Migraine: Symptoms, Types, Causes and Treatment

Migraines are more than just headaches—they are a complex, often debilitating neurological disorder that affects millions worldwide. For many, migraines can disrupt daily life, impact mental health, and pose significant challenges to effective management. This article provides a comprehensive, evidence-based overview of migraine symptoms, types, causes, and treatments, to empower patients and inform caregivers.

Symptoms of Migraine

Recognizing the full spectrum of migraine symptoms is key to understanding and managing this disorder. Migraines typically present in distinct phases, with a diverse range of symptoms that go well beyond head pain.

Symptom Phase	Common Symptoms	Notable Features	Source
Prodrome	Fatigue, yawning, cravings, mood changes	Can start hours to days before headache	4 6 5
Aura	Visual disturbances, tingling, speech changes	Occurs in ~1/3 of patients; may last up to 60 mins	6 14 9
Headache	Pulsatile/throbbing pain, nausea, photophobia, phonophobia, allodynia	Usually unilateral; 4–72 hours	1 2 5
Postdrome	Fatigue, cognitive impairment, mood swings	Can persist 24–48 hours after pain	4 5 6

Table 1: Key Symptoms

The Phases of a Migraine Attack

A migraine attack unfolds in several phases, each with its own characteristic symptoms:

• Prodrome (Premonitory Phase): Occurs hours to days before headache onset. Symptoms include fatigue, yawning, food cravings, neck stiffness, irritability, and changes in concentration or mood. Some individuals may also notice increased sensitivity to light or sound during this phase. Recognizing these early warning signs can help patients prepare for or even prevent a full-blown attack 4 5 6.

• Aura: Experienced by about one-third of migraine sufferers, aura involves transient neurological symptoms such as visual disturbances (flashing lights, zigzag lines), tingling or numbness, and, less commonly, speech or language problems. These symptoms usually develop gradually over several minutes and resolve within an hour 6 14 9.

• Headache Phase: The classic migraine headache is typically unilateral (one-sided), pulsatile or throbbing, and of moderate-to-severe intensity. It is often accompanied by nausea, vomiting, increased sensitivity to light (photophobia), sound (phonophobia), and sometimes smell (osmophobia). Many patients also report skin sensitivity (allodynia) or muscle tenderness. The headache phase can last from 4 to 72 hours if untreated 1 2 5.

• Postdrome: After the headache subsides, many patients experience a "migraine hangover," with symptoms such as fatigue, difficulty concentrating, mood changes, and generalized malaise. This phase can last up to two days 4 5 6.

Non-Headache Symptoms

Migraine is increasingly recognized as a systemic condition, not limited to headache alone. Recent studies reveal that nearly all patients experience at least one non-headache symptom during their attacks. These may include:

• Neck stiffness
• Thirst and cravings
• Abdominal pain
• Cognitive and mood changes (anxiety, depression, irritability)
• Fatigue and changes in alertness

Non-headache symptoms can occur in any phase of the migraine attack and are associated with greater disability, especially in chronic migraine 5 3.

Impact on Daily Life

Migraine symptoms are not only physically distressing but can also interfere significantly with work, school, and social activities. The unpredictability and severity of symptoms often lead to anxiety and depression, which in turn may worsen migraine burden 2 3.

Types of Migraine

Migraines are not one-size-fits-all. Understanding the different types can help guide diagnosis and management, as well as set realistic expectations for treatment.

Type	Defining Features	Prevalence/Notes	Source
Migraine without Aura	Headache without preceding aura	Most common type	9 2 10
Migraine with Aura	Transient neurological symptoms before/during headache	About 1/3 of cases	9 14 6
Chronic Migraine	≥15 headache days/month, ≥8 with migraine features	Higher disability; medication overuse common	10 5
Hemiplegic Migraine	Aura with motor weakness (genetic origin)	Rare, often familial	7 13 8

Table 2: Main Types of Migraine

Migraine Without Aura

This is the most prevalent form of migraine, characterized by recurrent attacks of headache without any preceding aura. The attacks typically have the classic features: unilateral, pulsating pain, nausea, and heightened sensitivity to light and sound. Diagnosis is based on clinical criteria, as there are no definitive biomarkers 2 9.

Migraine With Aura

In this type, the headache is preceded or accompanied by transient neurological symptoms known as aura. Visual disturbances are most common, but sensory, speech, or even motor symptoms can occur. Aura symptoms gradually develop over 5–60 minutes and resolve completely 9 14 6.

Chronic Migraine

Chronic migraine is defined as headaches occurring on at least 15 days per month for more than 3 months, with at least 8 days per month having migraine features. Chronic migraine is associated with greater disability, higher rates of medication overuse, and more comorbidities, including depression and anxiety 10 5.

Hemiplegic Migraine

A rare subtype, hemiplegic migraine includes aura with motor weakness and is often familial, linked to specific genetic mutations (e.g., CACNA1A, ATP1A2, SCN1A). These attacks can resemble stroke and require expert evaluation 7 13 8.

Other Subtypes

There are additional, less common subtypes of migraine, including vestibular migraine (with prominent dizziness/vertigo), retinal migraine (visual symptoms in one eye), and others, each with distinct features 9 10.

Causes of Migraine

Migraine arises from a complex interplay of genetic, neurovascular, and environmental factors. Understanding these underlying causes is critical for both patients and clinicians.

Cause Type	Description	Key Insights/Examples	Source
Genetic	Family history, monogenic and polygenic forms	Hemiplegic migraine genes; GWAS loci	7 13 8
Neurovascular	Dysfunction in brain pathways, blood vessels	Trigeminovascular system, CGRP	1 12 15
Environmental	Triggers such as food, stress, sleep changes	Diet, hormones, sensory stimuli	2 18 5

Table 3: Core Causes and Contributing Factors

Genetic Susceptibility

Migraine has a strong genetic basis, with both rare monogenic and common polygenic forms:

• Monogenic Forms: Hemiplegic migraine is caused by mutations in genes affecting ion channels (CACNA1A, ATP1A2, SCN1A). These mutations alter glutamatergic neurotransmission and cortical excitability, lowering the threshold for migraine attacks 7 13 8.

• Polygenic Forms: Genome-wide association studies have identified over 38 loci associated with migraine risk, implicating both neuronal and vascular pathways. Family history remains a strong risk factor for developing migraine 7 13.

Neurovascular and Brain Mechanisms

Migraines are fundamentally disorders of the nervous system:

• Trigeminovascular System: Activation of this system plays a central role in migraine pain. It involves the trigeminal nerve, meningeal blood vessels, and the release of neuropeptides like CGRP, which promote inflammation and pain perception 1 12 15.

• Cortical Spreading Depression (CSD): CSD is a wave of neuronal depolarization across the cortex, believed to underlie aura symptoms and trigger activation of pain pathways 14 8.

• Altered Brain Function: Migraine brains show increased sensitivity to sensory inputs and impaired regulation of homeostasis, explaining prodromal symptoms and heightened environmental sensitivity 1 4 6 11.

Environmental and Lifestyle Triggers

Migraines can be provoked by a variety of triggers, which may differ between individuals:

• Dietary Triggers: Caffeine, alcohol, aged cheeses, chocolate, monosodium glutamate, and certain food additives are common triggers. About 20% of patients report a clear link to specific foods 2 18.

• Hormonal Changes: Particularly in women, hormonal fluctuations (e.g., menstrual cycle) can increase migraine frequency 9.

• Other Triggers: Stress, changes in sleep, sensory overload, weather changes, and medication overuse are also implicated 2 5 18.

Comorbid Conditions

Migraine often co-exists with other conditions such as anxiety, depression, and sleep disorders, which may share overlapping biological pathways and add to disease complexity and disability 3 5.

Treatment of Migraine

Migraine management is multifaceted, aiming to relieve acute attacks, reduce attack frequency, and improve quality of life. New therapies and integrative strategies are transforming care for many sufferers.

Treatment	Use Case/Stage	Examples/Notes	Source
Acute Medications	Relieve current attack	NSAIDs, triptans, antiemetics, CGRP antagonists	16 17 19 15
Preventive Meds	Reduce attack frequency	Beta-blockers, antiepileptics, CGRP mAbs, antidepressants	15 19 18
Behavioral	Lifestyle & trigger management	CBT, mindfulness, sleep hygiene, stress reduction	18 2 3
Integrative	Complementary therapies	Magnesium, riboflavin, acupuncture, yoga, PT	18 2

Table 4: Migraine Treatment Modalities

Acute (Abortive) Treatments

These are used at the onset of an attack to stop or lessen symptoms:

• First-Line: Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are effective for mild-to-moderate attacks. Combination analgesics (with caffeine) may also help 16 17 19.
• Triptans: Serotonin 5-HT1B/1D receptor agonists, effective for moderate-to-severe attacks. Should be avoided in patients with vascular disease or hemiplegic migraine 16 17.
• Anti-CGRP Drugs: Newly developed CGRP receptor antagonists (e.g., ubrogepant) and monoclonal antibodies (e.g., erenumab, fremanezumab) target the trigeminovascular system and are effective for acute and preventive treatment 15.
• Other Options: Antiemetics (e.g., metoclopramide), intranasal lidocaine, and dihydroergotamine are alternatives in refractory cases. Opioids and barbiturates should generally be avoided due to risk of overuse and dependency 16 17.

Preventive (Prophylactic) Treatments

For frequent or disabling migraines, preventive medications are prescribed to reduce attack frequency and severity:

• Pharmacological Options: Beta-blockers, antiepileptics (topiramate, valproate), tricyclic antidepressants, and newer anti-CGRP monoclonal antibodies 15 19.
• Tailoring Treatment: Choice depends on patient comorbidities, attack frequency, and tolerability.

Behavioral and Lifestyle Approaches

Non-pharmacological interventions play a crucial role in migraine management:

• Trigger Identification and Avoidance: Keeping a headache diary can help identify personal triggers, including dietary, sleep, and stress-related factors 2 18.
• Behavioral Therapies: Cognitive-behavioral therapy (CBT), mindfulness, yoga, and relaxation techniques have been shown to reduce migraine frequency and improve quality of life 18 3.
• Lifestyle Modifications: Regular sleep, hydration, and physical activity are beneficial 2 18.

Integrative and Complementary Therapies

Several evidence-based complementary treatments can be considered:

• Supplements: Magnesium, riboflavin, CoQ10, vitamin D, and butterbur (PA-free) have varying levels of evidence for migraine prevention 18.
• Physical Therapy and Acupuncture: These modalities are effective for some patients, especially those with associated neck pain or tension-type headache features 18.
• Caution: Always discuss new therapies with a healthcare provider to ensure safety and avoid harmful interactions.

Special Populations and Chronic Migraine

• Chronic Migraine: Requires careful management to avoid medication overuse and address comorbid conditions. Preventive strategies and behavioral interventions are especially important 10 5.
• Children, Adolescents, and Pregnant Women: Treatment options are more limited; acetaminophen and some NSAIDs may be used, but always under medical supervision 16.

Conclusion

Migraines are a complex and highly individualized neurological disorder, but increased understanding of their symptoms, types, causes, and treatment options is empowering patients and clinicians alike.

Key Takeaways:

• Migraine attacks unfold in distinct phases, each with their own set of symptoms, including many non-headache features.
• There are several types of migraine, with and without aura, and more disabling forms such as chronic and hemiplegic migraine.
• Migraine arises from a combination of genetic, neurovascular, and environmental factors; triggers vary widely between individuals.
• Treatment is multifaceted, involving acute and preventive medications, behavioral and lifestyle interventions, and sometimes integrative therapies.
• New drug classes targeting the trigeminovascular system and CGRP offer hope for more effective and better-tolerated therapies.

Understanding migraine as a complex brain disorder—not just a bad headache—opens the door to more compassionate care, better treatment choices, and improved quality of life for millions living with migraine.