Migraine
Also called: Migraine with aura, Migraine without aura
A common brain disorder causing recurrent attacks of throbbing, often one-sided headache with nausea and sensitivity to light and sound, sometimes preceded by visual or sensory aura.
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About 1 billion people; three times more common in women.
What happens in the body
A hyperexcitable brain; cortical spreading depression causes aura, and activation of the trigeminovascular system releases CGRP, producing pain and inflammation around meningeal vessels.
Causes
- Genetic predisposition with environmental triggers
Risk factors
- Family history
- Female sex and hormonal changes
- Triggers: sleep change, stress, missed meals, dehydration, alcohol, bright light, menstruation
Symptoms
- Moderate–severe throbbing headache lasting 4–72 hours
- Nausea or vomiting
- Sensitivity to light and noise
- Aura: zig-zag lines, blind spots, tingling or speech disturbance lasting under an hour
Diagnosis — tests and examinations
- Clinical history (ICHD criteria)
- Headache diary
- Brain imaging only for red-flag features
Treatment
Medicines and medical treatment
- Acute: aspirin, ibuprofen or paracetamol with an anti-emetic; triptans (sumatriptan, rizatriptan)
- Gepants (rimegepant, ubrogepant) or lasmiditan when triptans fail
- Prevention: propranolol, topiramate, amitriptyline, candesartan
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) or atogepant for frequent migraine
- Botulinum toxin for chronic migraine
Operations and procedures
- Nerve blocks and neuromodulation devices in selected patients
Self-care, home remedies and lifestyle
- Regular sleep, meals and hydration
- Identify and avoid triggers
- Limit painkillers to fewer than 10–15 days a month to avoid medication-overuse headache
- Regular exercise and stress management
Possible complications
- Medication-overuse headache
- Chronic migraine
- Slightly increased stroke risk with aura (especially with smoking and oestrogen pill)
Prevention
- Preventive medication and lifestyle regularity
Outlook
Often improves with age and effective treatment.
When to see a doctor
Seek urgent care for a sudden 'worst ever' headache, headache with fever and stiff neck, new neurological symptoms, or a new headache after 50.
Sources and further reading
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