Definition

A migraine is a common type of headache that may occur with symptoms such as nausea,
vomiting, or sensitivity to light. In many people, a throbbing pain is felt only on one side of the
head.
Some people who get migraines have warning symptoms, called an aura, before the actual
headache begins. An aura is a group of symptoms, usually vision disturbances, that serve as
a warning sign that a bad headache is coming. Most people, however, do not have such
warning signs.
See also:
Migraine without aura (no warning symptoms)
Migraine with aura (visual disturbances before the headache starts)
Mixed tension migraine (features of both migraines and tension headache)

Alternative Names
Headache - migraine

Causes, incidence, and risk factors

A lot of people get migraines -- about 11 out of 100. The headaches tend to start between the
ages of 10 and 46 and may run in families. Migraines occur more often in women than men.
Pregnancy may reduce the number of migraines attacks. At least 60 percent of women with a
history of migraines have fewer such headaches during the last two trimesters of pregnancy.
Until the 1980s, scientists believed that migraines were due to changes in blood vessels
within the brain. Today, most believe the attack actually begins in the brain itself, and involves
various nerve pathways and chemicals in the brain.
A migraine attack can be triggered by stress, food, environmental changes, or some other
factor. However, the exact chain of events remains unclear.
Migraine attacks may be triggered by:

Allergic reactions
Bright lights, loud noises, and certain odors or perfumes
Physical or emotional stress
Changes in sleep patterns
Smoking or exposure to smoke
Skipping meals
Alcohol
Menstrual cycle fluctuations, birth control pills
Tension headaches
Foods containing tyramine (red wine, aged cheese, smoked fish, chicken livers, figs,
and some beans), monosodium glutamate (MSG), or nitrates (like bacon, hot dogs,
and salami)
Other foods such as chocolate, nuts, peanut butter, avocado, banana, citrus, onions,
dairy products, and fermented or pickled foods

Symptoms
Migraine headaches, which can be dull or severe, usually:
Feel throbbing, pounding, or pulsating
Are worse on one side of the head
Last 6 to 48 hours
Symptoms accompanying migraines include:

Nausea and vomiting

Sensitivity to light or sound
Loss of appetite
Fatigue
Numbness, tingling, or weakness

Warning signs (auras) that can precede a migraine include seeing stars or zigzag lines, tunnel
vision, or a temporary blind spot.
Symptoms that may linger even after the migraine has gone away include:
Feeling mentally dull, like your thinking is not clear or sharp
Increased need for sleep
Neck pain

Signs and tests

Migraine headache may be diagnosed by your doctor based on your symptoms, history of
migraines in the family, and your response to treatment. Your doctor will take a detailed
history to make sure that your headaches are not due to tension, sinus inflammation, or a
more serious underlying brain disorder. During the physical exam, your doctor will probably
not find anything wrong with you.
Sometimes an MRI or CT scan is obtained to rule out other causes of headache like sinus
inflammation or a brain mass. In the case of a complicated migraine, an EEG may be needed
to exclude seizures. Rarely, a lumbar puncture (spinal tap) might be performed.

Treatment
There is no specific cure for migraine headaches. The goal is to prevent symptoms by
avoiding or altering triggers. When you do get migraine symptoms, try to treat them right
away. The headache may be less severe.
A good way to identify triggers is to keep a headache diary. See headache.
When migraine symptoms begin:
Rest in a quiet, darkened room
Drink fluids to avoid dehydration (especially if you have vomited)
Try placing a cool cloth on your head
Over-the-counter pain medications like acetaminophen, ibuprofen, or aspirin are often helpful,
especially when your migraine is mild. (Be aware, however, that chronic usage of such pain

medications may result in rebound headaches.) If these don't help, ask your doctor about
prescription medications.
Your doctor will select from several different types of medications, including:
Ergots like dihydroergotamine or ergotamine with caffeine (Cafergot)
Triptans like sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert),
frovatriptan (Frova), and zolmitriptan (Zomig); these are available as a tablet, nasal
spray, or self-administered injection
Isometheptene (Midrin)
Stronger pain relievers (narcotics)
Many of the prescription medications for migraines narrow your blood vessels. Therefore,
these drugs should not be used if you have heart disease, unless specifically instructed by
your doctor.
If you wish to consider an alternative, feverfew is a popular herb for migraines. Several
studies, but not all, support using feverfew for treating migraines. If you are interested in trying
feverfew, make sure your doctor approves. Also, know that herbal remedies sold in
drugstores and health food stores are not regulated. Work with a trained herbalist when
selecting herbs.
Support Groups
American Council for Headache Education - www.achenet.org
The National Migraine Association - www.migraine.org
National Headache Foundation - www.headaches.org

Expectations (prognosis)
Every person responds differently to treatment. Some people have rare headaches that
require little to no treatment. Others require the use of several medications or even occasional
hospitalization.

Complications
Migraine headaches generally represent no significant threat to your overall health. However,
they can be chronic, recurrent, frustrating, and they may interfere with your day-to-day life.
Stroke is an extremely rare complication from severe migraines. This risk may be due to
prolonged narrowing of the blood vessels, limiting blood flow to parts of the brain for an
extended period of time.

Calling your health care provider

Call 911 if:
You have unusual symptoms not experienced with a migraine before, like speech or
vision problems, loss of balance, or difficulty moving a limb
You are experiencing "the worst headache of your life"

Call your doctor immediately if:

Your headache pattern or intensity is different
Your headache gets worse when you lie down
Also, call your doctor if:
Previously effective treatments no longer help
Side effects from medication occurs (irregular heartbeat, pale or blue skin, extreme
sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea,
constipation, stomach pain, cramps, dry mouth, extreme thirst, or others)
You are likely to become pregnant -- some medications should not be taken when
pregnant

Prevention

Avoid smoking
Avoid alcohol
Exercise regularly
Get enough sleep each night
Learn to relax and reduce stress -- try progressive muscle relaxation (contracting and
releasing muscles throughout your body), meditation, biofeedback, or joining a
support group

If you get at least three headaches per month, your doctor may prescribe medication for you
to prevent recurrent migraines. Such prescription drugs may include:
Beta-blockers such as propranolol (Inderal)
Antidepressants, including tricyclics like amitriptyline (Elavil) or selective serotonin
reuptake inhibitors (SSRIs) such as fluoxetine (Prozac, Sarafem), paroxetine (Paxil),
or sertraline (Zoloft)
Anticonvulsants such as valproic acid (Depacon, Depakene), divalproex sodium
(Depakote), or topiramate (Topamax)
Calcium channel blockers such as verapamil

References
Morantz C. Practice Guideline Briefs. Am Fam Physician. Mar 2005; 71(5); 1019-899.
Schroeder BM . AAFP/ACP-ASIM release guidelines on the management and prevention of
migraines. Am Fam Physician. Mar 2003; 67(6): 1392, 1395-7.
Noble J, ed. Textbook of Primary Care Medicine. 3rd ed. St. Louis, MO: Mosby; 2001.
Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and
Clinical Practice. 5th ed. St. Louis, MO: Mosby; 2002.
Goetz CG, Pappert EJ. Textbook of Clinical Neurology. 2nd ed. Philadelphia, PA: Saunders;
2003.

Migraine Headache
Medical Author: Dennis Lee, MD
Medical Editors: Harley I. Kornblum, MD, PhD, Jay W. Marks, MD
What is a migraine headache?
What are the symptoms of migraine headaches?
How is a migraine headache diagnosed?
How are migraine headaches treated?
Non-medication therapies for migraine
Medication therapies for migraine
What is the treatment for moderate to severe migraine headaches?
Triptans
Ergots
Midrin
What other medications are used for treating migraine headaches?
How are migraine headaches prevented?
What are migraine triggers?
What should migraine sufferers do?
What are prophylactic medications for migraine headaches?
Who should consider prophylactic medications to prevent migraine
headaches?
How effective are prophylactic medications?
What is the proper way to use preventive medications?
What is the treatment for menstrual migraine?
Conclusions
Related migraine articles:
Migraine - on WebMD
What is a migraine headache?
A migraine headache is a form of vascular headache. Migraine headache is caused by a
combination of vasodilatation (enlargement of blood vessels) and the release of chemicals
from nerve fibers that coil around the blood vessels. During a migraine attack, the temporal
artery enlarges. (The temporal artery is an artery that lies on the outside of the skull just under
the skin of the temple.) Enlargement of the temporal artery stretches the nerves that coil
around the artery and causes the nerves to release chemicals. The chemicals cause
inflammation, pain, and further enlargement of the artery. The increasing enlargement of the
artery magnifies the pain.
Migraine attacks commonly activate the sympathetic nervous system in the body. The
sympathetic nervous system is often thought of as the part of the nervous system that
controls primitive responses to stress and pain, the so-called "fight or flight" response. The
increased sympathetic nervous activity in the intestine causes nausea, vomiting, and
diarrhea. Sympathetic activity also delays emptying of the stomach into the small intestine
and thereby prevents oral medications from entering the intestine and being absorbed. The
impaired absorption of oral medications is a common reason for the ineffectiveness of
medications taken to treat migraine headaches. The increased sympathetic activity also
decreases the circulation of blood, and this leads to pallor of the skin as well as cold hands
and feet. The increased sympathetic activity also contributes to the sensitivity to light and
sound sensitivity as well as blurred vision.
Migraine afflicts 28 million Americans, with females suffering more frequently (17%) than
males (6%). Missed work and lost productivity from migraine create a significant public
burden. Nevertheless, migraine still remains largely undertreated and underdiagnosed. Less
than half the sufferers are diagnosed by their doctors.

What are the symptoms of migraine headaches?

Migraine is a chronic condition of recurrent attacks. Most (but not all) migraine attacks are
associated with headaches. Migraine headaches usually are described as an intense,
throbbing or pounding pain that involves one temple. (Sometimes the pain can be located in
the forehead, around the eye, or the back of the head). The pain usually is unilateral (on one
side of the head), although about a third of the time the pain is bilateral. The unilateral
headaches typically change sides from one attack to the next. (In fact, unilateral headaches
that always occur on the same side should alert the doctor to consider a secondary
headache, for example, one caused by a brain tumor). A migraine headache usually is
aggravated by daily activities like walking upstairs. Nausea, vomiting, diarrhea, facial pallor,
cold hands, cold feet, and sensitivity to light and sound commonly accompany migraine
headaches. As a result of this sensitivity to light and sound, migraine sufferers usually prefer
to lie in a quiet, dark room during an attack. A typical attack lasts between 4 and 72 hours.
An estimated 40%-60% of migraine attacks are preceded by premonitory (warning) symptoms
lasting hours to days. The symptoms may include sleepiness, irritability, fatigue, depression
or euphoria, yawning, and cravings for sweet or salty foods. Patients and their family
members usually know that when they observe these warning symptoms that a migraine
attack is beginning.
An estimated 20% of migraine headaches are associated with an aura. Usually, the aura
precedes the headache, although occasionally it may occur simultaneously with the
headache. The most common auras are 1) flashing, brightly colored lights in a zigzag pattern
(fortification spectra), usually starting in the middle of the visual field and progressing outward
and 2) a hole (scotoma) in the visual field, also known as a blind spot. Some elderly migraine
sufferers may experience only the visual aura without the headache. A less common aura
consists of pins-and-needles sensations in the hand and the arm on one side or pins-andneedles sensations around the mouth and the nose on the same side. Other auras include
auditory (hearing) hallucinations and abnormal tastes and smells.
Complicated migraines are migraines that are accompanied by neurological dysfunction. The
part of the body that is affected by the dysfunction is determined by the part of the brain that
is responsible for the headache. Vertebrobasilar migraines are characterized by dysfunction
of the brainstem (the lower part of the brain that is responsible for automatic activities like
consciousness and balance). The symptoms of vertebrobasilar migraines include fainting as
an aura, vertigo (dizziness in which the environment seems to be spinning) and double vision.
Hemiplegic migraines are characterized by paralysis or weakness of one side of the body,
mimicking a stroke. The paralysis or weakness is usually temporary, but sometimes it can last
for days.
For approximately 24 hours after a migraine attack, the migraine sufferer may feel drained of
energy and may experience a low-grade headache along with sensitivity to light and sound.
Unfortunately, some sufferers may have recurrences of the headache during this period.
How is a migraine headache diagnosed?
Migraine headaches are usually diagnosed when the symptoms described above are present.
Migraine generally begins in childhood to early adulthood. While migraines can first occur in
an individual beyond the age of fifty, advancing age makes other types of headaches more
likely. A family history is usually present, suggesting a genetic predisposition in migraine
sufferers. In addition to diagnosing migraine from the clinical presentation there is usually an
accompanying normal examination.
Patients with the first headache ever, worst headache ever, or where there is a significant
change in headache or the presence of nervous system symptoms, like visual or hearing or
sensory loss, may require additional tests. The tests may include blood testing, brain
scanning (either CT or MRI), and a spinal tap.

How are migraine headaches treated?

Treatment is can include non-medication and medication approaches.
Non-medication therapies for migraine
Therapy that does not involve medications can provide symptomatic and preventative
therapy. Using ice, biofeedback, and relaxation techniques may be helpful at stopping an
attack once it has started. If possible, sleep is the best medicine. Preventing migraine takes
motivation for the patient to make some life changes. Patients are educated as to triggering
factors that can be avoided. These include smoking cessation, avoiding certain foods
especially those high in tyramine (sharp cheeses) or those containing sulphites (wines) or
nitrates (nuts, pressed meats). Generally, leading a healthy life style with good nutrition,
adequate water intake, sufficient sleep and exercise may be useful. Acupuncture has been
suggested to be a useful non-medication therapy.
Medication therapies for migraine
Individuals with occasional mild migraine headaches that do not interfere with daily activities
usually medicate themselves with over-the-counter (OTC, non-prescription) pain relievers
(analgesics). Many OTC analgesics are available. OTC analgesics have been shown to be
safe and effective for short-term relief of headache (as well as muscle aches, pains,
menstrual cramps , and fever) when used according to the instructions on their labels.
There are two major classes of OTC analgesics: acetaminophen (Tylenol) and non-steroidal
anti-inflammatory drugs (NSAIDs). The two types of NSAIDs are aspirin and non-aspirin.
Examples of non-aspirin NSAIDs are ibuprofen (Advil, Nuprin, Motrin IB, and Medipren) and
naproxen (Aleve). Some NSAIDs are available by prescription only. Prescription NSAIDs are
usually prescribed to treat arthritis and other inflammatory conditions such as bursitis,
tendonitis, etc. The difference between OTC and prescription NSAIDs may only be the
amount of the active ingredient contained in each pill. For example, OTC naproxen (Aleve)
contains 220 mg of naproxen per pill, whereas prescription naproxen (Naprosyn) contains 375
or 500 mg of naproxen per pill.
Acetaminophen reduces pain and fever by acting on pain centers in the brain. Acetaminophen
is well tolerated and generally is considered easier on the stomach than NSAIDs. However,
acetaminophen can cause severe liver damage in high (toxic) doses or if used on a regular
basis over extended periods of time. In individuals who regularly consume moderate or large
amounts of alcohol, acetaminophen can cause serious damage to the liver in lower doses that
usually are not toxic. Acetaminophen also can damage the kidneys when taken in large
doses. Therefore, acetaminophen should not be taken more frequently or in larger doses than
recommended on the label. For information, please read the Acetaminophen and Liver
Damage article.
NSAIDs relieve pain by reducing the inflammation that causes the pain (They are called nonsteroidal anti-inflammatory drugs or NSAIDs because they are different from corticosteroids
such as prednisone, prednisolone, and cortisone which also reduce inflammation).
Corticosteroids, though valuable in reducing inflammation, have predictable and potentially
serious side effects, especially when used long-term. NSAIDs do not have the same side
effects that corticosteroids have.
Aspirin, Aleve, Motrin, and Advil all are NSAIDs and are similarly effective in relieving pain
and fever. The main difference between aspirin and non-aspirin NSAIDs is their effect on
platelets. Platelets are small particles in the blood that cause blood clots to form. Aspirin
prevents the platelets from forming blood clots. Therefore, aspirin can increase bleeding by
preventing blood from clotting though it also can be used therapeutically to prevent clots from
causing heart attacks and strokes. The non-aspirin NSAIDs also have anti-platelet effects, but
their anti-platelet action does not last as long as aspirin.

Aspirin, acetaminophen, and caffeine also are available combined in OTC analgesics for the
treatment of headaches. Examples of such combination analgesics are Pain-aid, Excedrin,
Fioricet, and Fiorinal.
Finding an effective analgesic or analgesic combination often is a process of trial and error
because individuals respond differently to different analgesics. In general, a person should
use the analgesic that has worked in the past. This will increase the likelihood that an
analgesic will be effective and decrease the risk of side effects.
There are several precautions that should be observed with OTC analgesics:
Children and teenagers should not use aspirin for the treatment of headaches, other
pain, or fever, because of the risk of developing Reye's Syndrome, a life-threatening
neurological disease that can lead to coma and even death.
Patients with balance disorders or hearing difficulties should avoid using aspirin
because aspirin may aggravate these conditions.
Patients taking blood thinners such as warfarin (Coumadin) should not take aspirin
and non-aspirin NSAIDs without a doctor's supervision because they add further to
the risk of bleeding that is caused by the blood thinner.
Patients with active ulcers of the stomach and duodenum should not take aspirin and
non-aspirin NSAIDs because they can increase the risk of bleeding from the ulcer
and impair healing of the ulcer.
Patients with advanced liver disease should not take aspirin and non-aspirin NSAIDs
because they may impair kidney function. Deterioration of kidney function in these
patients can lead to rapid and life-threatening deterioration of their liver disease.
Patients should not overuse OTC or prescription analgesics. Overuse of analgesics
can lead to the development of tolerance (increasing ineffectiveness of the analgesic)
and rebound headaches (return of the headache as soon as the effect of the
analgesic wears off, usually in the early morning hours). Thus, overuse of analgesics
can lead to a vicious cycle of more and more analgesics for headaches that respond
less and less to treatment and occur more frequently.
What is the treatment for moderate to severe migraine headaches?
Migraine-specific abortive medications usually are necessary for moderate to severe migraine
headaches. The abortive medications for moderate or severe migraine headaches are
different than OTC analgesics. Instead of relieving pain, they abort headaches by
counteracting the cause of the headache, dilation of the temporal arteries. In fact, they cause
narrowing of the arteries. Examples of migraine-specific abortive medications are the triptans
and ergot preparations.
Triptans
The triptans attach to serotonin receptors on the blood vessels and nerves and thereby
reduce inflammation and constrict the blood vessels. This stops the headache. The triptan
with the longest history of use is sumatriptan (Imitrex). Sumatriptan is available in the United
States as an injection, oral tablet, and nasal spray. Zolmitriptan (Zomig) and rizatriptan
(Maxalt) are newer triptans that are available as oral tablets and as tablets that melt in the
mouth. Naratriptan (Amerge), almotriptan (Axert) and frovatriptan (Frovalan) are available
only as oral tablets.
Traditionally, triptans were prescribed for moderate or severe migraines after OTC analgesics
and other simple measures failed. Newer studies suggest that triptans can be used as the first

treatment for patients with migraines that are causing disability. (Significant disability is
defined as more than 10 days of at least 50% disability during a three-month period.).
Triptans should be used early after the migraine begins, before the onset of pain or when the
pain is mild. Using a triptan early in an attack increases its effectiveness, reduces side effects,
and decreases the chance of recurrence of another headache during the following 24 hours.
Used early, triptans can be expected to abort more than 80% of migraine headaches within 2
hours.
Side effects of triptans
The most common side effects of triptans are facial flushing, tingling of the skin, and a sense
of tightness around the chest and throat. Other less common side effects include drowsiness,
fatigue, and dizziness. These side effects are short-lived and are not considered serious.
The most serious side effects of triptans are heart attacks and strokes. Triptans are effective
in migraine headaches because they narrow arteries in the head; however, they also can
narrow arteries in the heart. In individuals without existing carotid or coronary artery disease,
the narrowing caused by triptans usually does not cause problems. However, in patients
whose carotid and coronary arteries are narrowed by atherosclerosis or who suffer from
intermittent spasm of the coronary arteries (a condition called Prinzmetal's or variant angina),
the narrowing caused by triptans can further reduce the flow of blood through the arteries and
have been reported to cause heart attacks and strokes. Therefore, triptans should not be
given to patients who have had heart attacks and strokes, or to patients who have symptoms
of atherosclerosis such as angina, transient ischemic attack (TIAs), and intermittent
claudication.
Healthy adults may have atherosclerosis and narrowing of the coronary arteries that are
"silent", that is, without past strokes, transient ischemic attacks, heart attacks, or angina.
Therefore, before prescribing a triptan, a doctor should evaluate patients for possible
atherosclerosis if they have one or more risk factors for developing atherosclerosis. These
risk factors include cigarette smoking, diabetes mellitus, high blood pressure, high levels of
LDL ("bad") cholesterol in the blood, obesity, male and over 40 years of age, female and
postmenopausal, or a family member(s) who have had heart attacks at an early age. Some
patients who are at risk should receive their first dose of a triptan in the doctor's office while
being monitored with an electrocardiogram (EKG).
Triptans can interact with other drugs. For example, there have been rare reports of triptans
causing a "serotonin syndrome" when given together with a selective serotonin reuptake
inhibitor. Selective serotonin reuptake inhibitors (SSRIs) are a class of medications widely
used to treat depression. The symptoms of serotonin syndrome include confusion, fever,
tremor, high blood pressure, diarrhea, and sweating. Certain triptans such as sumatriptan,
zolmitriptan, and rizatriptan can interact with monoamine oxidase inhibitors. Propranolol
(Inderal) can raise rizatriptan blood levels. Cimetidine (Tagamet) can increase zolmitriptan
blood levels.
Triptans should not be used in pregnant women and are not generally used in young children.
Ergots
Ergots, like triptans, are medications that abort migraine headaches. Examples of ergots
include ergotamine preparations (Ergomar, Wigraine, and Cafergot) and dihydroergotamine
preparations (Migranal, DHE-45). Ergots, like triptans, cause constriction of blood vessels, but
ergots tend to cause more constriction of vessels in the heart and other parts of the body than
the triptans, and their effects on the heart are more prolonged than the triptans. Therefore,
they are not as safe as the triptans. The ergots also are more prone to cause nausea and
vomiting than the triptans. The ergots can cause prolonged contraction of the uterus and
miscarriages in pregnant women.

Midrin
Midrin is used to abort migraine and tension headaches. It is a combination of isometheptene
(a blood vessel constrictor), acetaminophen (a pain reliever), and dichloralphenazone (a mild
sedative). It is most effective if used early during a headache; however, because of its potent
blood vessel constricting effect, it should not be used in patients with high blood pressure,
kidney disease, glaucoma, atherosclerosis, liver disease, or taking monoamine oxidase
inhibitors.
What other medications are used for treating migraine headaches?
Narcotics and butalbital-containing medications sometimes are used to treat migraine
headaches; however, these medications are potentially addicting and are not used as initial
treatment. They are sometimes used for patients whose headaches fail to respond to OTC
medications but who are not candidates for triptans either due to pregnancy or the risk of
heart attack and stroke.
In patients with severe nausea, a combination of a triptan and an anti-nausea medication, for
example, prochlorperazine (Compazine) or metoclopramide (Reglan) may be used. When
nausea is severe enough that oral medications are impractical, intravenous medications such
as DHE-45 (dihydroergotamine), prochlorperazine (Compazine), and valproate (Depacon) are
useful.
How are migraine headaches prevented?
There are two ways to prevent migraine headaches: 1) by avoiding factors ("triggers") that
cause the headaches, and 2) by preventing headaches with medications (prophylactic
medications). Neither of these preventive strategies is 100% effective. The best one can hope
for is to reduce the frequency of headaches.
What are migraine triggers?
A migraine trigger is any factor that causes a headache in individuals who are prone to
develop headaches. Only a small proportion of migraine sufferers, however, clearly can
identify triggers. Examples of triggers include stress, sleep disturbances, fasting, hormones,
bright or flickering lights, odors, cigarette smoke, alcohol, aged cheeses, chocolate,
monosodium glutamate, nitrites, aspartame, and caffeine. For some women, the decline in
the blood level of estrogen during the onset of menstruation is a trigger for migraine
headaches. The interval between exposure to a trigger and the onset of headache varies from
hours to two days. Exposure to a trigger does not always lead to a headache. Conversely,
avoidance of triggers cannot completely prevent headaches. Different migraine sufferers
respond to different triggers, and any one trigger will not induce a headache in every person
who has migraine headaches.
Sleep and migraine
Disturbances such as sleep deprivation, too much sleep, poor quality of sleep, and frequent
awakening at night are associated with both migraine and tension headaches, whereas
improved sleep habits have been shown to reduce the frequency of migraine headaches.
Sleep also has been reported to shorten the duration of migraine headaches.
Fasting and migraine
Fasting possibly may precipitate migraine headaches by causing the release of stress-related
hormones and lowering blood sugar. Therefore, migraine sufferers should avoid prolonged
fasting.

Bright lights and migraine

Bright lights and other high intensity visual stimuli can cause headaches in healthy subjects
as well as patients with migraine headaches, but migraine patients seem to have a lower than
normal threshold for light-induced pain. Sunlight, television, and flashing lights all have been
reported to precipitate migraine headaches.
Caffeine and migraine
Caffeine is contained in many food products (cola, tea, chocolates, coffee) and OTC
analgesics. Caffeine in low doses can increase alertness and energy, but caffeine in high
doses can cause insomnia, irritability, anxiety, and headaches. The over-use of caffeinecontaining analgesics causes rebound headaches. Furthermore, individuals who consume
high levels of caffeine regularly are more prone to develop withdrawal headaches when
caffeine is stopped abruptly.
Chocolate, wine, tyramine, MSG, nitrites, aspartame and migraine
Chocolate has been reported to cause migraine headaches, but scientific studies have not
consistently demonstrated an association between chocolate consumption and headaches.
Red wine has been shown to cause migraine headaches in some migraine sufferers, but it is
not clear whether white wine also will cause migraine headaches. Tyramine (a chemical found
in cheese, wine, beer, dry sausage, and sauerkraut) can precipitate migraine headaches, but
there is no evidence that consuming a low-tyramine diet can reduce migraine frequency.
Monosodium glutamate (MSG) has been reported to cause headaches, facial flushing,
sweating, and palpitations when consumed in high doses on an empty stomach. This
phenomenon has been called Chinese restaurant syndrome. Nitrates and nitrites (chemicals
found in hotdogs, ham, frankfurters, bacon and sausages) have been reported to cause
migraine headaches. Aspartame, a sugar-substitute sweetener found in diet drinks and
snacks, has been reported to trigger headaches when used in high doses for prolonged
periods.
Female hormones and migraine
Some women who suffer from migraine headaches experience more headaches around the
time of their menstrual periods. Other women experience migraine headaches only during the
menstrual period. The term "menstrual migraine" is used mainly to describe migraines that
occur in women who have almost all of their headaches from two days before to one day after
their menstrual periods. Declining levels of estrogen at the onset of menses is likely to be the
cause of menstrual migraines. Decreasing levels of estrogen also may be the cause of
migraine headaches that develop among users of birth control pills during the week that
estrogens are not taken.
What should migraine sufferers do?
Individuals with mild and infrequent migraine headaches that do not cause disability may
require only OTC analgesics. Individuals who experience several moderate or severe
migraine headaches per month or whose headaches do not respond readily to medications
should avoid triggers and consider modifications of their life-style. Life-style modifications for
migraine sufferers include:
Go to sleep and waking up at the same time each day.
Exercise regularly (daily if possible). Make a commitment to exercise even
when traveling or during busy periods at work. Exercise can improve the
quality of sleep and reduce the frequency and severity of migraine headaches.
Build up your exercise level gradually. Over-exertion, especially for someone
who is out of shape, can lead to migraine headaches.

Do not skip meals, and avoiding prolonged fasting.

Limit stress through regular exercise and relaxation techniques.
Limit caffeine consumption to less than two caffeine-containing beverages a
day.
Avoid bright or flashing lights and wearing sunglasses if sunlight is a trigger.
Identify and avoid foods that trigger headaches by keeping a headache and food
diary. Review the diary with your doctor. It is impractical to adopt a diet that avoids all
known migraine triggers, however, it is reasonable to avoid foods that consistently
trigger migraine headaches.
What are prophylactic medications for migraine headaches?
Prophylactic medications are medications taken daily to reduce the frequency and duration of
migraine headaches. They are not taken once a headache has begun. There are several
classes of prophylactic medications: beta blockers, calcium-channel blockers, tricyclic
antidepressants, antiserotonin agents and anticonvulsants. Medications with the longest
history of use are propranolol (Inderal), a beta blocker, and amitriptyline (Elavil), an
antidepressant. When choosing a prophylactic medication for a patient the doctor must take
into account the drug side effects, drug-drug interactions, and co-existing conditions such as
diabetes, heart disease, and high blood pressure.
Beta blockers
Beta-blockers are a class of drugs that block the effects of beta-adrenergic substances such
as adrenaline (epinephrine). By blocking the effects of adrenaline, beta-blockers relieve stress
on the heart by slowing the rate at which the heart beats. Beta-blockers have been used to
treat high blood pressure, angina, certain types or tremors, stage fright, and abnormally fast
heart beats (palpitations). They also have become important drugs for improving survival after
heart attacks. Beta-blockers have been used for many years to prevent migraine headaches.
It is not known how beta-blockers prevent migraine headaches. It may be by decreasing
prostaglandin production, though it also may be through their effect on serotonin or a direct
effect on arteries. The beta-blockers used in preventing migraine headaches include
propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor, Lopressor LA, Toprol XL),
nadolol (Corgard), and timolol (Blocadren).
Beta-blockers generally are well-tolerated. They can aggravate breathing difficulties in
patients with asthma, chronic bronchitis, or emphysema. In patients who already have slow
heart rates (bradycardias) and heart block (defects in electrical conduction within the heart),
beta-blockers can cause dangerously slow heartbeats. Beta-blockers can aggravate
symptoms of heart failure. Other side effects include drowsiness, diarrhea, constipation,
fatigue, decrease in endurance, insomnia, nausea, depression, dreaming, memory loss,
impotence.
Tricyclic antidepressants
Tricyclic antidepressants (TCAs) prevent migraine headaches by altering the
neurotransmitters, norepinephrine and serotonin, that the nerves of the brain use to
communicate with one another. The tricyclic antidepressants that have been used in
preventing migraine headaches include amitriptyline (Elavil), nortriptyline (Pamelor, Aventyl),
doxepin (Sinequan), imipramine (Tofranil), and protriptyline.

The most commonly encountered side effects associated with TCAs are fast heart rate,
blurred vision, difficulty urinating, dry mouth, constipation, weight gain or loss, and low blood
pressure when standing.
TCAs should not be used with drugs that inhibit monoamine oxidase such as isocarboxazid
(Marplan), phenelzine (Nardil), tranylcypromine (Parnate), and procarbazine (Matulane), since
high fever, convulsions and even death may occur. TCAs are used with caution in patients
with seizures, since they can increase the risk of seizures. TCAs also are used with caution in
patients with enlargement of the prostate because they can make urination difficult. TCAs can
cause elevated pressure in the eyes of some patients with glaucoma. TCAs can cause
excessive sedation when used with other medications that slow the brain's processes, such
as alcohol, barbiturates, narcotics, and benzodiazepines, e.g. lorazepam (Ativan), diazepam
(Valium), temazepam (Restoril), oxazepam (Serax), clonazepam (Klonopin), zolpidem
(Ambien). Epinephrine should not be used with amitriptyline, since the combination can cause
severe high blood pressure
Antiserotonin medications
Methysergide (Sansert) prevents migraine headaches by constricting blood vessels and
reducing inflammation of the blood vessels. Methylergonovine is related chemically to
methysergide and has a similar mechanism of action. They are not widely used because of
their side effects. The most serious side effect of methysergide is retroperitoneal fibrosis
(scarring of tissue around the ureters that carry urine from the kidneys to the bladder).
Retroperitoneal fibrosis, though rare, can block the ureters and cause backup of urine into the
kidneys. Backup of urine into the kidneys can cause back and flank (the side of the body
between the ribs and hips) pain and ultimately can lead to kidney failure. Methysergide also
has been reported to cause scarring around the lungs that can lead to chest pain, and
shortness of breath.
Calcium channel blockers
Calcium channel blockers (CCBs) are a class of drugs that block the entry of calcium into the
muscle cells of the heart and the arteries. By blocking the entry of calcium, CCBs reduce
contraction of the heart muscle, decrease heart rate, and lower blood pressure. CCBs are
used for treating high blood pressure, angina, and abnormal heart rhythms (e.g., atrial
fibrillation). CCBs also appear to block a chemical within nerves, called serotonin, and have
been used occasionally to prevent migraine headaches. The CCBs used in preventing
migraine headaches are diltiazem (Cardizem, Dilacor, Tiazac), verapamil (Calan, Verelan,
Isoptin), and nimodipine.
The most common side effects of CCBs are constipation, nausea, headache, rash, edema
(swelling of the legs with fluid), low blood pressure, drowsiness, and dizziness. When
diltiazem or verapamil are given to individuals with heart failure, symptoms of heart failure
may worsen because these drugs reduce the ability of the heart to pump blood. Verapamil
and diltiazem may reduce the elimination and increase the blood levels of carbamazepine
(Tegretol), simvastatin (Zocor), atorvastatin (Lipitor), and lovastatin (Mevacor). This can lead
to toxicity from these drugs.
Anticonvulsants
Anticonvulsants (antiseizure medications) also have been used to prevent migraine
headaches. Examples of anticonvulsants that have been used are valproic acid,
phenobarbital, gabapentin, and topiramate. It is not known how anticonvulsants work to
prevent migraine headaches.
Who should consider prophylactic medications to prevent migraine headaches?
Not all migraine sufferers need prophylactic medications; individuals with mild or infrequent

headaches that respond readily to abortive medications do not need prophylactic

medications. Individuals who should consider prophylactic medications are those who:
1. Require abortive medications for migraine headaches more frequently than twice
weekly.
2. Have two or more migraine headaches a month that do not respond readily to
abortive medications.
3. Have migraine headaches that are interfering substantially with their quality of life and
work.
4. Cannot take abortive medications because of heart disease, stroke, or pregnancy, or
cannot tolerate abortive medications because of side effects.
How effective are prophylactic medications?
Prophylactic medications can reduce the frequency and duration of migraine headaches but
cannot be expected to eliminate migraine headaches completely. The success rate of most
prophylactic medications is approximately 50%. Success in preventing migraine headaches is
defined as more than a 50% reduction in the frequency of headaches. Prophylactic
medications usually are begun at a low dose that is increased slowly in order to minimize side
effects. Individuals may not notice a reduction in the frequency, severity, or duration of their
headaches for 2-3 months after starting treatment
What is the proper way to use preventive medications?
Doctors familiar with the treatment of migraine headaches should prescribe
preventive medications.
Decisions about which preventive medication to use are based on the side effects of
the medication and the medical conditions that the patient may have.
Propranolol (Inderal) often is used first, provided that the patient does not have
asthma, COPD or heart disease. Amitriptyline (Elavil) also is used commonly.
Preventive medications are begun at low doses and gradually increased to higher
doses if needed. This minimizes side effects from the medications. Preventive
medications are to be taken daily for months to years. When they are stopped, the
dose needs to be gradually reduced rather than abruptly stopped. Abruptly stopping
preventive medications can lead to headaches.
In some instances, more than one drug may be needed. Non-medication and
behavioral therapies also may be needed.
What is the treatment for menstrual migraine?
There are several aspects to treating menstrual migraines:
1. To abort menstrual migraine, take medications after the onset of menstrual migraine.
Generally, medications that are effective in aborting non-menstrual migraines are
effective at aborting menstrual migraines.
2. To prevent menstrual migraine, take medications just before the onset of
menstruation and continue for the duration of the expected headache. Taking
hormones such as estrogens or estrogen related medications also help to prevent
migraine.

3. To reduce the frequency and duration of menstrual migraine, take prophylactic

medications (such as beta blockers, calcium channel blockers, anticonvulsants,
tricyclic antidepressants) that are normally used on a continuous basis to prevent
non-menstrual migraines.
NSAIDs such as naproxen sodium (Aleve) or ibuprofen (Advil, Motrin) have been used
effectively to abort menstrual migraines. A combination analgesic containing acetaminophen,
aspirin, and caffeine (ACC) can also be used to treat menstrual migraines. For women whose
menstruation and menstrual migraines occur on a regular and predictable pattern, NSAIDs
may be used 24 hours before the expected onset of menstrual migraine and continued for the
expected duration of the headache. Since NSAIDs inhibit prostaglandins, they have the
added benefit of relieving menstrual cramps as well. For NSAIDs side effects and
precautions, please read the "Medication therapies for migraine" section of this article.
Triptans (naratriptan, rizatriptan, sumatriptan, zolmitriptan) have been found to be effective in
aborting menstrual migraines, as well as controlling the associated nausea and vomiting.
Sumatriptan given 2-3 days before and continued for the duration of the expected headache
was found to be effective in reducing the frequency and severity of menstrual migraine.
Naratriptan used in the same manner has also been found to be effective in preventing
menstrual migraine. However, in those cases where breakthrough headaches occurred, they
were just as severe as in patients taking placebo. For side effects and precautions of triptans,
please read the "Triptans" section of this article.
Dihydroergotamine (DHE) can be used as a nasal spray or given intramuscularly or
intravenously to abort menstrual migraines. Ergotamine (oral, rectal, or intranasal) and DHE
(intranasal, intramuscular, or intravenous) can be used around the time of menstruation
(several days before and continued for the duration of the expected headache) to prevent
menstrual migraines. For ergot side effects and precautions, please read the "Ergots"
section in this article.
If these medications are ineffective, doctors may try daily preventive medications such as
beta-blockers, anticonvulsants, calcium channel blockers, and tricyclic antidepressants to
reduce the frequency and the severity of menstrual migraines. The choice of the preventive
medications is based on the experiences and preferences of the doctor, the medication side
effects, and the woman's other associated medical conditions.
For women already taking preventive medications and yet still experience headaches, the
doses of preventive medications can be increased around the time of the menstruation (some
doctors use preventive medications only around the time of the menstruation). Alternatively
doctors may try hormone treatment.
Since a drop in estrogen level just prior to menstruation is the trigger for menstrual migraines,
estrogen replacement before menstruation has been used in preventing menstrual migraines.
For some women with menstrual migraine, Estradiol skin patches (such as TTS 50, TTS 100)
applied 2 days before menstrual migraine and continued for 7 days during the expected
headache period is effective. However, the dose of estrogen must be closely monitored, as
too high of a dose can actually trigger migraine in susceptible individuals.
Some women with difficult to treat menstrual migraines may be helped by using low dose oral
contraceptives to reduce the estrogen fluctuations. Other less frequently used medications for
menstrual migraines include tamoxifen, bromocriptine, danazol and gonadotropin-releasing
hormone (GnRH).
Conclusions
Migraine is often under-diagnosed and under-treated. There is no cure for migraine.
Nevertheless, there are numerous interventions that may help restore an improved life for
migraine sufferers. These measures should consider the various aspects of the particular

patient's condition. Triggering factors, nerve inflammation, blood vessel changes and pain are
each addressed aggressively. Individualizing treatment is essential for optimal outcome.
References:
1. Stephen D. Silberstein, MD, FACP. Practice parameter: Evidence-based guidelines for
migraine headache (an evidence-based review): Report of the Quality Standards
Subcommittee of the American Academy of Neurology. Neurology. 2000;55:754-762.
2. Roger Cady, MD, David W. Dodick, MD. Diagnosis and Treatment of Migraine. Mayo Clin
Proc. 2002;77:255-261.
3. Dowson AJ, Lipscombe S, Sender J, Rees T, Watson D. New Guidelines for the
Management of Migraine in Primary Care. Curr Med Res Opin. 2002;18(7):414-439.
4. Patwardhan MB, Samsa GP, Lipton RB, Matchar DB. Changing physician knowledge,
attitudes, and beliefs about migraine: evaluation of a new educational intervention. Headache.
2006 May;46(5):732-41.
5. Holroyd KA, Drew JB. Behavioral approaches to the treatment of migraine. Semin Neurol.
2006 Apr;26(2):199-207.
6. Ramadan NM. Migraine headache prophylaxis: current options and advances on the
horizon. Curr Neurol Neurosci Rep. 2006 Mar;6(2):95-9.
7. National Guideline Clearinghouse. Treatment of primary headache: acute migraine
treatment. Standards of care for headache diagnosis and treatment.
From: Landy S, Smith T. Treatment of primary headache: acute migraine treatment. In:
Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache
Foundation; 2004. p. 27-39. [11 references].
8. Vincenza Snow, MD. Acute Migraine Treatment Guideline. Annals of Internal Medicine.
2003 Oct 1; 139(7):603-4.
9. National Guideline Clearinghouse. Pharmacologic management of acute attacks of
migraine and prevention of migraine headache. From: Snow V, Weiss K, Wall EM, MotturPilson C. Pharmacologic management of acute attacks of migraine and prevention of
migraine headache. Ann Intern Med 2002 Nov 19;137(10):840-52. [121 references].
10. Goetz CG, Pappert EJ. Textbook of Clinical Neurology. 2nd ed. Philadelphia, PA:
Saunders; 2003.
Medically Reviewed by: Joseph Carcione, D.O., M.B.A., Board Certified Neurology
Call in Sick or Go to Work? Here's Some Advice
Sometimes it's hard to tell whether you're well enough to go to work. Here's how to tell
if you're contagious.
By Jeanie Lerche Davis
WebMD Feature
Reviewed By Michael Smith, MD

The alarm's buzzing ... but something's not right. You're sniffly, sneezy ... queasy. You have a
common cold. Or is it something worse? Should you drag yourself to work? Or spend the day
in front of the tube?
"Presenteeism" -- going to work when you're sick -- is as contagious as the flu. Millions of
Americans are doing it. By one estimate, upwards of 75% head to work with the common cold
or other problems.
Sure, sick employees keep the computer warm. But research shows that people sick with the
common cold are not very productive. In fact, their lost productivity accounts for up to 60% of
employer health costs -- more than if they'd taken a sick day.
So you wake up with a common cold or some other ailment that's getting you down. What
should you do?
To help you decide, Sharon Horesh, MD, instructor of clinical medicine at Emory University
School of Medicine in Atlanta, gives her advice.
Just keep this in mind: "There's no antibiotic that can get rid of the common cold or flu or
stomach virus," Horesh tells WebMD. "That's my pet peeve ... antibiotics only work with a
bacterial infection ... bacterial bronchitis, pneumonia, strep throat, earache, pink eye."
Also, be careful about which medications you take for the common cold, says Nathan Segall,
MD, a private practice allergy specialist in Atlanta.
The overwhelming majority reach for over-the-counter antihistamines, he says. But beware:
Even if it's a so-called "non-sedating antihistamine" it could cause sleepiness and mental
fogging, says Segall. "Some individuals will be more likely to have these side effects than
others will."
That turns into a double-whammy: The common cold itself will affect your ability to
concentrate because of clogged nasal passages and headache. Add a bit of drowsiness
(whether it's from the pills or from difficulty sleeping). Pretty soon, you're making mistakes at
the keyboard, barking at co-workers, generally feeling miserable. Even if it's just the common
cold, maybe you should have called in sick.
To keep it from happening again, here's a checklist of symptoms that help you determine if
you have a common cold or something else:
Sniffling
If you are sniffling -- but not achy, not feverish -- it's probably allergies. Get to work!
Sniffling, achy, tired, fever? You're coming down with the common cold or the flu. You are
contagious in those first days. You are miserable, face it. You're not going to get much done
at work. Also, you will recover quicker from the common cold or flu if you get some rest,
says Horesh.
Chills, Sweats
If your clothes are getting drenched, you likely have a fever. (A warm forehead is a very lowgrade fever or nothing at all.) When you have a fever, stay home -- you're contagious! It's
likely flu or, yes, the common cold. Drink fluids. Stay away from work until you feel better,
Horesh advises.
If you have a fever plus white patches on your tonsils (say "ah"), it may be strep throat. It's
highly contagious. You may need an antibiotic. See a doctor!

Coughing
If it's a tickle in the throat or it feels like postnasal drip, the cough is probably from allergies
or the common cold. Unless you've got other common cold symptoms, such as aches or
fever, get to work!
If the cough feels deep, makes you short of breath, and brings up green mucus, it's likely
more than the common cold -- perhaps bronchitis or pneumonia, according to Horesh. See
a doctor!
Earache
If your ear really hurts, if you can't hear well, you may have an ear infection. That's not
contagious. Congestion from a common cold can also leave your ear in pain. You need to
see a doctor to see which it is. You may need an antibiotic. Ear infections usually don't go
away on their own, she says.
Pinkeye
If your eyes are bright red, if there's creamy white stuff in the corners, if your eyelashes are
getting matted, that's likely pinkeye, which is highly contagious. Don't go to work. See a
doctor for an antibiotic. It's another infection that needs antibiotic help, Horesh tells WebMD.
Sinus Pain
Pain around the eyes, top of the forehead, the cheekbones, even the top of your teeth are
signs of a sinus infection, but it could be a common cold. Call in sick and see a doctor to see
if you need an antibiotic. Next day, you'll likely be able to get yourself to work since sinus
infections aren't typically contagious, Horesh advises.
Tummy Problems
A stomach virus -- nausea, vomiting, watery diarrhea, aches, low-grade fever -- can lay you
low for several days. For 24-48 hours, you'll be absolutely miserable. It can take up to five
days to recover. Drink lots of fluids, especially water, so you don't get dehydrated, says
Horesh.
For the first day or two, fluids and soup should be your diet. Then it's soft solids like mashed
potatoes, applesauce, Jell-O, toast, and bananas. Slowly get into solid foods like meat. If
you eat solid food too early, it just upsets your stomach more.
With food poisoning, vomiting and diarrhea usually occur six to 12 hours after you eat. Time
frame is helpful for distinguishing it from a stomach virus. With food poisoning, once you
vomit, you feel better.
Rule of thumb: If you can hold down food, you can go into work.
Sprains/Strains
Go to work if you sit at a computer all day. But if you're on your feet, you will have more
swelling, so wait until you can walk with little discomfort. An Ace bandage will give support
to an ankle so you won't reinjure it, Horesh advises. Anti-inflammatory pain relievers help
most people, even if they're not in a lot of pain, because they reduce swelling; take it with
food so your stomach isn't irritated.
An ice pack is a good way to reduce swelling without risking stomach problems.

Headaches/Migraines
Though headaches can be caused by things like the common cold, if you can't tolerate
noise or light, you likely have a migraine and shouldn't be at work, says Horesh. If you
haven't seen a doctor for your migraines, make an appointment. There's no point in
suffering with them. There are drugs you can take for migraines that start working within the
hour and shorten the migraine's duration.
Poison Ivy
This shouldn't keep you at home (unless your eyes are swollen shut). The rash is not
contagious and you can't pass it to anyone else. People often mistakenly think that the poison
ivy is spreading from one area of the body to another. However, poison ivy develops only
when you come in direct contact with uroshiol, the substance in poison ivy that triggers the
allergic reaction.
Published Oct. 6, 2004.