Types of migraine
The three main types are:
- migraine with aura
- migraine without aura
- migraine aura without headache
One in three people who get migraines have an aura. This is a warning sign that you’re about to have a migraine attack. It usually happens up to an hour before. Common symptoms are tingling sensations and visual problems like blurred vision.
You may experience more than one type of migraine attack, or change between types. Older people are most likely to have an aura without then developing a headache.
Other specific types of migraine may mainly affect children or women, last for a long time, run in families or be linked to particular symptoms. But the treatment is often the same for all forms of migraine.
Symptoms of migraine
You may notice signs that a migraine is on its way a few hours or even days before you have an attack. This is called the ‘prodrome’ or ‘premonitory phase’. You may yawn a lot, get cravings for certain food and have mood swings.
You may get aura symptoms as well, sometimes just minutes before your headache starts. You may have blurred vision or blind spots or see flickering lights. Your face, lips, tongue, arms or legs may tingle. You may feel dizzy or find it hard to speak clearly. These symptoms are only temporary but can last up to a couple of hours.
Migraine headaches can last for between four hours and three days. You’ll probably have a throbbing, pulsating or banging pain at the front or on one side of your head. Even everyday activity like walking or climbing stairs may make the pain worse.
Other common symptoms are:
- feeling or being sick
- stomach ache
- needing to urinate more often
- pain in your neck, behind your eyes and across your nose and jaw
- feeling hot or cold
- sensitivity to light, noise and smells
It can take a while to recover from a migraine. You may feel tired and irritable and find it hard to concentrate.
The number of migraines people get and how long they last varies a lot. Some get attacks once a year or less; others several times a week. If you have headaches for less than 15 days a month, this is called episodic migraine. More frequent attacks are referred to as chronic migraine.
Complications of migraine
You don’t usually need to visit a doctor if you get a migraine attack, especially if you’ve already been diagnosed and are getting treatment. But you should see your GP if:
- your migraines become more frequent or get worse over time
- you have your first migraine and you’re over 50
- you have a child under the age of 10 who develops a migraine
- you get a headache when you change posture, like standing up
- you have had cancer or have HIV and are getting new headaches
- a condition or medication you’re taking affects your immune system and you get new headaches
If your migraines seem connected to seizures, weight loss, fever, eye and speech problems or blackouts, and if you’re woken by headaches, your GP may want to refer you to a specialist for further investigation.
You should get immediate medical advice if:
- you have a sudden and very severe headache, sometimes called a ‘thunderclap’ headache
- you get different or more severe aura symptoms than usual, especially if you start to lose your balance, pass out, struggle to move or have double vision or problems in only one eye
Chronic migraine is when you get headaches on more than 15 days a month over at least three months. And on eight of these days you have a migraine. Chronic migraines can have a big effect on your life. You may take increasing amounts of medicine to help control your symptoms, but this can cause more headaches, called medication-overuse headaches. Your GP can provide advice on how to tackle this.
Hormonal changes in women
Women are three times more likely to get migraines than men. About 18 in every 100 women get migraines, while only about six in every 100 men do. Women who have migraines on average start when they’re about 18 years old. Men often start younger.
Women’s hormone levels can affect their migraines. Over half of women who have migraines say that their symptoms are linked to their periods (menstrual cycle). This is called menstrually-related migraine. But just one in 10 get migraines only during their period. This is known as menstrual migraine.
If you think you may be experiencing one of these, keeping a diary of your migraines and symptoms, over at least three menstrual cycles, may help identify which type you have. Your GP needs to know this to prescribe the most suitable treatment.
You may have migraines a couple of days before your period starts or finishes.
Migraines may stop or get better during pregnancy. There are migraine medicines you should avoid while pregnant (or breastfeeding). Your GP or pharmacist can advise on which painkillers and anti-sickness medicines are still safe to use.
You may find your migraines get more frequent and severe when you go through the menopause. Hormone replacement therapy (HRT) helps some women, but makes migraines worse for others. Changing the type of HRT, and how much you take, may help.
Oral contraceptives can also have an effect on your migraines. Some women find they make their migraines worse, but for other women oral contraceptives can improve migraines.
Tell your GP if you use an oral contraceptive and think it may be linked to your migraines. They may suggest you try a different pill or alter the schedule you use to take it.
You shouldn’t take the combined oral contraceptive pill if you get migraines with aura. This is the tingling sensation and visual problems like blurred vision you can get up to an hour before the attack. You should contact your GP about stopping this type of contraceptive if you have a migraine without aura and get new or more serious symptoms. You may be able to use a progesterone-only pill instead.
Risk of stroke
A stroke happens when the blood supply to part of your brain is cut off, causing damage to the brain cells.
You have a slightly higher risk of stroke if you have some types of migraine, especially migraines with aura. The risk is increased further if you smoke, have high blood pressure, high cholesterol levels or are overweight.
There’s an added risk of having a certain type of stroke if you’re a woman under 45 who gets migraines with aura. The risk is greater if you also smoke or take the combined oral contraceptive pill. The progesterone-only pill is a safer option.
Some of the symptoms of migraine and stroke are similar, although they appear at different rates. Auras can be confused with a transient ischaemic attack, which causes temporary signs of stroke. Some strokes cause a sudden severe headache, which could be mistaken for migraine. There’s also a rare type of stroke called a migrainous stroke that causes lasting neurological symptoms.
Talk to your GP if you’re worried that any of your migraine symptoms could be signs of stroke, or if you’re at increased risk of stroke.
Causes of migraine
Doctors don’t fully understand exactly what causes migraines. It used to be thought that migraine was mainly due to changes in blood vessels in the brain. Now there’s evidence that it may result from inflamed brain cells making nerve fibres over-sensitive and interpreting normal things as painful.
It’s believed aura symptoms could be caused by a reduction in the brain’s normal electrical activity.
Migraines also tend to run in families so there may be a genetic link. One rare type called ‘familial hemiplegic migraine’ is linked to changes in certain genes.
Some things known to make you more likely to get migraines are:
You may not be able to avoid these but most can be treated, for example, through therapy.
If you get migraines, you may notice certain everyday things that trigger an attack within a few hours or days. These are different for everyone, and you might not have any triggers at all.
Common triggers are:
- stress, or relaxing after a stressful period
- too much or too little sleep
- changes in sleep patterns, like shift work
- long-distance travel
- changes to mealtimes or missed meals
- certain food or drink, like cheese, chocolate and alcohol
- loud noises
- bright or flickering lights
- strong smells, including perfume
- a smoky or stuffy atmosphere
- extremes of weather
- strenuous exercise if you’re not used to it
- periods (menstruation)
If there’s an obvious link between something and a migraine attack, you can try to avoid or minimise it. Certain food and drink is a trigger for migraines in around one in five people. You should get advice from a dietitian if you're considering excluding lots of suspect foods.
It can be hard to detect specific triggers, especially when they may combine to start an attack, so try not to get too hung up on identifying them.
Diagnosis of migraine
There isn’t a specific test that can diagnose migraines. It’s more about piecing together information on your symptoms and identifying patterns. Migraines can be unpredictable so a definite diagnosis can take time.
It helps to keep a ‘headache diary’ for at least eight weeks. Note when you have headaches, the site of the pain, how long they last and how severe they are. Write down your symptoms – including how you feel up to three days before an attack – and possible triggers. Record what medications you take and what effect they have.
The Migraine Trust has a helpful migraine diary template that you can use.
This will help your GP spot a pattern. As well as your headaches, they’ll want to know about your health between attacks and any family history of migraines. Your GP may also examine you, particularly your scalp, neck, eyes, coordination and reflexes, and take your blood pressure.
For migraine without aura, you’ll need to have five or more migraines before your GP can confidently give a diagnosis. Each one will last between four hours and three days and feature certain symptoms.
A diagnosis of migraine with aura is based on two or more attacks when you get specific aura symptoms that each last under an hour.
Your GP will want to rule out other conditions that could be causing your headaches. They may refer you for tests, or to see a specialist if any symptoms aren’t typical of migraine like poor balance or double vision.
Treatment of migraine
There is no cure for migraines that stops them for good, although you’ll probably find your migraines get better as you get older. But there are treatments that can control your symptoms so they don’t affect your life as much. Others can stop you getting attacks so often or so severely.
It may take a while to find the treatment that works best for you. While this is happening, you’ll need to see your GP regularly to check how you’re doing. It can help to keep a record of your symptoms and how different treatments have worked, including any side-effects you’ve noticed.
Migraines can change over time. Once you’ve settled on a treatment, you should see your GP or pharmacist at least once a year to be sure it still meets your needs. You should contact your doctor if your migraines get more severe or more frequent.
When you get a migraine, it’s best to rest in a quiet, darkened room. Applying pressure, an ice pack or hot-water bottle to the painful area can help.
A healthy lifestyle and regular routine can improve your overall wellbeing and fitness. It’s particularly important to keep blood sugar levels steady. This can help you cope with or even reduce migraines.
- avoid skipping meals – eating little and often is best
- avoid getting dehydrated – drink plenty of water
- get enough sleep
- take regular exercise
- eat a balanced diet
Your practice nurse can give you advice on a healthy lifestyle, and on relaxation and stress management, which may help as well.
Different types of medicine are used to treat migraines, depending on your symptoms and how severe your migraines get. The important thing is to take them as soon as your migraine starts. A combination of medicines may work best.
You may have already been taking over-the-counter painkillers, such as ibuprofen, aspirin and paracetamol, for your headaches before your GP has diagnosed migraine. They may advise you carry on with these, if they help.
Your GP may suggest an anti-sickness (anti-emetic) tablet as well, especially if nausea or vomiting are among your main symptoms. You can buy over-the-counter medicines for motion sickness or to help calm your stomach. You should avoid painkillers containing codeine, which can make nausea worse.
You’ll want the painkillers to work quickly so you could try soluble painkillers, which dissolve in water, or fast-acting tablets. Always read the patient information leaflet that comes with your medicine. Some may not be suitable if you’re pregnant or have certain medical conditions. If you have any questions, ask your pharmacist for advice.
If over-the-counter medicines don’t help your migraines, your doctor may prescribe other types. Some prescription painkillers and anti-sickness medicines dissolve in your mouth or are taken as suppositories. This is better if you feel sick and find it hard to swallow tablets when you’ve got a migraine.
For more severe attacks your GP may suggest special anti-migraine medicines called triptans. They’re available as tablets, dissolvable wafers, nasal sprays or injections. Triptans may not be suitable if you have high blood pressure, or kidney or heart problems.
Unfortunately, up to half of all people who take triptans find their migraine symptoms come back within two days. Your GP may advise trying a combination of painkillers, anti-sickness medicines and triptans to reduce your symptoms and help you function normally.
If you use any type of painkiller for your migraine too frequently, it may become less effective and cause further headaches. You may get medication-overuse headaches if you use painkillers for 15 or more days a month. If you’re worried that you may have this type of headache, speak to your GP.
Prevention of migraine
As well as having a healthy lifestyle and avoiding things you know trigger your migraines, there are specific treatments that can stop you having attacks so often. Your GP may offer these if you have several migraine attacks a month that make it impossible to carry on as normal for days at a time. These preventive treatments may take a few weeks to become effective.
Medicines to prevent migraines may also be an option if treatments to reduce pain and other symptoms haven’t worked or aren’t suitable for you. Using these should mean you take fewer painkillers so there’s less risk of medication-overuse headaches.
You may be prescribed a low dose of medicines such as beta-blockers, amitriptyline or anticonvulsants. They are often used to treat other conditions like angina or epilepsy, but they may help to reduce the number of migraines you have. You’ll need to take them for up to six months, with regular check-ups to see what effect they’re having.
For some people with chronic migraines, regular Botox injections are a possible alternative. There’s also a treatment called occipital nerve block, which involves having local anaesthetic and steroids injected at the back of the head. There’s no strong evidence that this is effective for migraines, but it appears to work for some people. A specialist may provide it for your migraine if nothing else is working.
If medicines don’t work or you’d rather not take them, your GP may suggest a course of acupuncture. This isn’t widely available on the NHS so you’ll probably have to pay for it. Cognitive behavioural therapy, physiotherapy, stress management or relaxation with a skilled therapist may also help.
Some people find that the vitamin riboflavin may reduce migraine severity and frequency. This is found in dairy foods, green vegetables, whole grains, almonds, poultry and lean meat. You should talk to your pharmacist before taking any supplements or herbal remedies. They may interact with your medicines.
Specialist and emergency treatment of migraine
If your migraines change, don’t improve with treatment, or there’s uncertainty about the diagnosis, your GP may refer you to a specialist migraine clinic or a neurologist. This is a doctor who specialises in investigating, diagnosing and treating conditions of the nervous system.
You may need hospital treatment if you have a severe migraine that lasts more than three days, or if your GP is concerned about new symptoms. These may include seizures, feeling confused or a lack of coordination, which could indicate another condition.
Emergency treatment can involve giving you oxygen or injected migraine medicines that act quickly. You may need a drip inserted in a vein to rehydrate you, especially if you’ve been sick a lot.
FAQ: Is migraine different in children?
About one in 10 schoolchildren get migraines. They can start at any age.
Children’s migraines are generally shorter than adult attacks, but may still last for up to three days. They’ll often be completely fine in between.
They’re more likely to have pain over their whole head. (Headaches tend to be one-sided in adults.) Your child may feel sick or vomit. They may also have abdominal (tummy) pain rather than a headache. Asthma, allergies, travel sickness and seizures are more common in children who get migraines.
Younger children may be unable to explain their symptoms clearly, but you can guess at them from their behaviour. They may cover their eyes or ears from light and noise, close the curtains and want to lie down somewhere quiet.
It’s a good idea to keep a diary of your child’s migraines. Note their length and frequency, if anything triggers attacks, and what relieves symptoms. This will help your doctor to assess and treat them.
Most migraine treatments are suitable for children and adolescents. But they may be prescribed lower doses or take them differently. If they’re aged between 12 and 17, for instance, they’ll need to take triptans in a nasal spray, not tablets.
Face-to-face relaxation therapy and cognitive behavioural therapy may help reduce the pain.
Your GP may want your child to see a paediatric doctor specialising in migraines in children to make a definite diagnosis. A specialist may be able to suggest other treatment, particularly suited to children, when the usual medicines don’t work.
You should seek urgent medical help if your child has had a migraine for three days, or has a sudden, severe headache without any migraine symptoms.
FAQ: Is it safe to drive with a migraine?
If your migraine symptoms include visual disturbances, dizziness, and difficulty concentrating, these may make you vulnerable to errors when driving. If you get an attack while driving, pull over and stop as soon as you can. Always have your medication with you so you can treat your migraine immediately. But make sure your medicines won’t affect your ability to drive.
Your GP can advise you on whether you need to tell the Driver and Vehicle Licensing Authority (DVLA) about your migraines.
FAQ: What's transcranial magnetic stimulation?
A headache specialist may suggest you use something called a ‘transcranial magnetic stimulation device’ at home to reduce the severity of your migraines. This transmits magnetic pulses to your scalp. It may be an option if you can’t take medicines – if you’re pregnant, for example. There’s evidence these devices are safe and effective, but long-term research is going on.
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Reviewed by Vicky Burman, Freelance Health Editor, November 2016
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