Migraine: Triggers, Treatment and When a Headache Is Something Else
Migraine affects a large share of adults, most often women between their twenties and forties, and is consistently under-diagnosed. It is not a severe tension headache. It is a neurological disorder in which the brain becomes temporarily hypersensitive to light, sound, smell and movement.
What a migraine attack looks like
A typical attack has four possible phases, though not everyone experiences all of them.
- Prodrome, hours to a day before: yawning, mood change, food cravings, neck stiffness, difficulty concentrating
- Aura, in about a quarter of people: visual zigzags, blind spots, tingling spreading up an arm, or difficulty finding words, usually lasting 5-60 minutes
- Headache: often one-sided, throbbing, moderate to severe, worsened by movement, lasting 4 to 72 hours, with nausea and sensitivity to light and sound
- Postdrome: a day of feeling drained and slow
The features that most reliably separate migraine from tension headache are nausea, light sensitivity, and the fact that routine activity makes it worse.
Common triggers
Triggers vary between people and often need to combine before an attack starts.
- Missed meals and dehydration
- Irregular sleep, including sleeping in on weekends
- Stress, and often the let-down after stress rather than the stress itself
- Menstrual cycle hormone changes
- Bright or flickering light, loud noise, strong smells
- Alcohol, particularly red wine
- Excess caffeine, and equally caffeine withdrawal
- Weather and pressure changes
Food triggers are real but less common than popular lists suggest. A headache diary for six to eight weeks is more useful than eliminating foods on speculation.
Treating an attack
Speed matters more than strength. Treatment taken within the first 20-30 minutes works far better than the same drug taken two hours in.
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- Simple analgesics: paracetamol or an NSAID such as ibuprofen or naproxen at an adequate dose
- Triptans: sumatriptan, rizatriptan and others are migraine-specific and effective for moderate to severe attacks. They are not painkillers; they act on the migraine mechanism itself.
- Anti-nausea medication: domperidone or metoclopramide both relieve nausea and improve absorption of the other drug
- Dark, quiet room and sleep, which genuinely shortens attacks
Triptans should be avoided in uncontrolled hypertension, coronary artery disease and previous stroke.
Medication overuse headache
This is the most important pitfall. Taking acute painkillers on more than 10-15 days a month turns episodic migraine into daily headache. The headache then becomes driven by the treatment. The way out is withdrawal of the overused drug under medical supervision, plus preventive treatment.
Prevention
Preventive treatment is considered when attacks occur on four or more days a month, or fewer if they are disabling.
- Beta blockers such as propranolol
- Amitriptyline, especially where sleep is also disturbed
- Topiramate or sodium valproate, the latter avoided in women who could become pregnant
- Flunarizine, widely used in India
- CGRP monoclonal antibodies, a newer and highly effective class where older drugs fail
- Magnesium, riboflavin and coenzyme Q10 have modest but real supporting evidence
Prevention is judged over two to three months, and success is defined as roughly halving attack frequency, not eliminating migraine.
Non-drug measures that help
- Regular sleep and wake times, seven days a week
- Regular meals, not skipping breakfast
- Consistent hydration
- Aerobic exercise three times a week
- Limiting caffeine to a steady, modest amount rather than swinging between extremes
When a headache needs urgent assessment
Some headaches are not migraine. Seek medical attention urgently for:
- A sudden, severe headache reaching maximum intensity within a minute
- Headache with fever, neck stiffness or rash
- Headache with confusion, weakness, numbness, slurred speech or visual loss
- New headache after age 50
- Headache that is worse on lying down, coughing or straining
- Headache after a head injury
- A clear change in the pattern of a long-standing headache
- Headache in pregnancy with high blood pressure or swelling
This article is general health information. Migraine treatment should be chosen with a doctor, particularly before starting preventive medication.