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Migraine Headache

What is a migraine headache?

By far the most common type of headaches we see in our practice, migraines are the most frequent cause of disabling, recurring headaches.

What are the symptoms of a migraine?
Individual migraines are moderate to severe in intensity, often characterized by a throbbing or pounding feeling. Although they are frequently one-sided, they may occur anywhere on the head, neck, and face – or all over. At their worst, they are typically associated with sensitivity to light, noise, and/or smells. Nausea is one of the most common symptoms and it worsens with activity, which often results in patient disability. In many respects, migraines are much like alcohol-related hangovers.

Migraine pain can be felt in the face, where it may be mistaken for sinus headache – or the neck, where it may be mistaken for arthritis or muscle spasm. Complicating a migraine the diagnosis of migraine is that the headaches may be accompanied by other “sinus-like” symptoms, including watering eyes, nasal congestion, and a sense of facial pressure. Most patients who think they have sinus headache in fact have migraines.

In up to 25 percent of patients, the migraine headache pain may be preceded by an aura, a temporary neurological syndrome that slowly progresses and then typically resolves just as the pain begins. While the most common type of migraine aura involves visual disturbances (flashing lights, zig-zags, blind spots), many people experience numbness, confusion, trouble speaking, vertigo (spinning dizziness), and other stroke-like neurological symptoms. Some patients may experience their auras without headaches.

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How prevalent are migraines?
Migraines are about three times more common in women than men, and may affect more than 12 percent of the U.S. adults population. Migraines often run in families, and can start as early as elementary school, but most often in early adulthood. They often fade away later in life, but can strike at any time. The most common cause of recurring, disabling headaches, migraines are also the most common underlying cause of a disabling chronic daily headache. While migraines are the number one reason that patients see a neurologist, most cases are handled by primary care physicians.

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What triggers a migraine?
Triggers which can make the headaches more likely to occur on any given day include:

  • Alcohol
  • Weather changes
  • Lack of sleep
  • Schedule changes
  • Dehydration
  • Hunger
  • Certain foods
  • Strong smells
  • Teeth grinding at night
  • Menstruation

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How are migraines diagnosed?
Despite their dramatic symptoms, migraines are almost never due to any underlying problem that will show up on any testing, even on brain MRIs. In fact, many experts do not recommend brain imaging at all, even in severe cases, as long as the patient’s symptoms are typical for migraines, and a thorough neurological examination is normal.

There are extremely rare families who have migraines as a result of a single genetic mutation in one of four known genes that can lead to the condition called “familial hemiplegic migraine”. There are no genetic tests for the vast majority of patients. Thus, because the condition cannot be diagnosed by scan or by blood test, the diagnosis is “clinical”, made by an experienced physician.

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How are migraines treated?
Migraines that are severe, frequent, or that are accompanied by neurological symptoms are best treated preventatively, usually with a combination of dietary modification, lifestyle changes, vitamins, and daily prescription medications. Most of our best preventative medications are often used for other medical purposes as well; the majority are blood pressure drugs, antidepressants, or epilepsy medications. Individual headache attacks are best treated early, often with one or more of the following types of medications: triptans, NSAIDs, anti-emetics (anti-nausea), and sometimes narcotics or steroids.

Most migraines typically last a few hours to a couple of days and respond well to specific treatments. However, in some patients, The migraine is particularly severe and long-lasting—and may even become chronic, occurring continuously for weeks, months, or even years on end. If improperly managed or left untreated, intermittent migraines may essentially transform into a chronic daily headache, with continuous and smoldering symptoms that periodically erupt into a “full-blown” migraine. This condition is extremely difficult to treat.

Other patients may develop increasingly frequent headaches as a result of over-using their short-acting headache medications. See medication over-use headaches. While they are considered to be primary headaches, meaning that they have no known underlying cause, migraines are known to be associated with an increased risk of stroke, brain scarring as seen on MRI scans, a heart defect called a patent foramen ovale (PFO), and a number of other medical conditions.

At the Johns Hopkins Headache Center at Bayview, we have our expert physical therapists, nutritionists, and psychologists who work closely with our neurologists to help manage patients with frequent migraines. Biofeedback and relaxation techniques are available to complement our standard medical treatments.

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Online Seminar: Headaches in Children
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Watch neurosurgeon Dr. Michael Lim’s online seminar on medical and surgical treatment for trigeminal neuralgia.

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