Migraines: Symptoms, Types, Causes and Treatment

Migraines are more than just headaches—they’re complex neurological events that can disrupt daily life, productivity, and well-being. Affecting millions worldwide, migraines are characterized by a constellation of symptoms and phases, with significant variability in presentation and underlying causes. In this comprehensive article, we’ll guide you through the landscape of migraine symptoms, types, causes, and the modern approaches to treatment.

Symptoms of Migraines

Migraines present with a wide range of symptoms that extend far beyond head pain. Recognizing these symptoms is key to early diagnosis and effective management. Let’s explore the major features of migraine attacks and how they evolve over time.

Symptom	Description	Frequency/Timing	Source(s)
Headache	Throbbing, often unilateral pain	4–72 hours per attack	1, 2
Aura	Visual or sensory disturbances	Present in 1/3 of attacks	6, 10
Nausea/Vomiting	Gastrointestinal upset, urge to vomit	Common during headache phase	1, 2
Sensitivities	Photophobia, phonophobia, osmophobia	During and before headache	1, 3
Premonitory	Fatigue, mood changes, neck stiffness, food cravings	Hours to days before headache	3, 4, 6
Allodynia	Abnormal skin sensitivity	During headache phase	1, 5
Postdrome	Fatigue, cognitive sluggishness ("migraine hangover")	After headache resolves	4, 6

Table 1: Key Symptoms

The Four Phases of Migraine

Migraines often unfold in well-defined stages, each with unique symptoms:

• Premonitory (Prodrome) Phase: Occurs hours to days before the headache. Symptoms include fatigue, yawning, mood changes, neck stiffness, thirst, and food cravings. These early warning signs can help predict an impending attack and may be underrecognized by both patients and clinicians 3, 4, 6.

• Aura Phase: About 1 in 3 migraine sufferers experience aura, which typically involves visual disturbances (flashing lights, blind spots) or sensory changes. Aura usually lasts up to an hour and precedes the headache phase, but it can also occur during or after the headache 6, 10.

• Headache Phase: The classic migraine headache is throbbing or pulsatile, often on one side of the head but can be bilateral. It’s usually moderate to severe in intensity, worsened by physical activity, and accompanied by nausea, vomiting, and heightened sensitivity to light, sound, and smells. Many people also experience allodynia (pain from normally non-painful stimuli) and muscle tenderness 1, 2, 5.

• Postdrome Phase: After the headache resolves, patients may feel drained, have difficulty concentrating, and experience lingering sensitivities. This “migraine hangover” can last up to 24 hours 4, 6.

Non-Headache Symptoms

It’s important to recognize that migraines are not just about head pain. Non-headache symptoms are frequent and may include:

• Gastrointestinal symptoms (nausea, vomiting, abdominal pain)
• Sensory disturbances (visual changes, dizziness, vertigo)
• Cognitive and mood changes (difficulty thinking, irritability)
• Neck stiffness and thirst 4, 5

Patients who experience non-headache symptoms across all phases tend to have higher migraine-related disability and a greater likelihood of chronic migraine 4.

Types of Migraines

Migraines are classified into several types, each with distinct characteristics and diagnostic criteria. Understanding these types helps with tailored management and anticipates the course of the disorder.

Type	Main Features	Prevalence/Notes	Source(s)
Migraine without Aura	Headache, no aura, nausea, sensitivities	Most common	10, 2
Migraine with Aura	Aura (visual or sensory), followed by headache	~1/3 of cases	6, 10
Chronic Migraine	≥15 headache days/month, ≥8 are migrainous	Higher disability	10, 4
Hemiplegic Migraine	Aura with motor weakness	Rare, often familial	7, 13
Vestibular Migraine	Prominent dizziness/vertigo	Under-recognized	5, 10

Table 2: Migraine Types

Migraine Without Aura

This is the most prevalent migraine type. It’s characterized by recurrent attacks of moderate to severe headache, typically lasting 4–72 hours, often on one side of the head, pulsatile in nature, and accompanied by nausea and/or sensitivity to light and sound. There are no preceding neurological symptoms (aura) 2, 10.

Migraine With Aura

Roughly one third of migraineurs experience aura: transient neurological symptoms that usually precede the headache. Aura most often involves visual changes (zig-zag lines, blind spots, flashing lights) but can also include sensory, language, or motor disturbances. The headache may overlap with or follow the aura 6, 10.

Chronic Migraine

Defined as having headache on 15 or more days per month, with at least 8 days meeting criteria for migraine. Chronic migraine is associated with higher disability, more frequent non-headache symptoms, and often medication overuse 4, 10.

Hemiplegic Migraine

A rare but distinctive type, hemiplegic migraine presents with aura that includes motor weakness, often affecting one side of the body. It’s frequently familial, linked to mutations in specific genes (e.g., CACNA1A, ATP1A2, SCN1A) 7, 13.

Vestibular Migraine

Prominent dizziness, vertigo, and balance issues characterize vestibular migraine. These symptoms may occur with or instead of head pain, making diagnosis challenging. Vestibular symptoms are found in both classic migraine types but can dominate in some patients 5, 10.

Causes of Migraines

The root causes of migraines are complex, involving both genetic predisposition and environmental influences. Recent advances have deepened our understanding, revealing a multifaceted disorder of brain function and sensory processing.

Cause	Mechanism/Role	Key Details	Source(s)
Genetics	Inherited susceptibility; polygenic and monogenic forms	Multiple gene variants & mutations	7, 13
Neural Hyperexcitability	Overactive brain circuits, altered neurotransmission	Lower threshold for migraine	1, 9
Trigeminovascular System	Activation triggers headache pain	CGRP release, vascular changes	1, 9, 12
Cortical Spreading Depression	Wave of brain activity underlying aura	Linked to aura and pain	6, 9
Environmental Triggers	Foods, stress, hormones, sleep, sensory stimuli	Highly individual; modifiable	2, 18

Table 3: Migraine Causes

Genetic Factors

Migraine has a strong hereditary component. There are rare monogenic forms (e.g., familial hemiplegic migraine due to mutations in specific ion channel genes), as well as more common polygenic forms involving a constellation of genetic variants. These genes regulate neurotransmitters, synaptic plasticity, and vascular function. Genome-wide association studies have identified over three dozen genetic loci linked to migraine risk 7, 13.

Neural and Vascular Mechanisms

The modern view of migraine pathophysiology centers on the brain’s abnormal sensitivity and inability to regulate sensory input. Key elements include:

• Neuronal Hyperexcitability: Migraineurs’ brains are more easily activated by internal and external stimuli, possibly due to genetic influences on glutamate neurotransmission and synaptic regulation 1, 9.

• Trigeminovascular System: The trigeminal nerve and its connections to the brain’s blood vessels play a central role. Activation of this pathway leads to the release of neuropeptides, especially calcitonin gene-related peptide (CGRP), causing inflammation and dilation of blood vessels, triggering headache pain 1, 9, 12, 14.

• Cortical Spreading Depression: A slowly propagating wave of neuronal and glial depolarization across the cortex is thought to underlie aura and may trigger the trigeminovascular response 6, 9.

Environmental and Lifestyle Triggers

While genetics set the stage, various triggers can precipitate migraine attacks, including:

• Certain foods and additives (e.g., aged cheeses, chocolate, nitrates, aspartame, alcohol)
• Hormonal fluctuations (menstruation, pregnancy)
• Stress and sleep disturbances
• Sensory stimuli (bright lights, strong odors) 2, 18

Triggers are highly individual, and not all migraineurs are affected by the same factors.

Treatment of Migraines

Migraine treatment is multifaceted, aiming to relieve acute attacks and prevent future episodes. Recent advances offer new hope, with therapies targeted to migraine’s unique biology.

Treatment	Category	Key Examples/Uses	Source(s)
Acute Medications	NSAIDs, Triptans, Antiemetics	Ibuprofen, sumatriptan, metoclopramide	15, 16, 17
Preventive Drugs	Beta-blockers, Antiepileptics, CGRP inhibitors	Propranolol, topiramate, erenumab	14, 16
Non-Pharmacologic	Behavioral, Physical, Lifestyle	CBT, exercise, trigger avoidance	2, 18
Complementary	Supplements, Mind/Body	Magnesium, riboflavin, mindfulness	18
Procedures	Botulinum toxin, Surgery	Botox injections, nerve decompression	8

Table 4: Migraine Treatments

Acute (Abortive) Treatments

Acute therapy focuses on stopping or reducing the severity of attacks:

• NSAIDs and Analgesics: Ibuprofen, naproxen, and combination analgesics (acetaminophen/aspirin/caffeine) are first-line for mild to moderate migraines 15, 16, 17.
• Triptans: Sumatriptan, zolmitriptan, and others are highly effective for moderate to severe migraines, but should be avoided in people with vascular disease 15, 16, 17.
• Antiemetics: Drugs like metoclopramide can help with nausea and improve absorption of oral medications 15, 16.
• Other Options: Dihydroergotamine, intranasal lidocaine, and non-opioid combination analgesics can be used in selected cases; opioids are discouraged due to risk of dependency and medication-overuse headache 15, 16.

Early intervention is crucial—medications are most effective when taken at the onset of symptoms. Specific recommendations exist for children, adolescents, and pregnant women, emphasizing safety and efficacy 17.

Preventive (Prophylactic) Treatments

For frequent or disabling migraines, prevention is key:

• Traditional Options: Beta-blockers (propranolol), antiepileptics (topiramate), antidepressants (amitriptyline), and calcium channel blockers are established choices.
• CGRP Pathway Inhibitors: New monoclonal antibodies (erenumab, galcanezumab) and gepants target the CGRP pathway, reducing migraine frequency with few side effects 14.
• Botulinum Toxin: Approved for chronic migraine, Botox injections can reduce attack frequency and severity 8.

Choice of preventive therapy should be individualized, considering comorbidities and patient preference.

Non-Pharmacological and Complementary Therapies

• Behavioral Interventions: Cognitive behavioral therapy, biofeedback, and relaxation techniques are effective, especially when combined with medication 2, 18.
• Lifestyle Modifications: Identifying and avoiding personal triggers (dietary, environmental, stress) can reduce attack frequency 2.
• Supplements: Evidence supports magnesium, riboflavin, and CoQ10. Melatonin, vitamin D, and certain herbal remedies like butterbur (PA-free) have shown benefit in some studies 18.
• Mind/Body Approaches: Mindfulness, yoga, and tai chi may decrease headache frequency and improve quality of life. Physical therapy and acupuncture also have supporting evidence 18.

Interventional Procedures

• Botulinum Toxin (Botox): Especially useful for chronic migraine, with good evidence for efficacy 8.
• Surgical Approaches: For refractory cases, decompression of trigger sites or nerve release may be considered, with reported high success rates in selected patients 8.

Conclusion

Migraines are complex, disabling neurological disorders with broad-ranging symptoms and significant impact on quality of life. Advances in understanding migraine biology and genetics have led to new, more effective treatments. Successful management often requires a personalized, multidisciplinary approach.

Key Points:

• Migraines involve more than head pain, with distinct phases and a wide range of symptoms (including premonitory signs, aura, and postdrome).
• The main types are migraine without aura, with aura, chronic migraine, hemiplegic migraine, and vestibular migraine.
• Causes are multifactorial, involving genetic susceptibility, neural hyperexcitability, and environmental triggers.
• Treatment includes acute medications, preventive drugs, behavioral and lifestyle interventions, and, for some, interventional procedures or complementary therapies.
• Early recognition and individualized care are essential for optimal outcomes.

Migraines may be challenging, but with increased understanding and a tailored treatment plan, relief and improved quality of life are within reach.