Understanding and Managing Migraines 

Head-splitting pain. Hypersensitivity to light and noises. Overwhelming nausea. Each of these symptoms is hard enough to deal with on its own. Now imagine having them all at once, multiple times a month. That’s the reality for many people with migraines.

Migraines aren't just headaches—they're significant sources of pain that more than one billion people grapple with worldwide and are one of the leading causes of disability.

Living with migraines can be difficult, but there are many strategies to treat and prevent them. Meital Ben Dov, MD, a Columbia neuro-ophthalmology specialist, explains how to identify migraine symptoms, what causes them, and what to do—and avoid—to treat them effectively.

What are migraines?

Migraine is a neurological disease that causes a variety of symptoms, including recurrent, debilitating headaches. Migraine attacks happen when nerves in and near blood vessels are activated and send pain signals to your brain. Each of these attacks can last for weeks.

The main symptoms of a migraine are intense throbbing headache, typically on one side of your head, and the following:

• Sensitivity to light and/or sound 
• Blurry vision  
• Dizziness 
• Upset stomach, including nausea, vomiting, and loss of appetite 

Some people with migraines also experience auras. Auras are usually visual, sensory, physical, or verbal disturbances—such as seeing spots, lines, or flashes; vision loss; and tingling or numbness in limbs—that usually occur before or during headaches. 

Recognizing migraine symptoms 

Migraine has four phases. Not every person who has migraine experiences all four phases, and each attack can be different. Some symptoms can occur across more than one phase.  

1. Pre-headache: Can be experienced up to seven days before head pain starts. Signs include cravings, irritability, and tiredness. 
2. Aura: Aura can last up to 60 minutes before head pain starts. 
3. Head pain: What most people associate with migraine is the third phase, which can include nausea, vomiting, and the need to lie down. Pain lasts for at least four hours. The longer you wait to treat migraine, the longer it will last. 
4. Postdrome: After the headache, symptoms can still be intense, including feelings of confusion or brain fog, similar to a hangover.  

Identifying migraine triggers

Many situations can lead to a migraine. Some are out of our control, such as hormonal fluctuations, genetic factors, imbalances in brain chemicals like serotonin, and even changes in the weather.

Specific foods can also be triggers. Aged cheeses, processed meats, chocolate, caffeine, alcohol, MSG, artificial sweeteners, smoked foods, citrus fruits, bananas, and avocados are known to contribute to migraines.

Other potential factors include stress, certain medications, and environments with loud sounds or bright lights.

How to treat migraines

Though migraines are difficult to live with, there are several ways to relieve symptoms and prevent them from happening in the first place.

Lifestyle adjustments 

One of the most important strategies for managing migraines is avoiding triggers. Getting enough sleep, eating meals at consistent times, and being physically active can make a big difference in how often you experience migraines.

It can be hard to keep track of all of your potential triggers, so keeping a detailed diary of symptoms, sleep changes, menstrual cycles, ovulation, and food consumption can be invaluable.

Acute-phase medications  

The earlier migraines are treated, the better the results. For mild migraines, over-the-counter pain relievers like NSAIDs or acetaminophen can provide relief. When attacks include vomiting or nausea, antiemetic medication, such as metoclopramide or prochlorperazine, can address those symptoms. Antiemetics can be used alone or combined with a migraine-specific medication.

More severe cases might require prescription options, including: 

• Triptans: Triptans constrict blood vessels and block pain pathways in the brainstem. They work better when combined with NSAIDs than when used alone. 
• Ergotamine medications: Ergotamine medications constrict blood vessels and help treat pain. Some are combined with caffeine.
• Oral CGRP antagonists: These medicines regulate levels of a chemical messenger called CGRP, which affects how migraine pain is transmitted in the head. These are typically used when triptans aren’t effective or a patient can’t take them due to another condition. 

Long-term preventive treatment

When migraines are severe or frequent, prevention is an important strategy. Options for prevention include beta-blockers, antidepressants, antiepileptic drugs, and CGRP antagonists taken by mouth or injection.

It's essential to consult your neurologist, who can tailor treatment to your medical history. Some options include combining treatments, such as using beta-blockers for hypertension and migraines.

What not to do for your migraines

It's important to use caution and moderation when using acute headache treatments such as pain relievers, triptans, and ergots. Overreliance on these medications can lead to complications. 

Additionally, avoid using opioids and barbiturates. These substances are not only highly addictive, but also increase the risk of developing chronic daily headaches and can affect how well other preventive therapies work.

Migraines can be disabling, but they’re common and treatable. If you think you experience migraines, be sure to see a physician so you can get started on a treatment plan that works for you.