The Call-On-Doc Guide to Migraines

Considered a more severe headache, a migraine is often characterized by intense, throbbing pain, typically on one side of the head. The pain is often accompanied by other symptoms such as sensitivity to light, sound, or odors, nausea, and vomiting. Migraines can last anywhere from a few hours to several days, significantly impacting a person's ability to function and engage in daily activities. Unlike regular headaches, migraines are often accompanied by aura, which are sensory disturbances that can manifest as visual changes, tingling sensations, or difficulty speaking. Migraines are also known to have triggers such as certain foods, stress, hormonal changes, or environmental factors. While a regular headache can be bothersome, migraines are often more debilitating, causing significant pain and disruption to one's quality of life.

While research continues to expand, here are the most current factors known and suspected to cause migraines:

• Brain structure/function abnormalities: With the advancement of imaging technology in addition to other methods, doctors and researchers have found a number of trends in brain structure that are linked to migraines. 
  • Thalamus: The thalamus serves as a relay station for sensory information traveling from the body to the brain. It receives and filters sensory signals before transmitting them to higher cortical areas. Dysfunction in the thalamus can disrupt the filtering and processing of sensory information, leading to abnormal sensory perceptions and increased sensitivity to stimuli. (3)
  • Somatosensory Cortex: The somatosensory cortex is responsible for receiving and processing sensory information related to touch, pain, and other bodily sensations. Changes in the somatosensory cortex can result in altered processing of sensory inputs, leading to abnormal sensations, pain amplification, and hypersensitivity experienced during migraines. (3)
  • Insula: The insula is involved in the integration of sensory and emotional information. It plays a crucial role in the perception of pain and bodily sensations. Dysfunction in the insula can contribute to the abnormal processing of sensory signals, leading to altered pain perception, sensory amplification, and the experience of other sensory symptoms during migraines. (3)
  • Brainstem: The brainstem, particularly the trigeminal nucleus and related structures, is involved in pain modulation and sensory signaling. Abnormalities in the brainstem can affect the transmission and processing of pain signals, leading to an increased sensitivity to pain and sensory stimuli. (3)
• Central nervous system sensitization: In essence, central sensitization or CS refers to the increased responsiveness people feel from the nervous system and is a frequent symptom for those with migraines. While for some, this symptom causes increased pain for what is already painful; others will experience pain from what would generally be a painless part of their environment. More specifically, it increases the sensitivity and reactivity of pain-processing neurons in the central nervous system, amplifying pain signals. It then lowers the threshold for pain perception, making individuals more prone to experiencing pain. Lastly, it can enhance the responsiveness to triggers, such as light, sound, or certain odors, leading to characteristic sensitivity. (4)
• Genetic predisposition: Certain genetic variations or mutations certain genetic variations or mutations increase the likelihood of developing migraines. Multiple genes are thought to contribute to this predisposition, including those involved in regulating pain sensitivity, neurotransmitter function, and blood vessel function. These genetic factors can influence the susceptibility of an individual to triggers and the overall susceptibility to developing migraines. If one or both parents of a patient experience migraines, the patient has a higher risk of developing the condition. (5)
• Neurochemical imbalances: Several neurotransmitters and neurochemicals have been implicated in migraine pathophysiology, including serotonin, dopamine, calcitonin gene-related peptide (CGRP), and glutamate. More specifically: 
  • CGRP: Calcitonin gene-related peptide is a neuropeptide that plays a role in pain transmission. Elevated levels of CGRP have been observed during migraine attacks, and blocking CGRP receptors has shown efficacy in migraine treatment.
  • Dopamine: Imbalances in dopamine levels have been linked to migraine attacks. Both excessive and deficient dopamine levels have been implicated, suggesting a complex relationship between dopamine and migraine pathogenesis.
  • Glutamate: Glutamate is a major excitatory neurotransmitter in the brain. Imbalances in glutamate levels and altered glutamate signaling have been associated with migraines and increased neuronal excitability.
  • Serotonin: Fluctuations in serotonin levels have been associated with migraines. Low serotonin levels may contribute to the dilation of blood vessels and abnormal pain signaling, potentially triggering migraines. (6)
• Vascular changes: Vascular changes have long been associated with migraines, particularly with regard to the role of blood vessels in the onset and progression of migraine attacks. 
  • Neurogenic inflammation: Activation of sensory nerves, particularly the trigeminal nerve, leads to the release of various neuropeptides, including calcitonin gene-related peptides. CGRP causes blood vessels to dilate and promotes neurogenic inflammation, contributing to migraine-related pain and inflammation. (7)
  • Vasodilation: During a migraine attack, there is often a dilation or widening of blood vessels, particularly in the brain and surrounding areas. This vasodilation is thought to contribute to the throbbing pain experienced during migraines. (7)
  • Vascular hypersensitivity: Migraineurs may have a heightened sensitivity of blood vessels to various triggers, such as stress, certain foods, or hormonal changes. This vascular hypersensitivity can result in exaggerated vascular responses, leading to the initiation or exacerbation of migraine attacks. (7)

During a migraine, the brain undergoes a series of complex changes. One of the key events is the occurrence of cortical spreading depression, a wave of abnormal electrical activity that spreads across the brain's cortex. This wave is associated with altered blood flow, increased neuronal excitability, and abnormal neurotransmitter release. The brain also experiences changes in vascular tone, including vasodilation (widening of blood vessels) and vasoconstriction (narrowing of blood vessels), which contribute to the characteristic throbbing pain. Neural hyperexcitability and imbalances in neurotransmitters further contribute to altered pain processing, sensory sensitivities, and the occurrence of aura symptoms in some individuals. The trigeminal system, a major cranial nerve pathway, becomes activated, leading to the release of inflammatory substances and the initiation of pain signals. These events collectively result in the complex neurological symptoms experienced during a migraine, highlighting the intricate nature of the brain's involvement in this condition. (8)

• Aura: A specific neurological phenomenon that can precede or accompany a migraine headache. It involves a variety of sensory disturbances. Visual aura is the most common type, where people may see flashing lights, zigzag patterns, or temporary blind spots. Other forms of aura can include sensory changes such as tingling or numbness in the face or limbs, speech difficulties, and disturbances in hearing or smell. Aura typically lasts for a short duration, ranging from a few minutes to an hour, and is followed by the onset of the migraine headache.
• Fatigue: Migraine-related fatigue is characterized by a sense of physical and mental exhaustion, often described as feeling drained or depleted of energy. It can manifest as a persistent feeling of weariness, weakness, and a reduced ability to engage in normal daily activities. The fatigue can be both physical and cognitive, leading to difficulties with concentration, memory, and mental clarity. Even after the headache phase subsides, individuals may continue to experience lingering fatigue, which can persist for hours or even days, requiring additional rest and recovery. 
• Headache: The headache experienced during a migraine can be described as a pulsating or throbbing pain, often localized to one side of the head, but it can also affect both sides. The intensity of the headache can range from moderate to severe, making it difficult to carry out daily activities. The pain is often exacerbated by routine physical activity, such as walking or climbing stairs. 
• Nausea/Vomiting: Common symptoms that can accompany migraines, adding to the overall discomfort experienced during an episode. Individuals who experience migraine-related nausea often describe it as a sensation of queasiness or an unsettled stomach. It can range from mild discomfort to intense nausea, leading to a strong urge to vomit. The act of vomiting itself can provide temporary relief for some individuals, but it does not always alleviate the migraine symptoms completely. The combination of nausea and vomiting can further contribute to feelings of weakness, fatigue, and an overall sense of unwellness. 
• Increased sensitivity: Also known as hypersensitivity or sensory sensitivity, is a common experience for individuals during migraines. It can affect various sensory modalities and intensify the perception of stimuli. Sensitivity to light, known as photophobia, can make even normal levels of light uncomfortable or painful, leading to a preference for dimly lit environments or a need to wear sunglasses indoors. Sound sensitivity, referred to as phonophobia, can make even mild sounds seem excessively loud or bothersome, causing discomfort and the need for quiet surroundings. Additionally, some individuals may experience heightened sensitivity to smells (osmophobia) or touch (allodynia), where gentle touch or pressure can be perceived as painful or uncomfortable. These sensitivities can further contribute to the overall distress and discomfort experienced during a migraine episode.

Prodrome: The prodrome stage occurs before the onset of the actual headache and can last hours to a few days. During this stage, individuals may experience subtle changes that signal an impending migraine, such as mood swings, irritability, food cravings, increased urination, fatigue, or muscle stiffness.

Aura: The aura stage, which affects approximately one-quarter of migraine sufferers, involves reversible neurological symptoms that usually develop gradually over several minutes and last up to an hour. Visual disturbances, such as seeing flashing lights, zigzag patterns, or temporary blind spots, are the most common form of aura. Other sensory disturbances, including tingling or numbness in the face or limbs, speech difficulties, and auditory or olfactory disturbances, can also occur.

Headache: The headache stage is the most recognizable phase of a migraine. It typically features a pulsating or throbbing headache, often localized to one side of the head but it can also affect both sides. The pain can be moderate to severe and may be accompanied by symptoms like nausea, vomiting, sensitivity to light and sound, and fatigue. This stage can last anywhere from a few hours to several days.

Postdrome: The postdrome stage occurs after the headache has subsided, leaving individuals feeling drained and exhausted. Commonly referred to as the migraine "hangover," this stage can involve symptoms such as fatigue, difficulty concentrating, mood changes, muscle aches, and a general feeling of being unwell. The postdrome stage can last for hours to a couple of days before individuals fully recover.

Diagnosis: How do doctors tell if you have migraines?

Typically, a doctor will rely on the information conveyed to them by the patient when it comes to diagnosing migraines. This information will be the family history, a description of the symptoms, questions surrounding when migraines occur, and, if needed, a physical examination or neurological examination. (9) When it comes to needing further examination for more intensive treatment, doctors will conduct the following tests to gain further insights into the patient’s migraines: 

Blood tests: Although there is no specific blood test to diagnose migraines directly, these tests can help identify underlying medical conditions or factors that may contribute to or exacerbate migraines. For example, blood tests can assess thyroid function to rule out any hormonal imbalances, check for vitamin deficiencies, screen for autoimmune disorders, or detect signs of inflammation or infection. By evaluating these parameters, doctors can better understand if there are any additional health issues that may be triggering or influencing the frequency and severity of migraines.

Computerized tomography scan: A computerized tomography (CT) scan is a medical imaging technique that uses X-rays and computer processing to create detailed cross-sectional images of the body. A CT scan may be ordered to rule out other underlying causes or to investigate any structural abnormalities that could be contributing to the migraines. It can help detect conditions such as brain tumors, bleeding in the brain, or abnormalities in the blood vessels, which can present with symptoms similar to migraines.

Lumbar puncture: Also known as a spinal tap, is a medical procedure in which a needle is inserted into the lower back to collect a sample of cerebrospinal fluid (CSF) that surrounds the brain and spinal cord. A much rarer procedure when it comes to getting information about migraines plaguing a patient, the collected data can be analyzed for signs of inflammation, infection, or other abnormalities. Additionally, the procedure helps doctors rule out conditions such as meningitis, encephalitis, or autoimmune disorders that may present with headache symptoms similar to migraines. 

Magnetic resonance imaging: An MRI is a non-invasive imaging technique that uses a strong magnetic field and radio waves to generate detailed images of the body's internal structures, including the brain. MRI scans can help doctors gain more insight into a patient's migraines by providing highly detailed images of the brain and surrounding areas. These images can help identify any structural abnormalities, such as tumors, vascular malformations, or anatomical variations, that could be contributing to the migraines. MRI scans can also help rule out other conditions that may mimic migraines, such as strokes or multiple sclerosis, by visualizing the brain's anatomy and detecting any signs of damage or lesions. 

Migraine prescription treatment aims to relieve pain, and nausea as well as other symptoms. (9) On top of medication, a medical provider might recommend lifestyle changes for long-term management, such as:

• Maintain a consistent sleep schedule: Establish a regular sleep routine by going to bed and waking up at consistent times each day, even on weekends. Aim for around 7-8 hours of quality sleep per night.
• Identify and avoid triggers: Keep a headache diary to track potential triggers such as certain foods (e.g., chocolate, caffeine, aged cheeses), stress, hormonal changes, lack of sleep, bright lights, strong odors, or specific environmental factors. Once triggers are identified, try to minimize or avoid them as much as possible.
• Stay hydrated: Dehydration can be a migraine trigger for some individuals, so it's important to drink enough water throughout the day. Aim for the recommended daily water intake, which is typically around 8 cups (64 ounces) for adults.
• Practice stress management techniques: Stress is a common trigger for migraines. Engage in stress-reducing activities such as deep breathing exercises, meditation, yoga, or regular physical exercise. Find what works best for you to promote relaxation and manage stress levels.
• Maintain a balanced diet: Opt for a nutritious diet that includes a variety of fruits, vegetables, whole grains, and lean proteins. Avoid skipping meals, as low blood sugar levels can trigger migraines in some individuals. Limit the intake of processed foods, artificial sweeteners, and foods that are known to be triggers for you.
• Regular physical exercise: Engage in regular aerobic exercise, such as walking, swimming, or cycling, for at least 30 minutes on most days of the week. Regular exercise can help reduce the frequency and severity of migraines.

There are several different medications prescribed to treat migraines, the most common (and the ones prescribed online through CallonDoc) are:

• Amitriptyline: A medication that belongs to the class of tricyclic antidepressants. It is primarily used to treat depression, but it is also commonly prescribed for the prevention of migraines. Amitriptyline works by affecting the levels of certain neurotransmitters in the brain, which can help reduce the frequency and intensity of migraines in some individuals.
• Metoprolol: a medication from the beta-blocker class commonly used to treat various cardiovascular conditions. It works by blocking the effects of adrenaline on the heart, thereby reducing heart rate and blood pressure. In the context of migraines, metoprolol is sometimes prescribed as a preventive medication to help reduce the frequency and severity of migraines by regulating blood flow and reducing the hyperexcitability of nerves in the brain.
• NSAIDs: Nonsteroidal anti-inflammatory drugs, are a class of medications commonly used to relieve pain, reduce inflammation, and lower fever. They work by inhibiting the production of certain chemicals in the body that contribute to inflammation and pain. NSAIDs can be used to alleviate migraine symptoms, particularly when taken early in the onset of an attack, by reducing inflammation and constricting blood vessels in the brain.
• Propranolol: a medication from the beta-blocker class often prescribed for various cardiovascular conditions. It works by blocking the effects of adrenaline on the heart, thereby reducing heart rate and blood pressure. In the context of migraines, propranolol is frequently used as a preventive medication to decrease the frequency and severity of migraines by regulating blood flow and reducing the hyperexcitability of nerves in the brain.
• Topiramate: a medication primarily used to treat epilepsy, but it is also prescribed for migraine prevention. It works by affecting the activity of neurotransmitters in the brain, which helps reduce the frequency and intensity of migraines. Topiramate is thought to modulate the excitability of nerves and inhibit the release of certain neurotransmitters involved in migraine pathways, thereby providing preventive benefits for some individuals suffering from migraines.
• Triptans: A class of medications commonly used for the acute treatment of migraines. They work by binding to specific serotonin receptors in the brain and constricting blood vessels, reducing inflammation and relieving pain associated with migraines. Triptans can effectively alleviate migraine symptoms when taken at the onset of an attack and are available in various formulations, such as oral tablets, nasal sprays, and injections.

Coping mechanisms are actions you can take to alleviate the symptoms and strain caused by migraines. Some of the best methods known include applying a cold or warm compress to the head or neck, practicing relaxation techniques like deep breathing or meditation, and gently massaging tense muscles can provide relief. Such mechanisms are meant with the express purpose of alleviating a migraine attack and regaining at least some function. On top of medication, additional coping mechanisms usually include the following: 

• Finding a quiet, dark environment: Sensory stimulation can exacerbate migraine symptoms, so finding a calm and dimly lit space can help reduce discomfort.
• Applying a cold or warm compress: Placing a cold or warm compress on your head, neck, or forehead may provide temporary relief by numbing the area or relaxing tense muscles.
• Practicing relaxation techniques: Deep breathing exercises, progressive muscle relaxation, or guided imagery can help relax your body and reduce stress and tension associated with migraines.
• Massage: Gently massaging your temples, neck, or shoulders can help alleviate muscle tension and promote relaxation.
• Getting or staying hydrated: Dehydration can sometimes trigger or worsen migraines, so make sure to drink plenty of water or herbal tea to stay hydrated.
• Taking over-the-counter pain relievers: Non-prescription pain medications such as acetaminophen, ibuprofen, or aspirin can be taken early in the onset of a migraine to potentially reduce pain and discomfort.
• Avoiding triggers: If you are aware of specific triggers that commonly lead to your migraines, such as certain foods, bright lights, or strong odors, try to avoid them or minimize your exposure.

How and why migraines develop differ from person to person, making it difficult to give an answer that works universally. However, when they can be identified, preventive measures for migraines often involve identifying triggers and making lifestyle adjustments to minimize their impact. This can include maintaining a regular sleep schedule, managing stress through relaxation techniques or therapy, staying hydrated, and adopting a healthy lifestyle with regular exercise and balanced nutrition. If you or a loved one experiences regular migraines, consult with a CallonDoc provider today for a treatment plan with further steps to prevent regular and uncomfortable migraines.

1. Amiri, Parastoo et al. “Migraine: A Review on Its History, Global Epidemiology, Risk Factors, and Comorbidities.” Frontiers in neurology vol. 12 800605. 23 Feb. 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8904749/. 
2. “The Facts About Migraine.” American Migraine Foundation, 28 March 2019, https://americanmigrainefoundation.org/resource-library/migraine-facts/.
3. Goadsby, Peter J et al. “Pathophysiology of Migraine: A Disorder of Sensory Processing.” Physiological Reviews vol. 97,2 (2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5539409/. 
4. Suzuki, Keisuke et al. “Central Sensitization in Migraine: A Narrative Review.” Journal of pain research vol. 15 2673-2682. 7 Sep. 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9464439/.
5. Bron, Charlene et al. “Exploring the Hereditary Nature of Migraine.” Neuropsychiatric disease and treatment vol. 17 1183-1194. 22 Apr. 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075356/. 
6. Aggarwal, Milan et al. “Serotonin and CGRP in migraine.” Annals of neurosciences vol. 19,2, 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117050/. 
7. Mason, Bianca N, and Andrew F Russo. “Vascular Contributions to Migraine: Time to Revisit?.” Frontiers in cellular neuroscience vol. 12 233. 3 Aug. 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6088188/. 
8. Charles, Andrew, and K C Brennan. “The neurobiology of migraine.” Handbook of clinical neurology vol. 97 (2010), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5494713/. 
9. “Migraine - Diagnosis and treatment.” Mayo Clinic, 2 July 2021, https://www.mayoclinic.org/diseases-conditions/migraine-headache/diagnosis-treatment/drc-20360207.