Migraine Pain Guide

Migraine

Migraines are part of a group of conditions called Chronic Overlapping Pain Conditions (COPCs). These are long-lasting pain conditions that often occur together in the same person. In simple terms, this means someone may live with more than one type of chronic pain at the same time.

These conditions are called “overlapping” because they share common features:

• Pain lasts for months or years
• The pain may be widespread or affect different parts of the body
• Tests and scans often look normal, even though the pain is very real

Many experts believe COPCs are linked to how the nervous system processes pain. Instead of pain coming only from injured tissues, the brain and nerves become extra sensitive, amplifying pain signals. This can make everyday sensations feel painful and cause symptoms such as fatigue, poor sleep, headaches, and difficulty concentrating (“brain fog”).

Living with chronic overlapping pain conditions can be frustrating, especially when symptoms don’t fit neatly into one diagnosis. Treatment often focuses on improving sleep, calming the nervous system, managing pain, and supporting overall quality of life—rather than treating just one body part.

Most importantly, COPCs are real medical conditions, and people who live with them are not imagining their symptoms. With the right care and support, many patients can find ways to reduce symptoms and improve daily functioning.

What are Migraines?

Migraine is a neurovascular brain disorder affecting about 13% of people. Migraines are more than just really bad headaches. They are a collection of neurological symptoms that include severe throbbing pain, often on one side of the head, and can include nausea, vomiting, dizziness, visual disturbances, tingling or numbness in the extremities or face, and sensitivity to light, sound, smell, and touch.

What causes Migraines?

The exact causes of migraines are still unknown. It used to be thought that the dilation and constriction of blood vessels in the head were the primary cause of migraine pain. Therefore, early medicine focused on the blood vessels. It is now believed that migraines are caused by nerve pathways and brain chemicals.

There is growing evidence that migraines are hereditary. Individuals with a family history of migraines are at increased risk of having migraines. This genetic tendency for migraines results in a brain that is extra sensitive to stimuli that triggers a series of neurological events, such as abnormal firing of neurons, altered blood flow, and changes in levels of neurochemicals. Triggers vary greatly by person and over time.

Potential triggers include:

• Foods: alcohol, caffeine, chocolate, nitrates (found in processed meats like hot dogs and deli meat), artificial sweeteners, and monosodium glutamate or MSG (found in processed foods, canned foods, or Asian foods)
• Lifestyle: eye strain (especially from staring at a computer or TV for long periods of time), fatigue or lack of sleep, stress, dehydration, lack of physical activity, smoking, physical posture (e.g. sleeping in an unusual position, or sitting at a desk for a long time)
• Infection: cold, flu, or sinus infections
• Environmental: weather changes, allergens, bright or flickering lights, high altitudes, strong odors, and tobacco smoke
• Hormone fluctuations from menstruation, ovulation, menopause, pregnancy, birth control pills, and hormone replacement therapy

Types of Migraines:

The two major types of migraine are migraine without aura and migraine with aura. Aura is defined as neurological changes that occur prior to head pain. Aura symptoms may serve as warning signs for a headache. Aura symptoms tend to grow or spread gradually, usually lasting a few minutes to one hour (see below for more information on aura).

Here are some of the sub-types of migraines:

Migraine without aura (“common migraine”)

• Symptoms include pulsing or throbbing pain most often on one side of the head, nausea, vomiting, light and sound sensitivity, and pain that is made worse by physical activity.
• Lacks the warning phases (prodrome and aura)

Migraine with aura (“complicated migraine”, or “classic or classical migraine”)

• Headache is preceded by aura symptoms
• Occurs in about 25% of people with migraines
• Aura involves sensory changes, such as seeing flashing lights, zig zag lights, numbness, or vertigo. Please see below for more information on aura.

Migraine without head pain (“typical aura without headache”)

• Also called a Silent or Acephalgic Migraine.
• Aura symptoms are present without headache.

Hemiplegic Migraine:

• This type of migraine feels more like a stroke.
• People with this migraine develop weakness on one side of the body.
• Other common symptoms include the sensation of “pins and needles”, visual aura, and loss of sensation on one side of the body.
• May not include severe head pain.

Retinal Migraine:

• Temporary loss of vision in one eye.
• Most common in women during childbearing years.
• The blindness can last for as short as one minute to as long as months.
• There is little understanding about retinal migraine but it may be a sign of a more serious issue.

Chronic Migraine:

• More than 15 days a month with migraine.
• Symptoms and their severity may vary greatly on any given day.

What are the Phases of Migraine?

Prodromal Phase:

• Occurs hours or 1–2 days before the onset of head pain

• Symptoms may include:

  • Fatigue
  • Nausea
  • Blurred vision
  • Difficulty concentrating
  • Neck stiffness
  • Sensitivity to light and/or sound
  • Excessive yawning
  • Paleness

Aura Phase (not always present):

• Symptoms last a few minutes to one hour.

• Symptoms vary and may include:

  • Visual:

    • Occurs in over 90% of patients with migraine with aura
    • Zig zag lines or lights
    • Spots of flickering light
    • Blurred vision

  • Body sensations:

    • Pins and needles
    • Numbness, often in the hands and face

  • Cognitive, speech, language:

    • Often, people feel like they are not thinking clearly

    • Less frequently, people describe difficulty with written and spoken words

      • This may be difficulty in understanding what others are saying, putting words together, and/or processing written words
      • Some people may have slurred or garbled speech

  • Vertigo (a feeling of being off balance and dizziness)

  • Tinnitus (ringing or buzzing in the ear)

Headache Phase:

• Typically, throbbing pain on one side of the head. However, people can have pain on both sides of the head and without throbbing.
• Other common symptoms include nausea, vomiting, and sensitivity to light and sound.
• Without treatment, the headache may continue for up to 72 hours.

Postdromal Phase:

• Postdromal symptoms may occur after the headache and last for up to 48 hours.

• Also called the “migraine hangover”.

• There is less understanding of the Postdromal Phase.

• Symptoms may include:

  • Fatigue
  • Elated mood
  • Depressed mood
  • Achiness
  • Mental fogginess
  • Acute pain after coughing and sudden movements

Diagnosis:

Migraine is diagnosed by taking a careful assessment of the symptoms, reviewing family history, conducting medical tests, and eliminating other possible causes of the headache. Testing may include imaging from CT or MRI. Use of a headache diary can be a helpful tool for diagnosis and to better understand the frequency and severity of attacks, triggers, and responses to treatments.

Who treats Migraines?

Migraines are often treated by primary care or family medicine physicians and neurologists. Mental health providers trained in pain and headache treatments are often included in treatment and focus on techniques for managing pain, increasing quality of life, improving lifestyle behaviors that trigger or worsen symptoms, and decreasing stress.

Treatment of Migraines:

Although there is no current cure for migraines, there are treatments that help with preventing and managing symptoms. There is ongoing research on new migraine treatments (see American Migraine Foundation for more information).

• Short-term medications are used at the onset of migraine to try to stop a migraine once it has started or to decrease the symptoms. They are not used to prevent migraine, and are generally not useful for other types of pain, unless it is associated with migraine headache.

• Preventative medication focuses on reducing migraine frequency and severity. Several types of medications are approved to prevent migraines, and they work in different ways:

  • Anticonvulsants, also used to prevent seizures, such as valproic acid (e.g. Depakote) or topiramate (e.g. Topamax)
  • Botulinum toxin (Botox): periodic injections into the face and scalp.
  • Beta-blockers, which relax blood vessels, such as propranolol (e.g. Inderal) or metoprolol (e.g. Lopressor)
  • Calcium-channel blockers, which reduce the constriction of blood vessels, such as verapamil (e.g. Verelan) or diltiazem (e.g. Cardizem)

• Opioids are not recommended as a treatment for migraine due to lack of efficacy for migraines, their side effects, potential for dependence, and possible overdose death.

• It is important to use medications only as directed and not overuse medicine as this might lead to overuse (medication rebound) headaches and unwanted side effects.

• Non-medication preventative treatments include:

  • Trigger avoidance
  • Cognitive behavioral therapy
  • Biofeedback
  • Mindfulness-based therapy
  • Relaxation techniques
  • Behavioral therapy
  • Anti-inflammatory diet

• There are many new treatments currently being studied for migraines. For example, Cefaly® is a new non-drug and non-invasive treatment for migraines. Cefaly® is a device that is temporarily placed on the forehead and sends micro-impulses to the trigeminal nerve to relieve pain and prevent future migraines.

ADDITIONAL RESOURCES

American Migraine Foundation

• What Type of Headache Do I Have?
• The Science of Migraine – How to Deal With Postdrome
• What to Know About the New Anti CGRP Migraine Treatment Options
• Integrative and Complementary Migraine Treatments

Headache Classification Committee of the International Headache Society (HIS). 2013. The international classification of headache disorders, (beta version). Cephalalgia. 33:629–808. DOI: 10.1177/0333102413485658

International Headache Society