Migraine

Migraines normally involve a severe type of headache, often accompanied by other symptoms like nausea, sensitivity to light and sound, and visual disturbances. Migraine headaches differ from normal headaches because the pain is severe and can stop you from going about normal daily life while they happen.

The causes of migraines are not well understood, but people can sometimes identify and avoid their migraine triggers to reduce the frequency of migraine attacks. There are treatments to relieve the pain and symptoms of migraines, which you take when a migraine starts. There are also preventative treatments which you would typically take every day.

Not all migraines are the same. Migraine without aura is the most common type of migraine, involving a severe headache and other symptoms. A migraine with aura starts with warning signs ranging from visual disturbances to physical changes like pins and needles. Some people experience the migraine aura without a headache, known as silent migraine.

Migraine symptoms

A migraine without aura is the most common type of migraine. Symptoms can differ, but the main characteristic is a severe headache, worse than a ‘normal’ headache. Common symptoms of migraine include:

Pulsating or throbbing pain, often on one side of the head, but sometimes both.
Headache that often worsens with physical activity.
Pain that gradually gets worse, rising to a peak.
Feeling and or being sick.
Sensitivity to light and or sound.

Other symptoms of migraine include:

Stomach pain
Diarrhoea
Sweating
Feeling hot or cold
Inability to concentrate

Some people get a migraine headache without the other symptoms.

People who experience migraine with aura typically share the symptoms above but also get warning signs of an oncoming migraine, known as an aura. This type of migraine is less common than migraine without aura. Aura symptoms can include:

Visual aura - tends to affect one side of your vision and can include temporary partial vision loss, seeing bright flashing lights, and zig-zag lines.
Physical aura - numbness and pins and needles starting in your hand and travelling up the arm to the face, lips and tongue. Speech problems can also occur.

Other types of migraine aura include food cravings, experiencing a strange smell, and different strange feelings.

Migraines often come in stages:

A pre-headache stage (called prodrome) in which your mood, energy and appetite can be affected.
Aura with visual disturbances or other changes that act as a warning sign.
Headache, a throbbing pain often accompanied by a range of other symptoms.
Resolution (or postdrome) when the migraine pain and symptoms like nausea subside, but you may feel wiped out and need rest.

Migraines affect children and adults and are more common in women than men (Source: NICE). The frequency of migraines varies. Some people with chronic migraines have them frequently, and others get them from time to time (episodic migraine).

Migraines with aura are a risk factor for ischaemic stroke, but the overall risk is still low (Source: American Journal of Medicine). Other factors can increase the risk of stroke, including taking the combined contraceptive pill, so if you have suffered from migraine with aura, you will generally be advised against taking the pill.

Some symptoms that resemble a migraine attack can be the sign of a medical condition such as stroke or meningitis. If you or someone you’re responsible for has the following symptoms, call 999: Weakness or paralysis in the arms or on one side of the face; slurred speech; an excruciating headache, worse than ever before; headache accompanied by rash, fever, stiff neck, seizures, and double vision.

How long do migraines last for?

Migraines can last from four to 72 hours (Source: NICE), so they can be very disruptive, especially if you frequently have them. By getting to know your migraines, you can spot the signs and take medicine early to prevent a full migraine attack, limiting the severity and length of time you’re affected.

Migraine causes

The exact causes of migraines aren’t well understood, but scientists believe they may be due to changes in brain chemicals, nerves, and blood vessels. The reasons for these changes aren’t clear, but in the case of menstrual migraine, it’s thought changing levels of the hormone oestrogen are the cause.

You’re more likely to get migraines if there is a family history of them, pointing to the possibility of a genetic factor. Women are more likely to have migraines than men as the hormones involved in menstruation and menopause can play a role in migraines.

If you repeatedly get migraines, it’s worth keeping a migraine diary. You can note the timing and symptoms of migraine attacks and what happened in the lead-up. This can help you identify your migraine triggers. Triggers can vary in different people, and there are lots of possible triggers that can prompt migraines:

Hormones - some people experience migraines around the time of their period. If you only have migraines at this time, you may have menstrual migraine. Hormonal changes during menopause can also trigger migraines.
Emotions - stress, anxiety, shock, and depression can all be migraine triggers.
Physical changes - being tired, sleep-deprived, jet-lagged, and having low blood sugar, are all potential physical triggers for migraine.
Diet - as well as irregular meals and dehydration, particular food and drinks can trigger migraines for some people. Triggers include alcohol and caffeine, foods such as chocolate, citrus, and some cheeses. Other dietary triggers include foods with tyramine (cured meats, yeast extract, pickled and smoked fish) and foods with monosodium glutamate (MSG).
Environment - spending time in bright light, in front of a flickering screen, in a smoky or noisy place, changes in the climate, strong scents and stuffy rooms can all be potential triggers.
Medication - some medicines can trigger migraines in people, including sleeping tablets, contraceptive pills, and HRT (hormone replacement therapy).

Migraine treatment

There are different treatments for migraine relief, and it can help to combine some of them. Speak to your GP if over-the-counter medicines don’t work for you or if your migraine attacks are frequent (more than five a month). Your GP can make a diagnosis of migraine based on your symptoms and may be able to offer preventative treatments (see below).

Most migraine treatments cannot be used at all, or should be used sparingly, while pregnant or breastfeeding. Speak to your GP or midwife for advice, and limit your migraine triggers as much as possible.

Paracetamol, ibuprofen, or aspirin can help relieve migraine pain. The best time to take painkillers is at the start of a migraine, giving them time to work before the pain is too severe. Soluble painkillers enter the bloodstream faster than tablets and are a better option for some people. Children under 12 should not take aspirin.

It’s best not to regularly take the maximum dose of painkillers, as they can become less effective over time and potentially lead to medication overuse headaches.
Triptans are an alternative to painkillers that can ease migraine symptoms. They work by narrowing the blood vessels in the brain, as they are thought to widen during migraines. You take this medicine when a headache is developing. If your migraines are menstrual-related, you may get triptan to take from the start of your period or a few days before until it ends.

There are different triptan medicines. You might try more than one before finding the type that works for you. Sumatriptan is available from pharmacists without a prescription, but only if a doctor has already diagnosed you.

Triptans are unsuitable for children and have side effects, including tingling, flushing, a heavy feeling in the face, limbs and chest, nausea and dry mouth. These side effects are usually mild and tend to get better.
Medicine that relieves nausea (known as anti-emetics) can relieve the sickness that often accompanies migraines. Some of these are available for children. Even if you don’t experience nausea with your migraines, they can sometimes relieve migraine symptoms. You take these tablets as soon as you notice symptoms beginning.
Your GP may refer you to a specialist or migraine clinic for chronic migraines. They can offer treatments not available through your GP. For example, transcranial magnetic stimulation (TMS) can be used to treat migraine with aura. It uses a small electrical device held to your head which sends magnetic pulses through the skin (Source: NHS). This treatment is only used under specialist supervision because the long-term side effects aren’t yet known.

Ocular migraine

Ocular migraine, also known as retinal migraine, involves temporary partial or total vision loss in one eye. Retinal migraine symptoms may include a headache but not necessarily. Your vision goes back to normal after an ocular migraine. A healthcare professional should check any sudden vision change or vision loss, especially if you’ve never experienced ocular migraines before.

Migraine aura

Less common than migraine without aura, this type of migraine involves warning signs that a migraine is coming. Migraine aura symptoms can include:

Visual disturbances include flashing lights, blind spots, and shapes like zig-zags.
A numb sensation like pins and needles, usually in one hand travelling up the arm and face.
Speech and concentration problems.

Symptoms typically last up to an hour before the migraine headache starts.

Cluster headaches

Cluster headaches are excruciating and one-sided and often felt around the eye. They may happen every day, in bouts lasting several weeks or months at a time (typically four to 12 weeks), before they subside. They are rare and more common in men and may start in the 30s or 40s. (Source: NHS). Specialist treatment is often required.

Migraine prevention

One way to prevent migraines is to identify and avoid your migraine triggers. By keeping a migraine diary, you might be able to pinpoint what triggers lead to migraine attacks. Knowing your triggers can allow you to make lifestyle changes to reduce the frequency of your migraines. Many people have found the following approaches can help:

Keeping regular mealtimes
Staying hydrated and avoiding caffeine and alcohol
Including exercise as part of your routine
Getting enough sleep

The demands of daily life might make it hard, but if you can identify and gradually start managing your triggers, you could begin to feel the benefits.

If managing your migraine triggers doesn’t help, there are prevention medications. You normally take preventative treatments every day instead of at the start of a migraine. These include:

Propranolol - a beta-blocker medicine used to treat high blood pressure, which can prevent migraines. Propranolol isn’t suitable for people with heart problems, COPD, and asthma. Side effects include cold hands and feet, pins and needles, and sleep problems.
Anticonvulsant medications such as topiramate - originally an epilepsy medication, now often used to prevent migraines. You shouldn’t take this while pregnant, and it can stop hormonal contraceptives from working properly. It can bring side effects such as feeling or being sick, constipation, diarrhoea, drowsiness, sleep problems and reduced appetite.
Botulinum toxin type A (botox) - chronic migraine sufferers for whom other treatments haven’t worked may be offered botox under the care of a specialist. Botox is injected into specific muscles in the head and neck muscles.
Amitriptyline - this antidepressant, although not licensed for treating migraines, is sometimes given by medics.
Monoclonal antibodies - this treatment is given by injection every month or few months if you have severe migraines and at least three other preventative treatments have been unsuccessful.

Frequently asked questions

The pain of a migraine is often much worse than other headache pain such as sinus or tension headaches. Migraine attacks commonly have other symptoms as well as head pain such as feeling or being sick, being sensitive to light and noise, and sometimes starting with an aura which can be visual disturbances or other changes.
A migraine differs from other types of headache in being more painful, with a pulsating or throbbing pain and is often one-sided. It can feel quite intolerable and often comes with other symptoms like feeling or being sick and being sensitive to noise and light. Many people must stop their daily activities to rest in a dark room until they recover.

Conclusion

Migraines are common, and for many people, they only occur occasionally. It’s possible to treat migraine with non-prescription painkillers and prevent them if you spot and avoid your migraine triggers. Chronic migraines are harder to live with, and if you get regular severe migraine attacks, your GP may be able to prescribe preventative treatments or refer you to a specialist for more support. Migraines can cause quite dramatic visual disturbances and changes. If you notice a sudden loss of vision and haven’t previously been diagnosed with ocular migraines, get urgent medical help.

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Medically reviewed by: The Royal College of Ophthalmologists on 22/08/2022

Edited by: Nick Astbury FRCS FRCOphth FRCP
Clinical Associate Professor
LSHTM

The Royal College of Ophthalmologists champions excellence in the practice of ophthalmology and is the only professional membership body for medically qualified ophthalmologists. The RCOphth is unable to offer direct advice to patients. If you’re concerned about the health of your eyes, you should seek medical advice from your GP, optometrist or ophthalmologist.