The Everything Guide To Migraines

This article was last updated on April 16, 2022

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If you’ve ever suffered from a migraine, you know how debilitating and downright awful it can be. If you haven’t, well, count yourself very lucky. According to the U.S. Department of Health and Human Services, 29.5 million Americans (or 12% of us) suffer from migraine pain and symptoms, with the majority of those sufferers being women.

Now here’s the really scary part: It’s not known exactly what causes migraines. According to Dr. Michael Cutrer, chair of the Division of Headache, Department of Neurology at the Mayo Clinic, we do know that migraineurs (the common term for migraine sufferers) carry one or more genetic variants that makes them more susceptible. However, we don’t know exactly what those variants are yet.

“When you have susceptibility to migraine, you have an unstable interface between the environment and that part of the nervous system that controls pain sensation in your head and neck,” he says. “Everyone has the equipment and structure needed to have a migraine. What differs is the threshold for activation is lower for those people [who are more susceptible].” And for what little we know about how migraines actually work, we know even less about the best way to treat them. Awesome.

The news isn’t all bleak, though, as there are some promising new drugs on the horizon — not to mention a wide variety of alternative treatments and supplements that have been shown to provide relief. Here, we break down the nitty gritty details on migraines, from what exactly they are, to common triggers and effective ways to manage the pain. Read on for the downlow on those headaches from hell.


So, What Exactly Is A Migraine?

While the basic symptom of a migraine — intense pain in your head — is the same as a headache, a few more qualifiers are needed in order to be categorized as such. According to Dr. Juline Bryson, attending neurologist at the Headache Institute at St. Luke’s-Roosevelt Hospital, you must have at least two out of the four following things in order for your headache to be considered a migraine: the pain must be unilateral and throbbing in nature, be of moderate to severe intensity (meaning it prevents you from functioning normally), is made worse with movement, and, most importantly, should last 4-72 hours and be associated with nausea or sensitivity to light and sound. It can also be accompanied by an aura (more on that later), and a sensitivity to certain smells. Dr. Bryson also notes that you are unable to call it a migraine until you have had five of them, in order to establish a pattern.

Unfortunately, it’s hard for those who have not suffered from a migraine to understand just how bad it actually is. As such, many non-sufferers don’t tend to take migraineurs’ attacks very seriously. “A headache hurts, but won’t stop you in your tracks,” explains Dr. Bryson. “A migraine, if you don’t treat it, you lose one to three days. Your life comes to a complete and utter halt. A headache means you might be achy until you take an aspirin. A migraine means you’re stuck alone in a dark room in horrific pain, unable to hear even the sound of your children’s voices or the TV — at the very best nauseous and the very worst vomiting uncontrollably. It’s really hard for people to understand just how catastrophic they feel.”


Probable Cause

As mentioned earlier by Dr. Cutrer, the exact genetic variants that cause migraines are unknown. There is fairly convincing evidence that migraines are passed down in certain families, and they’re linked to menstrual hormones in many women, but that isn’t the case across the board. In some women, the migraine attacks can occur independently of their menstrual flow. 

Dr. Bryson notes that in many of her patients, she sees the same personality type: “People who have migraines are extremely caring, emotional spenders that are happy to soak up everyone else’s negativity. They are very responsible, but they tend to pooh-pooh the pain.”

Think of a headache like a warning alarm generated by your nervous system to protect your brain. “The system that gives you a migraine headache is the same one that gives you a headache if had a tumor or bleeding in the brain,” says Dr. Cutrer. “The difference is that with a migraine, it is a false alarm. Migraineurs are genetically set up to repeatedly have activation of this headache alarm by things that don’t actually threaten the brain.” It’s basically warning you about a danger that’s not really there.


Trigger Happy

While the cause of a migraine is genetic, certain common environmental triggers can provoke an attack. Some are avoidable, but sadly, others are out of your control. One of the most common uncontrollable triggers is the weather — that’s right, Mother Nature really isconspiring against you. “Changes in the barometric pressure are a powerful trigger, specifically lower barometric pressure. My phone calls from patients go up when the weather pattern is unstable,” muses Dr. Cutrer.

Another uncontrollable trigger? Hormones. “Estrogen is inflammatory,” says Dr. Bryson. “It’s most inflammatory when it’s fluctuating, but its mere presence is inflammatory, which is why many women’s migraines begin at puberty — during their first period — and then get better after menopause.” Our bodies have a natural fluctuation of estrogen, which releases inflammation and can trigger headaches. That’s why, says Dr. Bryson, about two days before your period, you are more likely to get a migraine. Estrogen levels drop, and that same inflammation that can cause cramping will also trigger your head pain. There is one reprieve from the hormone roller coaster: pregnancy. Dr. Bryson says 80% of her patients notice a dramatic improvement in their migraines by the second or third trimester.

As far as controllable triggers go, Dr. Cutrer says things like stress, too much or too little sleep, exposure to glaring lights, strong smells or perfumes, and dips in your blood sugar (i.e. missing a meal) can all set off your warning system and cause a migraine.

The most important thing to remember is that triggers are cumulative. What sets you off one day might not have any effect on you the next. “They aren’t like an on or off light switch,” says Dr. Bryson. “People think, ‘Sometimes I can drink wine and it doesn’t give me a migraine, so red wine must not be a trigger,’ but if the barometric pressure is affecting them or hormone levels are fluctuating, it can trigger a migraine.” Adds Dr. Cutrer, “On a given day you have a threshold for what it takes to activate you. Maybe one of these things by itself doesn’t activate you, but a combination might.”


Diet Dilemmas

Ah, your diet. Along with being the culprit behind everything from intestinal issues toacne, turns out it can also be a huge migraine trigger. Foods like aged cheese, gluten, red wine, artificial sweeteners, preservatives, nitrates, walnuts, almonds, chocolate, MSG, and dried fruits have all been linked to migraines. 

Not every food will set every migraineur off, nor will it set you off every time, but these foods are a known quantity. So, if you’ve experienced issues with them in the past, it’s probably best to avoid the ones that have a history of triggering you. Dr. Cutrer does note that sometimes it’s not an instantaneous thing — a migraine may not manifest for a few hours, so keep that in mind while you are monitoring possible trigger foods.

Magnesium deficiency is another common lead-up to migraines, according to Meg Richichi, an integrative women’s health practitioner. “In my practice, anyone coming in with a headache, I take a look at their other symptoms. That usually leads me to believe that they are suffering from magnesium deficiency.” Richichi identifies these symptoms as PMS, constipation, irritability, insomnia, and muscle and neck tension. Plus, she says, when you are under stress, your body actually uses more magnesium, so it’s a vicious cycle.

However, she notes that it’s not a one-stop fix, because as previously noted, a migraine can be triggered by a variety of environmental issues. Richichi suggests you check with your doctor to see if you are deficient in magnesium. If so, she recommends patients start on a daily minimum of 400mg of magnesium citrate, although she has also put some of her clients on up to 300 mg, three times a day. Check with your health care provider to find your optimal dosage.


Righteous Aura, Bro

Over a quarter of people with migraine get transient neurological symptoms with some of their attacks. These symptoms are called migraine aura. Dr. Cutrer says there are four main types of auras: Visual, sensory, language disturbance, and hemiplegic. “Visual, the most common type, is when an area in the vision is first distorted and then you loose the image,” he says. This can manifest as zig-zagging lines, shimmery lights, or a halo; be present in one or both eyes; move across your visual field, and then turn into a blind spot. 

In a sensory aura, the second most common, patients will feel a wave of tingling or pins and needles down one side of their body. This could be up and down the arm, on the face, even inside the mouth. This is usually followed by a numbness in that area. 

The third most common type is a language disturbance, in which people make word mistakes and garble their sentences (similar to talking in tongues). Finally, the most rare is the hemiplegic migraine, otherwise known as unilateral paralysis.

Dr. Cutrer says all of these symptoms can last anywhere from five minutes to an hour. They can also occur in a sequence, or you can have more than one at once. People used to think that in order for you to have a migraine, you had to have an aura, but we now know that’s not true. “Two-thirds of the people who get migraines headaches do not get auras,” he says. Dr. Bryson notes that some women who suffer from migraines have to be extra-careful and cannot be on hormonal birth control — people who get auras are at a much higher risk for stroke, and estrogen can increase that risk.


Drug Deal

There are many drugs available on the market now specifically aimed at migraines, and a few that are aimed at treating other maladies, but that have proved effective in fighting migraines. There are two classes of medications: preventative, those that are aimed at reducing the frequency and severity of attacks; and avoidance, which look to shorten the duration of the migraine — over-the-counter pills like Excedrin Migraine or naproxen.

“The problem with those acute treatments are that they give you no protection from a headache the next day,” says Dr. Cutrer. They’re also not great for long-term use as they can cause some GI issues, and, if you use them too much, they can actually cause you to have more migraines. Because many of these drugs have caffeine in them, so they can give you withdrawal headaches. “Part of the withdrawal system from caffeine is a mild pressure-like headache, but in a migraineur that little pressure-like headache can cause a bigger headache — it’s like a blasting cap in a keg of dynamite,” he says. Anti-inflammatories like Advil or aspirin can provide relief for some, but not Tylenol, says Dr. Bryson, as that only really works on a fever, not a headache.

In the avoidance category you’ll find triptans like Immitrex, Relpax, and Axert, which are highly effective in most people and can often work even in severe migraine attacks. However, people with heart problems or uncontrolled hypertension should not take them. Anti-depressants, anti-convulsants, beta-blockers, calcium channel blockers, and some non-steroidals have also been found to provide relief in some people, when taken every day, by decreasing the severity and frequency of migraine attacks. Injectables like Ketorolac can be helpful to some, as can dihydroergotamine (DHE), but you need to go to the hospital to get an IV of that. Dr. Cutrer says he has high hopes for a forthcoming intranasal form of DHE, which will allow access to the drug without requiring a hospital visit. 

Surprisingly, another treatment is Botox. When injected into the hairline, it can help turn off those nerves that are too activated. “I was skeptical at first, but I started doing it because I see people at the Mayo Clinic who have been through 12 neurologists and have been told that they are crazy,” says Dr. Cutrer. “I want every arrow in the quiver that I can to help these people, so despite my skepticism, I tried injecting Botox in patients who had been unresponsive to all of the standard preventative treatments. Much to my surprise, about 60% of the people I gave the Botox to got better. Another good thing about Botox is that is has very few side effects — it does not cause sleepiness or weight gain like many of the anti-migraine treatments that are commonly used.” One thing to note with Botox: it can be very difficult to get your insurance company to cover it, so be prepared to do plenty of legwork to get your insurance on board.



One of the biggest issues migraineurs have is the toll that many of these prescription drugs take on their body. Patients may cycle through many different drugs without finding one that helps, and they wind up dealing with some pretty serious side effects. That’s why alternative therapies can be a practical option for those people who are sick of the drugs, or who have no desire to get on them. They can also be used in conjunction with a drug regimen to help control and manage pain.

Multiple recent studies have covered the pain relief benefits provided by acupuncture, and both Dr. Bryson and Richichi have seen positive effects from the treatment. “When I combine acupuncture with nutrition [makeovers] in my patients, I have really amazing results,” says Richichi. Adds Dr. Bryson, “Acupuncture can help a third of migraine sufferers, but I don’t believe it has anything to do with technique. As a needle penetrates the skin, it releases endorphins, which help with pain.”

Since many people complain of pain in their neck and shoulders, Richichi has her patients lie on their stomachs while she focuses on releasing trigger points in the upper neck, shoulders, and back. “I also insert points on the feet and hands to draw energy down and out of the head — we call this Rising Yang in Chinese medicine,” she says. While most acupuncture treatments have needles inserted for only 30-45 minutes, Richichi says she keeps needles in for migraine treatments for an hour, to help maximize benefits and provide optimal relief for muscles in spasm.

Certain exercises, such as light cardiovascular work or yoga (avoid Bikram, as Dr. Bryson says the dehydration could trigger a migraine), can all be beneficial in pain management. “Stretching really helps some people,” says Richichi. “Because their neck, back, and shoulder muscles are incredibly tight, stretching those areas can make a big difference.” For some at-home relief, she suggests you take a tennis ball, put it behind your back, and lean against a wall. Move your body so that the tennis ball rolls around the border of your scapula or between your scapula and spine to loosen up muscles in your upper back and both sides. Along those lines, chiropractors can also be a treatment option to look into, although Dr. Cutrer warns patients away from those practicians who audible crack necks — look for one that is willing to be gentle, so as not to risk serious damage to your body.

And, if prescription drugs aren’t your thing, there are some natural supplements that have a history of efficacy.”Petadolex, which is an extract of butterbur root, can be as effective as some prescription medicines,” says Dr. Bryson. “Just be sure you are getting the root — the leaves have been shown to cause toxicity.” She recommends finding a brand from Germany, as they are much more stringent with their control and testing of supplements than the U.S. is. She also suggests feverfew (although she notes that it can make some people’s headaches worse), B2 (otherwise known as riboflavin), and coenzyme Q10, although she does caution that there are not enough studies to back up the effects of vitamins on migraines.


The Bottom Line

While we have some clues as to migraine triggers and treatments, there’s still a long way to go before we can fully understand this disease. “Migraines are the red-headed stepchildren of research,” says Dr. Bryson. “There is just not much funding for us, and that prevents us from doing more studies and finding a better way to treat migraines. So, one of our biggest obstacles is that there are very few headache specialists and even less funding for research.” 

And, since doctors have no effective way of determining which medications will prove most effective, as every migraine is individual, they are left playing, as Dr. Cutrer calls it, an educated guessing game. “We’re still in the very early stages of treating this disease,” he says. “Our goal is to identify and find the variants that cause it, but we still have a lot of steps before that can happen. I’m hoping the tech that’s evolving in this decade can help us treat this more as a serious scientific thing that we can help rather than a casual ‘try this, try that.'”

Until that day comes, all three sources suggest that if you think you might be suffering from migraines, that you should keep a headache journal. Write down your sleep habits, what you eat, track your menstrual flow, and note any headaches that occur, making sure to note the duration of the pain and what kind of symptoms you are having. 

Once you have an accurate idea of if you are indeed suffering from migraines, get thee to the doctor. “Find a specialist, preferably one with a fellowship or who is boarded in headache medicine,” says Dr. Bryson. “You can’t just go to any neurologist and expect them to know exactly how to help. They are also treating M.S. and Parkinson’s — they can’t be perfect at everything.” Adds Dr. Cutrer, “The treatments we have are still imperfect, but at least a specialist will make sure you have different trials and combinations of therapies.” 

If you don’t live near a specialist or are unable to get to one, Dr. Cutrer suggests checking out the American Headache Society or theMigraine Research Foundation to arm yourself with information before you head to a doctor. Above all else, Dr. Cutrer says to be sure you avoid seeing a doctor who just prescribes you a pain pill and dismisses you — pain meds don’t help solve the underlying issue and will not help you manage your migraines. No doctor should ever make you feel like there’s something wrong with you, or that your symptoms aren’t valid. If yours does, find yourself another, more qualified and compassionate doctor, stat.

Above all else, don’t put yourself last or think that you are doomed to a life of chronic pain. “There’s no extra credit for needless suffering,” says Dr. Cutrer. “You’ve only got one life, and a migraine can make your life miserable and exhausting — you miss out on so much. So, try to find a resource that is in your reach and pursue it.”

Illustrated by Zhang Qingyun

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