia [Internet]. 2024 Sep 11;44(9). Available from: https://journals.sagepub.com/doi/10.1177/03331024241269735
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  15. Pourahmadi M, Dommerholt J, Fernández-De-Las-Peñas C, Koes BW, Mohseni-Bandpei MA, Mansournia MA, Delavari S, Keshtkar A, Bahramian M. Dry Needling for the Treatment of Tension-Type, Cervicogenic, or Migraine Headaches: A Systematic Review and Meta-Analysis. Physical Therapy. Oxford University Press; 2021. PMID: 33609358
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