MIGRAINE

ABOUT MIGRAINE

In this section, you or a loved one can find out more about migraine the disease as well as treatments for migraine. We also provide practical advice about migraine and offer tips on how to tap into your support network. Read on and you’ll find answers to some of your questions as well as links to resources with more information. Being informed is an important first step towards becoming an active decision-maker in your care plan.

WHAT IS MIGRAINE?

Migraine has been reported to be a leading cause of disability in the world, second only to low back pain.

Migraine is a headache involving severe throbbing pain or a pulsing sensation, usually on one side of the head, that gets worse with physical activity. The pain is generally around the temple and eye, but it can also be felt anywhere in the head and neck.

Migraines are frequently accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with your daily activities.

For some people, an “aura” occurs before or with the headache. An aura is most commonly visual (flashes of light or blind spots) but it can also be tingling or numbness in an arm, leg and face or difficulty speaking.

Doctors classify migraine as with and without aura and by frequency of headache.

  • Episodic - less then 15 days per month of migraine/headaches.
  • Chronic - the most severe form of migraine involving 15 days or more of headache per month for more than three months which, on at least 8 days per month, has the characteristics of a migraine headache.

Migraines have 4 main phases; however, not everyone experiences all phases.

  • Prodrome (preheadache): The first phase may or may not occur, but if it does it can last from hours to days. It can have many symptoms, such as fatigue, food cravings, constipation, mood changes, neck and muscle stiffness, increased urination, fluid retention, frequent yawning, problems concentrating
  • Aura: can last from 5 minutes to an hour; about a third of people with migraine experience an aura
  • Headache: Typically, this starts on one side of your head and then spreads to the other side; it can last from 4 to 72 hours
  • Postdrome: can last a day or two. It can be called a migraine “hangover” and can affect about 80% of people with migraines

Phases of a migraine headache

phase of migraine

Adapted from Cleveland Clinic and Andreou et al.

Finding out you suffer from migraine headaches can leave you feeling overwhelmed, so it's crucial to reach out for help and information from people who are close to you and to your healthcare team. Along with obtaining the best possible medical support and treatment, it is important to make your emotional and physical wellbeing a priority, to ask for help and support when you need it, and to nurture relationships with compassionate people who enrich your life. You don't have to do it alone – there are many ways to manage your daily life with your healthcare team, family, and friends, as you will see in the following sections.


WHAT CAUSES MIGRAINE HEADACHES?

Scientists do not completely understand what causes migraines; however, genetics, environmental factors as well as electrical and neurochemical mechanisms seem to play a role.

About aura

In people who suffer from migraines, the nerve cells in the brain are more easily stimulated. When electrical activity due to stimulation spreads through the brain (called “cortical spreading depression” or CSD), various functions, including vision, sensation, balance, muscle coordination, and speech, may be temporarily affected leading to the symptoms of aura visual such as flashes of light or blind spots, tingling or numbness in an arm, leg and face or difficulty speaking.

The CDS “wave” can lead to aura

caus of migraine

Adapted from Migraine Canada

The headache

The actual migraine headache occurs when the trigeminal nerve in the brain is stimulated. This nerve may release substances that cause painful inflammation in the blood vessels of the brain as well as the layers of tissues that cover the brain. This inflammation causes the main symptoms of migraine such as the throbbing headache, nausea, vomiting, and sensitivity to light and sound.

CGRP is a chemical in the brain and nervous system involved in the transmission of pain as well as the resulting reaction of tissues and blood vessels.

When a migraine occurs, the trigeminal nerve is stimulated which causes it to release substances that cause painful inflammation in the brain.

Adapted from Science News 2021

Brain chemicals

Imbalance in brain chemicals such as serotonin (which helps regulate pain in your nervous system) and calcitonin gene-related peptide (CGRP) (an inflammatory substance that dilates blood vessels and causes pain) could also be involved in the migraine attack.

Triggers of migraine:

Migraine triggers increase the chances that you will have a migraine attack. These triggers can be from within your body such as hormones and feelings, or external, like weather changes and smells.

Triggers can vary between people and sometimes more than one trigger is needed to cause an attack.

Common triggers include:

  • Hormonal changes in women such as fluctuations in estrogen before or during menstrual periods, pregnancy, and menopause
  • Head trauma
  • Lack of exercise
  • Sleep changes e.g., missed sleep or getting too much sleep
  • Medications (including nitroglycerin, histamine, reserpine, hydralazine, ranitidine, estrogen [e.g., oral contraceptives and hormone replacement therapy])
  • Stress
  • Drinks such as red wine and coffee (too much coffee as well as too little – caffeine withdrawal can lead to migraines)
  • Sensory stimuli such as bright or flashing lights can induce migraines, as can loud sounds. Strong smells — such as perfume, paint thinner, second-hand smoke, and others — trigger migraines in some people
  • Physical factors - Intense physical exertion, including sexual activity, might provoke migraines
  • Weather changes. A change of weather or barometric pressure can prompt a migraine
  • Skipping meals and the following foods:
    • Citrus fruits
    • Nuts
    • Onions
    • Nitrites (found in processed, cured, or preserved meat)
    • Aged or strong cheeses, sour cream, yogurt, other dairy products
    • Smoked fish, pickled herring
    • Chocolate
    • Eggs
    • Beans
    • Fatty foods
    • Yeast extracts
  • Food additives such as the sweetener aspartame and the preservative monosodium glutamate (MSG)

FAST FACTS

 
  • Migraine is a headache that usually involves severe throbbing pain or a pulsing sensation, generally on one side of the head.1
  • Migraine is often accompanied by nausea, vomiting, and sensitivity to light and sound as well as smell sensitivity, difficulty focusing and dizziness.1,2
  • Migraine affects over 1 billion people worldwide.3
  • An estimated 8.3% of Canadians suffer from migraines.4
  • Occurrence of migraine has been reported to be highest in the 35 to 39 year old age group.3
  • Migraine is twice as likely among women (~20%) compared with men (~10%); up to 10% of children and about 3.5% of the elderly experience migraines.5,6
  • Migraine attacks affect work, school, home life as well as social situations.7
  • Migraine attacks can last from hours to days.1,2

References:

  1. Migraine Canada. The Migraine Family: categories and groups.
  2. Mayo Clinic. Migraine. Symptoms and causes.
  3. Aschina M et al. Migraine: epidemiology and systems of care. 2021.
  4. Statistics Canada. Prevalence of migraine in the Canadian household population. 2014.
  5. GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
  6. Andreou AP, Edvinsson L. Mechanisms of migraine as a chronic evolutive condition. The Journal of Headache and Pain 2019;20:117.
  7. Ailani J et al. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61:1021–1039.

WHAT ARE THE EFFECTS OF MIGRAINE?

A prognosis is the doctor’s best estimate of how disease will affect a person and how that person will likely respond to treatment.

Migraine prognosis:

  • Migraine frequency can fluctuate between chronic and episodic.
  • When migraine is chronic, prolonged periods without the disease can occur.
  • The severity and frequency of migraine attacks tend to decrease with increasing age.
    • After 15 years with migraines, about 30% of men and 40% of women no longer experience migraine attacks.

To be diagnosed with migraine, the International Headache Society specifies that patients must have had at least 5 headache attacks that lasted 4–72 hours (untreated or unsuccessfully treated) and that the headache must have had at least 2 of the following characteristics:

  • On one side of the head
  • Pulsating
  • Moderate or severe pain
  • Aggravated by or causing avoidance of routine physical activity (such as walking or climbing stairs)

In addition, during the headache you must have had at least 1 of the following:

  • Nausea and/or vomiting
  • Sensitivity to light and sound

The signs and symptoms of migraine will vary between patients, between migraine episodes and between phases of an episode in a patient.

Commonly reported symptoms that occur in 4 phases of a migraine headache

phase of migraine

Adapted from Cleveland Clinic, Mayo Clinic and Andreou et al.

Are there other associated conditions?

Associated conditions that can occur in people with migraine include:

  • insomnia
  • depression
  • anxiety
  • stomach problems
  • chronic neck and low back pain
  • certain types of heart disease
  • allergies/ hay fever
  • epilepsy
  • arthritis (type unknown)
  • stroke
  • rheumatoid arthritis
  • asthma
  • vitamin D deficiency
  • obesity
  • post traumatic stress disorder
  • Tourette syndrome

Complications

Complications are conditions that result from migraine, examples of complications include:

  • Chronic migraine
  • Seizures
  • Stroke
  • Persistent aura

SUPPORT MEANS EVERYTHING

When you have migraine, you may need different types of support at different times. Your friends and family can help, along with your team of health care professionals.

Living with migraine can make you feel isolated and sad; especially when you must adapt or change your daily routine, see many health care practitioners, and learn medical terms. But you don’t need to do it alone.

Other sources of support are people who have gone through what you’re going through. These people understand how you feel, they can tell you what to expect, how they coped, and give you hope for the future. You can get in touch with people in your situation through organized support programs. Benefits of these programs include making friends who understand your disease, being able to open up about difficulties in your life and learning new coping skills. If you’re interested in an organized support program, ask your doctor or other member of your healthcare team for more information. Contacting Migraine CanadaThis link opens the page in another browser window., the Headache Canada Network (ESC)This link opens the page in another browser window., the Canadian Migraine SocietyThis link opens the page in another browser window. and, in Quebec, Migraine QuebecThis link opens the page in another browser window. can also give you access to people and resources.

When you’re living with migraine, it’s invaluable to keep the lines of communication open with your family, friends and coworkers: they can’t understand what it’s like to live with migraine if you don’t talk openly about it.

Here are some tips and helpful insights we’ve learned from migraine patients:

When we stop doing the things we love, our mood drops, and it becomes even harder to get motivated. Keeping fun in your life is absolutely essential — make it a top priority. It boosts your mood, your relationships, and your energy level. Find one activity you love — even a small one — that you can add to each week without fail, and one you can add to each day. Once they become routine, you'll start feeling better and will want to add more.

Migraine is different for every patient. Don't hesitate to ask questions and get involved in decision-making regarding your health. And keep in mind there are many options available to you, so if one approach isn’t working, another one might.

Here are some tips on how to get the most out of your appointment with people on your healthcare team:

  • Before the appointment:
    • Write down your goals (e.g., establish a treatment plan or simply better understand migraine)
    • Keep a Headache Diary that includes:
      • Your triggers
      • All symptoms you experience even if they are not related to headache (such as digestive problems)
      • Change in your headaches or other symptoms over time
      • Updated complete list of the medications and supplements (and their doses) that you are currently taking
      • Effect of any medications you take
    • List any questions you have
  • During the appointment:
    • Be open and honest about how you’re feeling and how the different symptoms of the disease affect your quality of life
    • Take notes
    • Ask who you should call if something happens between scheduled appointments

There are independent patient associations and organizations that may be able to help you learn more

Learn more

LIFESTYLE OPTIONS

Lifestyle options

If you suffer from migraine headaches, it’s important to have strategies on sleep, regular exercise, proper nutrition and hydration, maintaining a migraine diary and stress management. Identifying and managing your triggers as well as proper posture are also important. Talk to your health care professional for more guidance. While there’s no cure yet for migraine, a healthy lifestyle certainly supports overall health.

Key elements of lifestyle have been recently published in the Cleveland Journal of Medicine (Volume 86, November 2019). Just remember the acronym “SEEDS”:

  • Sleep
  • Exercise
  • Eating and hydration
  • Diary
  • Stress

Poor sleep can be a migraine trigger.

Here is some general guidance to improve your sleep:

  • Use your bedroom to represent sleep:
    • If you can’t fall asleep in 20-30 minutes, you should leave the bedroom, so you don’t associate it with frustration and anxiety.
  • Keep your bedroom quiet, dark, and cool (consider a white noise machine)
  • No screens (TV, phone, laptops, tablets) in the bedroom
  • Try to go to bed at the same time each night
  • Do not take naps during the day
  • Try bedtime relaxation techniques such as progressive muscle relaxation
  • Look into sleep restriction therapy (the goal of this therapy is to be asleep 90% of the time in bed)

If you have been diagnosed with a disorder called “sleep apnea” (breathing stops and starts repeatedly while sleeping), your doctor will have specific advice for you. People with chronic migraine are more likely to suffer from sleep apnea.

Exercise may be helpful in managing migraine by decreasing the number of migraine days and reducing the intensity and duration of migraine headaches.

Exercise advice:

  • Aim at 30 to 60 minutes of exercise 3 to 5 times a week
  • You can start small with as little as 5 minutes per week
  • Gradually increase the amount of time and frequency of exercise
  • Try to choose a type of exercise you enjoy
  • If you find your migraine headaches are stopping you from exercising, talk to your doctor about preventive treatment

People with migraine should eat regular healthy meals, drink enough water, and limit caffeine consumption.

In the prodrome of a migraine episode, you may experience several symptoms including food cravings. The prodrome can occur up to 72 hours before a headache, so it can be difficult telling the difference between a craving and a trigger. Make sure to keep a careful record of cravings in your migraine diary.

General diet and hydration tips:

  • Keep in mind that there is no specific “migraine diet”
  • Eat healthy meals at least 3 times a day; 5 to 6 meals per day when hunger is a trigger
  • Avoid skipping any meals
  • Stop consuming caffeine or consistently limit yourself to 1–2 cups of brewed coffee (200 mg of caffeine per day)
  • Achieve and maintain your optimal weight
  • Stay hydrated, aiming for 7–8 glasses (8-oz) of water per day

When planning meals, consider the above advice and consult Canada’s Food guide for help making healthy food choices.

Eating regular meals is particularly important for people who suffer from migraine headaches – migraine tends to be more common when meals are skipped, especially breakfast. Eating breakfast within 30 min to an hour of rising in the morning is considered to be optimal. Long periods of time between meals can trigger migraine attacks, or lead to more severe headaches because of low blood sugar levels.

In people with migraine, caffeine can act in a range of ways:

  • Caffeine may be a migraine trigger.
  • Stopping caffeine may be a migraine trigger. People with migraine who consume caffeine regularly can become prone to attacks if they decrease or stop their intake.
  • Caffeine affects sleep: It can take up to a full day to completely eliminate caffeine from your body so the effects of caffeine can affect your sleep even if you only have a cup of coffee in the morning. Poor sleep is a trigger for migraine.
  • Caffeine can help to treat a migraine headache. Caffeine can boost the effect of other pain killers.

Caffeine can be in coffee, black, white, and green tea, energy drinks, soft drinks, chocolate as well as over the counter supplements and medications. According to Migraine Canada, the jury is out on whether its best to reduce caffeine intake (to 200 mg per day or lower) or to stop altogether. If you choose to reduce your caffeine intake, here are some tips:

  • Do not stop caffeine suddenly! This may result in a withdrawal headache.
  • Reduce caffeine slowly by week (at each week cut out the equivalent of ½ to 1 cup of coffee tea, or soft drink).
  • If you get a withdrawal headache, you can treat it with caffeine or with your usual treatment for acute headaches.

Maintaining a migraine diary will help you and your doctor understand your current headache pattern, assess how you are responding to treatment, and monitor how much treatment you are using.

Diary tips:

  • Track your headaches, any medications you use and their effects in a migraine diary (see below)
  • Bring the diary to appointments with your doctor

What you can include in your diary:

  • Headache frequency, duration, and intensity
  • Medication use and effect, including:
    • Effect or lack of effect
    • Side effects such as medication overuse headaches
  • Headache effect on daily activities including work
  • Potential triggers
  • Lifestyle habits

Migraine Canada offers a mobile diary app as well as access to various printed versions.

People with migraines tend to experience stress. Stress can trigger migraine and the pain of migraine creates more stress. Also, your body can get accustomed to stress so a weekend off (of work for example) can be a trigger leading to a “let down” migraine.

One of the most effective things you can do to control migraine is to reduce your stress.

Here are a few tips to reduce stress:

  • Prioritize: when making your to do lists, assess each item by how much stress it will cause and eliminate or minimize stress-causing items whenever possible
  • Schedule in time for you (a half hour “breathing” period can make all the difference)
  • Make time for relationships and personal growth (do something fun!)
  • Be assertive and be clear with other people on what you want and don’t want

In addition to the above, there are specific techniques that can help you manage stress:

  • Behavioral management (can be individual or group sessions; teaches you how behaviors and thoughts affect your perception of pain)
  • Mindfulness (this is awareness of thoughts, feelings, and sensations in the present moment without judgment)
  • Biofeedback (a relaxation technique that uses special equipment to teach you how to monitor and control certain physical responses to stress, e.g., muscle tension)
  • Relaxation techniques like visualization or progressive muscle relaxation

COMPLEMENTARY THERAPY OPTIONS

Some complementary non-traditional therapies may help with chronic migraine pain. These include:

  • Acupuncture
  • Chiropractic, massage, and craniosacral therapy
  • Meditation and yoga
  • Herbs e.g., feverfew
  • Vitamins and minerals

MEDICAL TREATMENT

Medical treatment for migraine includes medicines (pharmacologic treatment) as well as neuromodulation (which uses a device that uses electrical currents or magnets to adjust or change activity in the brain).

Pharmacologic treatment:

Pharmacologic therapies used for the treatment of migraine can be classified as:

  • Acute - to treat individual migraine attacks (reverse or at least stop the progression of a migraine headache)
  • Preventive - to prevent migraine headaches

In addition, when acute treatments do not bring relief, other treatments known as “rescue” treatments can be used. These treatments can be self-administered or administered by a doctor.

With many drug treatments, medication overuse headaches can occur.

When medications taken to relieve headaches are taken too often, they can make the brain more prone to headaches and therefore contribute to the headache problem.

How medication overuse is defined depends on the medication class in question, for example:

  • Use of triptans, opioids, or combination of acute treatments - ten or more days per month
  • Use of simple pain killers, such as non-steroidal anti-inflammatory drugs (NSAIDS) - 15 or more days per month
limit water evaporation

Adapted from Migraine Canada

Risk factors for medication overuse headaches:

  • Not modifiable: being female, suffering from other chronic pain conditions, age less than 50 years old, high intensity of headaches, and a lower level of education (e.g., not completing high school)
  • Modifiable: obesity, lack of exercise, smoking, taking tranquilizers and opioids, suffering from anxiety and depression

Pharmacologic treatments for migraine

Types of pharmacologic treatments that can be used to treat migraine headaches are listed below. Please note that the listings of side effects included here are not complete.

Simple analgesics:
  • Blocks the synthesis of prostaglandins (chemicals that cause inflammation and swelling)
  • Side effects may include: liver problems, skin reactions, medication overuse headache, tinnitus (ringing in the ears).
Non-steroidal anti-inflammatory drugs (NSAIDs)
  • NSAIDs block an enzyme (called “COX”) that produces inflammatory chemicals
  • Side effects may include: heartburn, constipation, nausea, bloating, nervousness, or sleeplessness, vomiting, ringing, or buzzing in the ears or diarrhea
Triptans:
  • Triptans work by constricting blood vessels in the head
  • Side effects may include: chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea and throat symptoms
Ergot derivatives
  • Act on serotonin receptors
  • Side effects: include nasal irritation, nasal congestion, excessive sneezing, runny nose, taste disturbance, application site reactions, nausea and vomiting

Anti-seizure treatments:

  • Affect chemicals in the brain that are involved in sending signals to the nerves
  • Side effects may include: co-ordination problems, difficulty concentrating, slow thinking, confusion and forgetfulness, dizziness, tiredness, tingling, headache, upper respiratory tract infection (e.g., colds, bronchitis) and drowsiness.

Antihypertensives:

  • Act to lower blood pressure
  • Side effects may include: abdominal pain, nausea, vomiting, loss of appetite, diarrhea, headache, trouble sleeping (insomnia), nightmares, fatigue, cold hands and feet, numbness and spasms in your fingers followed by warmth and pain (Raynaud’s phenomenon), weakness

Selective Calcium-Entry Blockers

  • Prevent calcium overload in the cells
  • Side effects may include: sleepiness, tiredness, weight gain (and/or increased appetite), depression, restlessness, trembling or uncontrolled movements of the face or the arms and legs. Older people may experience stiffness or slowness of movement

Anti-CGRP monoclonal antibodies

  • During a migraine, blood levels of CGRP are increased. CGRP antibodies work by blocking CGRP.
  • Side effects may include injection site itching, redness, swelling, pain, bruising or hardness, constipation, muscle spasm, itching, allergic reactions such as rash or swelling, difficulty breathing, hair loss, mouth/lip sores, dizziness, nasopharyngitis (stuffy nose and sore throat)

Injectable toxin

  • In chronic migraine, believed to block pain signals, which indirectly block the development of a migraine.
  • Side effects may include pain, tenderness and/or bruising at the site of injection. Other side effects include malaise (generally feeling unwell), weakness and rarely, changes in the way the heart beats, chest pain, skin rash and allergic reaction (symptoms: shortness of breath, wheezing or difficulty breathing; swelling of the face, lips, tongue or other parts of the body; rash, itching or hives on the skin); anaphylaxis; heart problems; seizures; swallowing and breathing problems.

Neuromodulation devices use electrical currents or magnets to adjust or change activity that occurs in the brain. This technique may be used to help stop attacks that are already underway and it can also be used preventatively.

Side effects of neuromodulation may include light-headedness, dizziness , tingling, ringing in the ears, or the occasional headache.

Depending on the severity of your migraines, you may have one or more of the following people on your healthcare team:

  • Family physician
  • Physical therapists
  • Occupational therapists
  • Neurologist
  • Walk-in clinic physician
  • Pediatrician
  • Nurse practitioner
  • Pharmacist
  • Psychologist
  • Nutritionist/dietician
  • Chiropractors

Other healthcare professionals may also be involved, such as nurses and social workers.


Disclaimer

Please note that the information on this Web site should not be used as a substitute for seeking medical advice or treatment from a physician. You should not use this information to diagnose or treat a medical condition or health problem. Speak to your health care provider if you have any questions about your medical condition, symptoms, or treatment options.

Resources

 

Migraine Canada

migrainecanada.org

Migraine Canada is a nationally registered not-for-profit organization dedicated to improving the lives of all Canadians living with migraine and other headache disorders.

Headache Canada Network

www.headachenetwork.ca/about

The Headache Canada Network is a non-profit, research-oriented organization for migraine. Its mission is to study and understand migraine and provide education about the condition and its treatment.

Canadian Migraine Society

www.migrainesociety.ca

Patient-led community dedicated to empathy, education and empowerment for Canadians living with migraine.

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