Migraine: Overview and Risk Factors

Migraine headaches are common. Although not life-threatening, they are painful and debilitating: Each year migraines cause more than 150 million lost workdays and more than 300,000 lost school days in the United States alone.

In most cases, migraines begin gradually and occur on only one side of the head. The pain is usually described as "pulsating" or "throbbing." It usually lasts for several hours, and can sometimes last for days. Many migraine-sufferers say movement or activity worsens the headache, and they often prefer to lie still in a dark, quiet room until the headache goes away.

In addition, migraines are often associated with symptoms beyond the typical headache. These symptoms may include nausea, vomiting, photophobia (fear of light), phonophobia (fear of sound), and difficulty speaking.

Before the headache starts, some people experience unusual sensory experiences known as an aura. These may include visual changes (such as flashing lights or "zig-zag" lines), altered taste or smell, or tingling in the hands, tongue, or face. The aura may last for a few minutes or up to an hour, and the headache follows immediately afterwards.

Although doctors do not know exactly why migraines occur, there are several known triggers that can cause migraine attacks. These include stress, menstrual periods, overexertion, lack of sleep, fasting, bright lights, strong odors, changes in the weather, birth control pills, and certain food substances, such as dairy products, chocolate, eggs, or other foods (see Nutritional Considerations).

Risk Factors

• Genetics: Migraines tend to run in families.
• Gender: Women are affected about three times more often than men.

Diagnosis

Usually, the description of the headache is enough to make the diagnosis (i.e., where it hurts, how often it occurs, what triggers it), without any specialized tests.
In rare cases, a headache may be a sign of a more serious disorder. If one of the following “danger signs” occurs, a physician should be notified immediately:

• A sudden onset of a severe headache that feels like "the worst headache of your life."
• A severe headache that accompanies a fever or a stiff neck.
• A headache associated with confusion or loss of consciousness.
• A headache that occurs following head trauma.
• A headache that is associated with other neurologic symptoms, such as numbness of the arms or face, weakness, dizziness, difficulty walking, or disturbance of vision.

In such cases, further testing will be necessary, and may include blood tests, CT scan or MRI of the head, or lumbar puncture ("spinal tap").

Treatment

• Prevention is, by far, the best approach. It helps to avoid situations that trigger or exacerbate migraines (see below). It is also useful to maintain a regular sleep schedule and avoid spicy foods, alcohol, and caffeine in the four-hour period before bedtime.  Stress management can cut down on migraine frequency.
• Even minor exposures to triggers can cause a migraine attack. These include:
• Dietary triggers (see Nutritional Considerations)
• Sensory triggers: Bright or flickering lights, strong odors, and loud noises.
• Environmental triggers: Changes in the weather, seasonal changes, long-distance travel, and altitudes (e.g., plane flights).
• Lifestyle triggers: Stress, significant life changes (e.g., death of a loved one, divorce, job change, moving, and schedule changes), intense or irregular physical activity, dieting or fasting, abnormal sleeping patterns.
• Hormonal triggers: Menstrual period, ovulation, and hormone replacement therapy.
• Tylenol, aspirin, ibuprofen, and other over-the-counter pain medications are often effective, especially if used as soon as the migraine attack or aura begins. However, they should not be used too often. If these medications are being used regularly they can lead to a syndrome of daily headaches, and other side effects. Your doctor may prescribe a stronger medication to treat or prevent the headaches.
• If over-the-counter pain medications do not effectively treat the headache, your doctor may prescribe stronger medications. The most common are the triptan medicines (e.g., sumatriptan, rizatriptan, almotriptan, zolmatriptan). These drugs should be avoided during pregnancy.
• In people who have very frequent (more than four per month) or very severe migraines, a daily medication may be necessary to prevent future attacks.

Nutritional Considerations

In research studies, the most common dietary triggers are dairy products, chocolate, eggs, citrus fruits, meat, wheat, nuts, tomatoes, onions, corn, apples, and bananas. Certain beverages, such as alcohol (especially red wine) and caffeinated beverages, can also trigger migraines.

An elimination diet can be used to identify trigger foods: Start with a simple diet that includes only those foods that have not been associated with migraine, such as brown rice, cooked or dried fruits (cherries, cranberries, pears, prunes), cooked vegetables (artichokes, asparagus, broccoli, chard, collards, lettuce, spinach, string beans, squash, sweet potatoes, tapioca, and taro), plain or carbonated water, and condiments (modest amounts of salt, maple syrup, vanilla extract).

When migraines improve (usually within a week or so), add the eliminated foods back to the diet, one at a time, every other day, and keep a careful diary to observe which foods may be causing the migraines to occur.

When a food is found that seems to be associated with a migraine attack, it should be removed from the diet for at least one to two weeks and then reintroduced to see if the same reaction occurs.

For details on migraines and elimination diets, you may wish to consult Foods That Fight Pain, by Neal Barnard, M.D.

• Caffeine may improve migraines, or may be the cause of migraines. During a migraine attack, drinking one or two cups of strong black coffee may stop the attack. In regular caffeine users, slowly decreasing daily caffeine consumption may help prevent further attacks.
• Some evidence suggests that supplementation with riboflavin or magnesium may help prevent migraine attacks. Menstruating women are at increased risk for magnesium deficiency.
• Herbal therapies, such as feverfew and butterbur, have been shown to be effective in some individuals. However, further study is needed.