Migraine

Overview

Migraine is a neurological condition in which recurring attacks of head pain are accompanied by a range of other symptoms. These include nausea, sensitivity to light and sound, and, in some people, temporary visual or sensory disturbances. It is far more than a bad headache. An attack is a whole-body event driven by changes in how the brain processes pain, sensory input and certain chemical signals, and it can interfere with work, family life and ordinary daily activity.

Migraine is common. Roughly one in seven people worldwide is thought to live with it, which places it among the most frequent neurological conditions. It is most often first noticed in adolescence or early adulthood and is most common between the ages of about 18 and 44. Women are affected about two to three times as often as men, a difference that becomes clear after puberty and is closely tied to hormonal changes.

An individual attack typically lasts from around four hours to three days if untreated, though some are shorter and a few are longer. Some people have one or two attacks a year, while others have several each week. Between attacks, many people feel entirely well, though others describe worry about when the next one will arrive.

Migraine is a long-term (chronic) condition with no single test and no one-size-fits-all treatment. It can, however, be managed. Effective options exist for stopping attacks once they start and for reducing how often they happen. Understanding the pattern of attacks, the medicines used, and the warning signs that call for urgent assessment helps people have more useful conversations with their healthcare team. This page is a general reference and cannot replace an individual assessment.

The Stages of a Migraine Attack

A migraine attack is often described as unfolding in up to four phases. Not everyone experiences all of them, and the phases can blur together, but knowing the pattern helps explain why symptoms can begin well before the pain does.

Prodrome

The prodrome, sometimes called the premonitory phase, can begin hours or even a day or two before head pain. Common features include unusual tiredness, yawning, neck stiffness, mood changes (irritability or low mood, occasionally an unexplained lift in mood), food cravings, increased thirst or urination, and difficulty concentrating. Some people learn to recognise their own prodrome, and this can be useful because early treatment of an attack sometimes works better. Food cravings in this phase are sometimes mistaken for triggers: the craving is a symptom of the attack beginning, not its cause.

Aura

Aura refers to temporary neurological symptoms that develop gradually over several minutes and typically last between five and sixty minutes. About one in three people with Migraine experiences aura at least sometimes. Visual aura is by far the most common and may include shimmering or zigzag lines, flickering lights, blind spots, or a expanding patch of altered vision. Others experience tingling or numbness, often starting in the hand and spreading up the arm toward the face, or trouble finding words. Less often, aura involves speech difficulty or, rarely, weakness. Aura symptoms generally resolve completely. Head pain may follow within an hour, though sometimes aura occurs with little or no headache.

Headache phase

The pain phase is what most people associate with Migraine. The pain is often described as throbbing or pulsing and is moderate to severe. It frequently affects one side of the head, though it can be on both sides or switch from attack to attack. Pain tends to worsen with routine physical activity such as climbing stairs, which is one reason people with Migraine often prefer to lie still in a dark, quiet room. Nausea, vomiting, and sensitivity to light (photophobia), sound (phonophobia) and sometimes smell accompany the pain.

Postdrome

After the pain eases, many people enter a postdrome, sometimes nicknamed a migraine hangover. It can last up to a day or more. People describe feeling drained, foggy, weak or unusually sensitive, and some feel mildly euphoric or notice lingering soreness of the scalp or neck. Sudden head movement may bring back a brief echo of the pain.

Symptoms

Migraine symptoms vary widely between individuals and from one attack to the next in the same person. The core pattern is moderate to severe head pain together with associated features, but the full picture can be much broader.

Typical symptoms include:

• Throbbing or pulsating head pain, often one-sided, commonly around the temple, forehead or behind one eye
• Nausea, sometimes with vomiting
• Sensitivity to light, sound and, less often, smells
• Worsening of pain with movement, bending or coughing
• Neck tightness or pain, which is a very frequent accompaniment and often leads people to assume a tension-type or sinus problem
• Dizziness or a sense of unsteadiness
• Difficulty concentrating, slowed thinking or trouble finding words
• Cold hands, pale skin or sweating
• Scalp tenderness, sometimes making brushing hair or wearing glasses uncomfortable

Some people also notice autonomic symptoms such as a watery eye, a blocked or runny nose, or facial pressure. Because these features overlap with sinus conditions, a large proportion of what people call sinus headaches turn out, after assessment, to be Migraine. Genuine sinus infection usually brings fever, thick nasal discharge and facial tenderness, and tends not to recur monthly without other signs.

In children, attacks are often shorter, more likely to affect both sides of the head, and more likely to include prominent stomach symptoms such as abdominal pain and vomiting. Some children have recurring episodes of vomiting or abdominal pain without much head pain, a pattern that may be related to Migraine and sometimes evolves into typical attacks later.

Types of Migraine

Several recognised forms exist. Classification is based on the pattern of symptoms and how often attacks occur.

Migraine without aura

This is the most common form. Attacks involve the headache and associated symptoms described above, without the neurological warning phase.

Migraine with aura

Attacks are preceded or accompanied by aura, most often visual. The same person may have attacks both with and without aura. Aura is clinically relevant beyond comfort because it influences choices about certain medicines, particularly estrogen-containing contraception.

Chronic Migraine

Chronic Migraine is diagnosed when headaches occur on 15 or more days per month for more than three months, with at least eight of those days having features of Migraine. It often develops gradually from episodic Migraine, and factors such as frequent use of acute pain medicines, poor sleep, obesity, depression and anxiety are associated with that progression. Chronic Migraine usually calls for specialist-informed preventive treatment.

Menstrual-related Migraine

Many women notice that attacks cluster around menstruation, tied to the fall in estrogen just before a period. Attacks that occur in this window can be longer, more severe and harder to treat than other attacks. In some women, attacks occur almost exclusively around menstruation.

Vestibular Migraine

Vestibular Migraine features recurrent episodes of vertigo or dizziness, with or without headache, in a person who has a history of Migraine. Episodes can last minutes to days and often involve motion sensitivity and unsteadiness. It is one of the more common causes of recurrent spontaneous vertigo and is frequently under-recognised.

Hemiplegic Migraine

This rare form involves temporary weakness on one side of the body as part of the aura, along with other aura symptoms. Because the weakness closely resembles a stroke, it requires careful evaluation, especially the first time it occurs. Some forms run in families and are linked to specific gene variants.

Migraine with brainstem aura

Aura symptoms originate from the brainstem and may include slurred speech, vertigo, ringing in the ears, double vision, and reduced coordination, alongside typical Migraine features, without muscle weakness.

Retinal Migraine

A rare form involving repeated episodes of vision loss or disturbance in one eye only, usually lasting less than an hour and followed by headache. Because one-eye vision loss can signal other serious eye or vascular problems, it needs prompt medical assessment.

Status migrainosus

An unusually long and severe attack lasting more than 72 hours. It may require treatment in an emergency department or hospital, particularly if vomiting prevents fluids and medicine from staying down.

Causes

The exact cause of Migraine is not fully understood. Current thinking describes it as a disorder of brain excitability and sensory processing rather than a problem with blood vessels alone, which was the older explanation. Genetic susceptibility and environmental influences both appear to play a role.

What happens in the brain

During an attack, activity changes across several brain regions, including the brainstem and hypothalamus, which help regulate sleep, appetite, hormones and pain. Aura is linked to a slow wave of altered electrical activity that spreads across the brain surface, known as cortical spreading depression. Pain is thought to arise when the trigeminal nerve system, which supplies sensation to the face and the coverings of the brain, becomes activated. Activated nerve endings release signalling molecules, including calcitonin gene-related peptide (CGRP). CGRP promotes inflammation and widening of blood vessels around the brain and heightens pain signalling. The discovery of CGRP's role led directly to newer targeted treatments.

Genetics

Migraine often runs in families. A person with a parent who has Migraine has a noticeably higher likelihood of developing it, and the likelihood rises further if both parents are affected. Studies have identified many common gene variants that each add a small amount of susceptibility. A few rare forms, such as familial hemiplegic Migraine, follow a clearer single-gene pattern.

Hormones

The difference between women and men in Migraine frequency points to a strong hormonal influence. Attacks often become more frequent around the first period, cluster around menstruation, may improve during pregnancy (especially in the second and third trimesters), and often change around perimenopause. Estrogen fluctuation rather than absolute level seems to matter most.

Triggers

Many people can identify factors that make an attack more likely. A trigger does not cause Migraine itself, but it may lower the threshold in someone already susceptible. Triggers vary a great deal between individuals, and the same factor may not provoke an attack every time. Commonly reported triggers include:

• Changes in sleep, including too little, too much or irregular patterns
• Stress, and also the letdown period after stress ends, which is why some people have attacks at weekends or at the start of a holiday
• Skipped meals, fasting or dehydration
• Hormonal shifts, particularly around menstruation
• Bright or flickering lights, glare and strong smells
• Weather or barometric pressure changes
• Alcohol, especially red wine, and sometimes certain foods
• Caffeine excess or caffeine withdrawal
• Intense or unaccustomed physical exertion
• Certain medicines, including some vasodilators

It can be hard to separate true triggers from early symptoms of an attack already under way. A craving for chocolate, for example, may be part of the prodrome. Because of this, restrictive elimination diets are not generally recommended without good evidence that a particular food is involved, and keeping a diary is more informative than guessing.

Risk Factors

Several factors are associated with a greater likelihood of developing Migraine or having it become more frequent.

• Family history: having a close relative with Migraine is one of the strongest risk factors.
• Sex: after puberty, women are considerably more likely than men to be affected.
• Age: Migraine most often begins in adolescence or early adulthood and is most prevalent between roughly 18 and 44, tending to ease for many people after midlife.
• Hormonal factors: menstruation, pregnancy, perimenopause and some hormone-containing medicines can shift attack patterns.
• Other health conditions: depression, anxiety, sleep disorders, epilepsy and certain cardiovascular conditions occur more often alongside Migraine. The relationships are often two-way rather than simple cause and effect.
• Obesity: associated with a higher frequency of attacks and a greater chance of progression to chronic Migraine.
• Frequent use of acute pain medicines: can increase headache frequency over time (see medication overuse below).
• Head or neck injury history: may be linked with new or worsening headaches in some people.

Diagnosis

There is no blood test or scan that confirms Migraine. Diagnosis is made mainly from the history of symptoms and a physical and neurological examination. A clinician will ask when attacks began, how long they last, where the pain is felt, what it feels like, what accompanies it, what makes it better or worse, and whether any relatives are affected. Details about aura, menstrual patterns, sleep, caffeine, medicine use and stress help round out the picture.

Diagnostic criteria used by clinicians look for a minimum number of attacks of a certain duration with specific features, such as one-sided location, pulsating quality, moderate to severe intensity, worsening with activity, and nausea or sensitivity to light and sound. Applying these consistently helps distinguish Migraine from other headache disorders, including tension-type headache, cluster headache and medication overuse headache.

Many clinicians suggest keeping a headache diary for several weeks. Recording the date, timing, severity, accompanying symptoms, possible triggers, menstrual cycle, and medicines taken (and whether they helped) can reveal patterns and give a more reliable basis for treatment decisions than memory alone.

When imaging or other tests are used

For typical Migraine with a normal examination, brain imaging is usually not needed. MRI or CT scanning may be recommended to rule out other causes when there are unusual or concerning features, for example:

• A sudden, explosive headache that reaches peak intensity within a minute
• A new type of headache beginning after age 50
• An abnormal neurological examination
• Aura that is atypical, such as lasting more than an hour or including weakness
• Headache with fever, stiff neck, or a rash
• Headaches following a head injury
• A marked change in the established pattern of headaches
• Headache that worsens consistently over weeks, or is worse when lying down or on waking

Additional tests such as blood work, an eye examination or lumbar puncture are used selectively, depending on what other conditions are being considered.

Treatment

Management of Migraine generally has three parts: treating individual attacks (acute treatment), reducing how often and how severely attacks happen (preventive treatment), and addressing lifestyle and contributing factors. Treatment is individualised, and what helps one person may not help another. A healthcare professional can advise on what suits a particular person, taking into account other medical conditions, other medicines, pregnancy plans, and attack patterns.

Acute treatment of attacks

The goal is to stop pain and associated symptoms and restore normal function. A general principle is that treatment tends to work best when taken early in the headache phase, while pain is still mild, although guidance about the timing of specific medicines (particularly in relation to aura) varies and is worth discussing with a clinician.

Simple pain relievers. For mild to moderate attacks, over-the-counter analgesics are often the first step. These include non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen and aspirin, as well as acetaminophen. Combination products containing caffeine can be more effective for some people but carry a higher risk of overuse. NSAIDs can irritate the stomach and affect the kidneys and cardiovascular system in susceptible people, so they are not suitable for everyone.

Triptans. Triptans such as sumatriptan, rizatriptan, zolmitriptan, eletriptan and naratriptan act on serotonin receptors to reverse the pain-signalling processes of an attack. They come as tablets, nasal sprays, injections and dissolving wafers, which matters when nausea or vomiting makes swallowing tablets difficult. They are generally avoided in people with a history of heart disease, stroke, uncontrolled high blood pressure, or certain unusual forms of Migraine such as hemiplegic or brainstem aura, and can interact with some other medicines. Common side effects include tingling, flushing, and a sensation of tightness in the chest, throat or jaw, which is usually brief but should be discussed with a clinician if it occurs.

Gepants. Ubrogepant, rimegepant and atogepant belong to a class that blocks CGRP receptors. Ubrogepant and rimegepant are used to treat attacks, and rimegepant and atogepant can also be used for prevention. Because they do not constrict blood vessels, they may be an option for some people who cannot take triptans.

Lasmiditan. This medicine acts on a specific serotonin receptor subtype without narrowing blood vessels. It can cause drowsiness and dizziness, and recommendations about driving afterwards apply.

Anti-nausea medicines. Antiemetics such as metoclopramide or prochlorperazine can relieve nausea and vomiting and may also help the pain itself. They are often used alongside other treatments.

Ergot derivatives. Dihydroergotamine, given by injection or nasal spray, is sometimes used for prolonged or severe attacks. It has significant restrictions and interactions and is generally supervised by a specialist.

Emergency or hospital treatment. For severe, prolonged attacks, treatment may include intravenous fluids, injectable anti-nausea medicines, anti-inflammatory medicines, or corticosteroids, delivered in a clinical setting.

Preventive treatment

Preventive treatment is usually considered when attacks are frequent, severe, long-lasting, disabling despite acute treatment, or when acute medicines cannot be used or are being used too often. The aim is typically to reduce attack frequency by about half or more, rather than to eliminate attacks entirely. Preventive medicines are usually started gradually, tried for a couple of months or more before judging their effect, and reviewed regularly.

• Beta-blockers such as propranolol and metoprolol, commonly used for prevention, though they may not suit people with asthma, very low blood pressure or certain heart rhythm problems.
• Anticonvulsants such as topiramate, and in some settings valproate. These have important considerations around pregnancy, and valproate in particular carries serious risks to a developing baby, so use in people who could become pregnant is tightly restricted.
• Antidepressants such as amitriptyline and venlafaxine, which can help even in people who are not depressed, and may be useful where sleep or coexisting low mood is a factor.
• Candesartan, a blood-pressure medicine that some people find helpful for prevention.
• CGRP-targeting monoclonal antibodies: erenumab, fremanezumab, galcanezumab and eptinezumab, given by injection or infusion at intervals. These were designed specifically for Migraine prevention. Constipation and raised blood pressure are among the side effects noted for some of them.
• OnabotulinumtoxinA injections, approved for chronic Migraine, given by a trained clinician in a repeating schedule roughly every three months.

Side effects, other health conditions and personal preferences all shape which medicine is chosen. Several options may need to be tried before the best fit is found.

Non-drug approaches

Non-medicine measures can meaningfully support medical treatment:

• Regular routines: consistent sleep and wake times, regular meals, and adequate hydration.
• Regular aerobic exercise: activities such as walking, swimming or cycling, built up gradually, have evidence for reducing attack frequency in some people.
• Stress management: relaxation training, biofeedback and cognitive behavioural therapy have evidence of benefit, particularly as add-ons to other treatment.
• Mindfulness and yoga: may help some people cope and may reduce the burden of attacks.
• Acupuncture: shows some benefit in studies for a number of people, though results vary.
• Neuromodulation devices: several devices that stimulate nerves through the skin have regulatory clearance for acute or preventive use in some countries.
• Supplements: magnesium, riboflavin (vitamin B2) and coenzyme Q10 have some supportive evidence for prevention, although quality of evidence varies, and anyone considering them should check with a clinician or pharmacist about suitability and interactions. Feverfew and butterbur have been discussed in the past, but concerns about product quality and liver safety, particularly with butterbur, mean they are generally not favoured.

Medication overuse headache

Using acute headache medicines too often can paradoxically lead to more frequent headaches, a condition called medication overuse headache. It is generally linked to regular use of simple analgesics on about 15 or more days a month, or of triptans, opioids, ergots or combination analgesics on about 10 or more days a month, over three months or longer. Opioids and butalbital-containing products carry particular concern and are generally discouraged for Migraine because of overuse risk and limited benefit. Recognising the pattern matters, because the usual management involves a supervised reduction in the overused medicine, often combined with starting a preventive treatment. Stopping suddenly without guidance can cause temporary worsening, so medical advice is worthwhile.

Hormonal considerations

For menstrual-related Migraine, strategies include short-term preventive use of certain medicines around the time of the period, or adjustments to hormonal contraception. Estrogen-containing contraceptives are generally avoided in people with Migraine with aura because of a small additional increase in stroke risk, and the decision should be made with a clinician who knows the person's full history, including smoking and blood pressure.

Migraine in pregnancy and in children

Migraine often improves during pregnancy, but not always, and treatment choices need extra care because several preventive medicines are unsuitable. Acetaminophen is commonly regarded as a first-line option during pregnancy, but any medicine use in pregnancy or breastfeeding should be discussed with a healthcare professional. In children and adolescents, simple pain relievers are usually the starting point, and some triptans are approved for older children and teenagers. Sleep, regular meals, hydration and reducing screen-related eye strain are often emphasised, and a clinician can advise on appropriate options.

Complications

Most people with Migraine do not develop serious complications, but the condition can have significant effects beyond the attacks themselves.

• Medication overuse headache: as described above, one of the more common and avoidable complications.
• Chronification: progression from occasional to chronic Migraine in some people, associated with greater disability.
• Status migrainosus: a prolonged attack that may require hospital care.
• Persistent aura without infarction: aura symptoms that last longer than a week without evidence of a stroke on imaging. This is rare.
• Migrainous infarction: a rare event in which a stroke occurs during an attack with typical aura. It is uncommon but recognised.
• Cardiovascular associations: large studies have found that Migraine with aura, especially in women, is associated with a modestly higher risk of stroke and heart disease. The absolute risk for any individual remains small, and managing blood pressure, cholesterol, smoking, and other contributing factors is considered important.
• Mental health effects: depression, anxiety and sleep difficulty are more common in people with frequent Migraine, and living with unpredictable attacks can be emotionally draining.
• Social and economic impact: lost work or school days, reduced productivity and difficulty planning events are frequently reported.
• Seizures: rarely, a seizure may be triggered by a Migraine attack (sometimes called migralepsy).

Prevention and Self-Management

Complete prevention is not realistic for most people, but there is meaningful scope to reduce frequency and make attacks easier to manage.

• Keep a diary. A record of attacks, triggers, medicine use and menstrual timing can reveal patterns and show how well a treatment plan is working.
• Protect sleep. Aim for regular bedtimes and wake times, including at weekends. Both short and excessive sleep can contribute to attacks.
• Eat regularly and hydrate. Long gaps between meals and dehydration are among the commonly reported triggers.
• Moderate caffeine. A small, steady intake is tolerated by many, whereas large or erratic amounts and abrupt withdrawal can provoke attacks.
• Limit alcohol if it is found to be a personal trigger.
• Exercise gradually and regularly. Sudden intense exertion can provoke an attack in some people, so slowly building up is generally preferred.
• Manage stress. Relaxation methods, pacing activity and attention to workload can help, as can counselling or therapy when stress and mood are intertwined with attacks.
• Watch acute medicine use. Tracking how many days per month acute treatment is taken can help avoid medication overuse headache.
• Review other medicines. Some prescriptions can aggravate Migraine, so it is worth raising Migraine with whoever prescribes them.

Living with Migraine

For many people, the greatest challenge of Migraine is its unpredictability. Planning around attacks, explaining them to others, and managing the fear of the next one can be as demanding as the attacks themselves. Several practical approaches are often discussed.

Having a personal plan can reduce anxiety. This may include knowing which medicine to take at the first sign of an attack, keeping it within easy reach at home and work, and having a quiet, dark place to rest when possible. Some people find a cool cloth on the forehead or neck, gentle rest, and sipping fluids helpful alongside medicine.

Communication matters too. Employers, teachers and family members often benefit from understanding that Migraine is a medical condition with real neurological symptoms, not simply a headache that could be pushed through. Adjustments such as flexible hours, reduced screen glare, breaks from bright light, or a quiet space during an attack can make a significant difference. In many places, workplace or school accommodations may be available for chronic conditions.

Many people find that Migraine changes over time. Some experience fewer attacks after menopause or in later life, whereas for others the pattern shifts rather than disappears. Regular follow-up is useful so that treatment can be adjusted as life circumstances, hormonal status and health conditions change. If a treatment is not working, that is useful information to share rather than a reason to give up, as newer options have expanded considerably in recent years.

Support from others who understand can also be valuable. Patient organisations and online communities offer information and peer support, though advice from them should be balanced against guidance from a healthcare professional. For general, reliable background reading, the MedlinePlus Health Topics library and research updates from the National Institutes of Health are useful starting points.

When to Seek Help

Most Migraine attacks, however unpleasant, are not dangerous. Some headaches, however, signal a serious underlying problem and need urgent medical attention. The following situations call for emergency care, such as calling emergency services or going to the nearest emergency department:

• A sudden, severe headache that reaches full intensity within about a minute, often described as the worst headache of a lifetime (a thunderclap headache), which can indicate bleeding in or around the brain
• Headache accompanied by confusion, slurred speech, difficulty understanding speech, drooping of the face, or weakness or numbness on one side of the body
• Sudden loss of vision, double vision, or loss of balance or coordination that is new or does not settle
• Headache with fever, a stiff neck, and sometimes a rash or marked sensitivity to light, which may point to meningitis
• Headache following a blow or injury to the head
• A seizure or fainting associated with headache
• Aura symptoms that are entirely new, unusually prolonged, or involve weakness, particularly if they begin suddenly
• Headache accompanied by persistent vomiting that prevents keeping down fluids or medicine

It is also appropriate to arrange a prompt (non-emergency) medical appointment when:

• Headaches begin for the first time after age 50
• The usual pattern of headaches changes noticeably, becoming more frequent, more severe or different in character
• Headaches steadily worsen over days or weeks, or are worse on waking, lying down, coughing or straining
• Acute medicines are needed on a large number of days each month, or they stop working
• Attacks regularly cause missed work, school or social activities
• Headaches occur in someone with a weakened immune system, a history of cancer, or while taking blood-thinning medicine
• There are concerns about medicine side effects, pregnancy planning, or hormonal contraception in someone who has Migraine with aura

Anyone who is unsure whether a particular headache is a typical Migraine attack or something else should seek medical advice instead of waiting. Healthcare professionals would rather assess a headache that turns out to be benign than miss one that is not.