Common symptoms of a migraine

The main symptom of a migraine is usually an intense headache on 1 side of the head.

The pain is usually a moderate or severe throbbing sensation that gets worse when you move and prevents you carrying out normal activities.

In some cases, the pain can occur on both sides of your head and may affect your face or neck.

Additional symptoms

Other symptoms commonly associated with a migraine include:

• feeling sick
• being sick
• increased sensitivity to light and sound, which is why many people with a migraine want to rest in a quiet, dark room

Some people also occasionally experience other symptoms, including:

• sweating
• poor concentration,
• feeling very hot or very cold
• tummy (abdominal) pain
• diarrhoea

Not everyone with a migraine experiences these additional symptoms and some people may experience them without having a headache.

The symptoms of a migraine usually last between 4 hours and 3 days, although you may feel very tired for up to a week afterwards.

Symptoms of aura

About 1 in 3 people with migraines have temporary warning symptoms, known as aura, before a migraine.

These include:

• visual problems – such as seeing flashing lights, zig-zag patterns or blind spots
• numbness or a tingling sensation like pins and needles – which usually starts in 1 hand and moves up your arm before affecting your face, lips and tongue
• feeling dizzy or off balance
• difficulty speaking
• loss of consciousness – although this is unusual

Aura symptoms typically develop over the course of about 5 minutes and last for up to an hour.

Some people may experience aura followed by only a mild headache or no headache at all.

When to get medical advice

You should see a GP if you have frequent or severe migraine symptoms that cannot be managed with occasional use of over-the-counter painkillers, such as paracetamol.

Try not to use the maximum dosage of painkillers on a regular or frequent basis as this could make it harder to treat headaches over time.

You should also make an appointment to see a GP if you have frequent migraines (on more than 5 days a month), even if they can be controlled with medicine, as you may benefit from preventative treatment.

You should call 999 for an ambulance immediately if you or someone you're with experiences:

• paralysis or weakness in 1 or both arms or 1 side of the face
• slurred or garbled speech
• a sudden agonising headache resulting in a severe pain unlike anything experienced before
• headache along with a high temperature (fever), stiff neck, mental confusion, seizures, double vision and a rash

These symptoms may be a sign of a more serious condition, such as a stroke or meningitis, and should be assessed by a doctor as soon as possible.

Find out more about diagnosing migraines

Stages of a migraine

Migraines often develop in distinct stages, although not everyone goes through all of these:

1. prodromal (pre-headache) stage – changes in mood, energy levels, behaviour and appetite that can occur several hours or days before an attack

2. aura – usually visual problems, such as flashes of light or blind spots, which can last for 5 minutes to an hour

3. headache stage – usually a pulsating or throbbing pain on 1 side of the head, often accompanied by feeling sick, vomiting or extreme sensitivity to bright light and loud sounds, which can last for 4 to 72 hours

4. resolution stage – when the headache and other symptoms gradually fade away, although you may feel tired for a few days afterwards

The exact cause of migraines is unknown, but they're thought to be the result of abnormal brain activity temporarily affecting nerve signals, chemicals and blood vessels in the brain.

It's not clear what causes this change in brain activity, but it's possible that your genes make you more likely to experience migraines as a result of a specific trigger.

Migraine triggers

Many possible migraine triggers have been suggested, including hormonal, emotional, physical, dietary, environmental and medicinal factors.

These triggers are very individual, but it may help to keep a diary to see if you can identify a consistent trigger.

It can also sometimes be difficult to tell if something is really a trigger or if what you're experiencing is an early symptom of a migraine attack.

Hormonal changes

Some women experience migraines around the time of their period, possibly because of changes in the levels of hormones such as oestrogen around this time.

These type of migraines usually occur between 2 days before the start of your period to 3 days after.

Some women only experience migraines around this time, which is known as pure menstrual migraine.

But most women experience them at other times, too, and this is called menstrual-related migraine.

Many women find their migraines improve after the menopause, although the menopause can trigger migraines or make them worse in some women.

Emotional triggers:

• stress
• anxiety
• tension
• shock
• depression
• excitement

Physical triggers:

• tiredness
• poor-quality sleep
• shift work
• poor posture
• neck or shoulder tension
• jet lag
• low blood sugar (hypoglycaemia)
• strenuous exercise, if you're not used to it

Dietary triggers:

• missed, delayed or irregular meals
• dehydration
• alcohol
• caffeine products, such as tea and coffee
• specific foods, such as chocolate and citrus fruit
• foods containing the substance tyramine, which include cured meats, yeast extracts, pickled herrings, smoked fish (like smoked salmon), and certain cheeses (such as cheddar, stilton and camembert)

Also, foods that have been stored at room temperature, rather than being refrigerated or frozen, can have rising levels of tyramine.

Environmental triggers:

• bright lights
• flickering screens, such as a television or computer screen
• smoking (or smoky rooms)
• loud noises
• changes in climate, such as changes in humidity or very cold temperatures
• strong smells
• a stuffy atmosphere

Medicines:

• some types of sleeping tablets
• the combined contraceptive pill
• hormone replacement therapy (HRT), which is sometimes used to relieve symptoms associated with the menopause

There's no specific test to diagnose migraines. For an accurate diagnosis to be made, a GP must identify a pattern of recurring headaches along with the associated symptoms.

Migraines can be unpredictable, sometimes occurring without the other symptoms. Obtaining an accurate diagnosis can sometimes take time.

Seeing a GP

On your first visit, a GP may carry out a physical examination and check your vision, co-ordination, reflexes and sensations.

These will help rule out some other possible underlying causes of your symptoms.

They may ask if your headaches are:

• on 1 side of the head
• a pulsating pain
• severe enough to prevent you carrying out daily activities
• made worse by physical activity or moving about
• accompanied by feeling and being sick
• accompanied by sensitivity to light and noise

Migraine diary

To help with the diagnosis, it can be useful to keep a diary of your migraine attacks for a few weeks.

Note down details including:

• the date
• time
• what you were doing when the migraine began
• how long the attack lasted
• what symptoms you experienced
• what medicines you took (if any)

Regularly taking frequent doses of painkillers is an important reason why migraines can become difficult to treat. Doing so can cause a medication overuse headache.

Overuse headaches are usually caused by taking painkillers on a long-term basis and not because of exceeding, or just sticking to, the recommended dose.

It'll be very helpful to keep a record of what painkillers you take and how often you take them.

You should not take painkillers on more than 10 days every month in the long term.

It may also be helpful for women to make a note when they start their period, as this can help your GP identify potential triggers.

Read more about keeping a migraine diary on The Migraine Trust website.

Referral to a specialist

A GP may decide to refer you to a neurologist, a specialist in conditions affecting the brain and nervous system, for further assessment and treatment if: 

• a diagnosis is unclear
• you experience migraines on 15 days or more a month (chronic migraine)
• treatment is not helping to control your symptoms

There's currently no cure for migraines, although a number of treatments are available to help ease the symptoms.

It may take time to work out the best treatment for you. You may need to try different types or combinations of medicines before you find the most effective ones.

If you find you cannot manage your migraines using over-the-counter medicines, your GP may prescribe something stronger.

During an attack

Most people find that sleeping or lying in a darkened room is the best thing to do when having a migraine attack.

Others find that eating something helps, or they start to feel better once they have been sick.

Painkillers

Many people who have migraines find that over-the-counter painkillers, such as paracetamol, aspirin and ibuprofen, can help to reduce their symptoms.

They tend to be most effective if taken at the first signs of a migraine attack, as this gives them time to absorb into your bloodstream and ease your symptoms.

It's not advisable to wait until the headache worsens before taking painkillers, as it's often too late for the medicine to work.

Tablets you dissolve in a glass of water (soluble painkillers) are a good alternative because they're absorbed quickly by your body.

If you cannot swallow painkillers because of nausea or vomiting, suppositories may be a better option. These are capsules that are inserted into the bottom.

Cautions

When taking over-the-counter painkillers, always make sure you read the instructions on the packaging and follow the dosage recommendations.

Children under 16 should not take aspirin unless it's under the guidance of a healthcare professional.

Aspirin and ibuprofen are also not recommended for adults who have a history of stomach problems, such as stomach ulcers, liver problems or kidney problems.

Taking any form of painkiller frequently can make migraines worse. This is sometimes called a medication overuse headache or painkiller headache.

Speak to a GP if you find yourself needing to use painkillers repeatedly or over-the-counter painkillers are not effective.

They may prescribe stronger painkillers or recommend using painkillers along with triptans.

If they suspect the frequent use of painkillers may be contributing your headaches, they may recommended that you stop using them.

Triptans

If ordinary painkillers are not helping to relieve your migraine symptoms, you should make an appointment to see a GP.

They may recommend taking painkillers in addition to a type of medicine called a triptan, and possibly anti-sickness medicine.

Triptan medicines are a specific painkiller for migraine headaches. They're thought to work by reversing the changes in the brain that may cause migraine headaches.

They cause the blood vessels around the brain to narrow (contract). This reverses the widening of blood vessels that's believed to be part of the migraine process.

Triptans are available as tablets, injections and nasal sprays.

Common side effects of triptans include:

• warm sensations
• tightness
• tingling
• flushing
• feelings of heaviness in the face, limbs or chest

Some people also experience feeling sick, a dry mouth and drowsiness.

These side effects are usually mild and improve on their own.

As with other painkillers, taking too many triptans can lead to a medication overuse headache.

Your GP will usually recommend having a follow-up appointment once you have finished your first course of treatment with triptans.

This is so you can discuss their effectiveness and whether you had any side effects.

If the medicine was helpful, treatment will usually be continued.

If they were not effective or caused unpleasant side effects, your GP may try prescribing a different type of triptan as how people respond to this medicine can be highly variable.

Anti-sickness medicines

Anti-sickness medicines, known as anti-emetics, can successfully treat migraine in some people even if you do not experience feeling or being sick.

These are prescribed by a GP, and can be taken alongside painkillers and triptans.

As with painkillers, anti-sickness medicines work better if taken as soon as your migraine symptoms begin.

They usually come in the form of a tablet, but are also available as a suppository.

Side effects of anti-emetics include drowsiness and diarrhoea.

Combination medicines

You can buy a number of combination medicines for migraine without a prescription at your local pharmacy.

These medicines contain both painkillers and anti-sickness medicines.

If you're not sure which one is best for you, ask your pharmacist.

It can also be very effective to combine a triptan with another painkiller, such as ibuprofen.

Many people find combination medicines convenient.

But the dose of painkillers or anti-sickness medicine may not be high enough to relieve your symptoms.

If this is the case, it may be better to take painkillers and anti-sickness medicines separately. This allows you to easily control the doses of each.

Acupuncture

If medicines are unsuitable or do not help to prevent migraines, you can try acupuncture.

Some GP surgeries offer acupuncture, but most do not, so you may have to pay for it privately.

Evidence suggests a course of up to 10 sessions over a 5- to 8-week period may be beneficial.

Find out more about acupuncture

Seeing a specialist

If the treatments above are not effectively controlling your migraines, your GP may refer you to a specialist migraine clinic for further investigation and treatment.

In addition to the medicines mentioned above, a specialist may recommend other treatments, such as transcranial magnetic stimulation.

Transcranial magnetic stimulation

In January 2014, the National Institute for Health and Care Excellence (NICE) approved the use of a treatment called transcranial magnetic stimulation (TMS) for the treatment and prevention of migraines.

TMS involves holding a small electrical device to your head that delivers magnetic pulses through your skin.

It's not clear exactly how TMS works in treating migraines, but studies have shown that using it at the start of a migraine can reduce its severity.

It can also be used in combination with the medicines mentioned above without interfering with them.

But TMS is not a cure for migraines and does not work for everyone.

The evidence for its effectiveness is not strong and is limited to people who have migraine with aura.

There's also little evidence about the potential long-term effects of the treatment, although studies into the treatment have so far only reported minor and temporary side effects.

These include:

• slight dizziness
• drowsiness and tiredness
• a muscle tremor that can make it difficult to stand
• irritability

NICE recommends that TMS should only be provided by headache specialists in specialist centres because of the uncertainty about the potential long-term side effects.

The specialist will keep a record of your experiences using the treatment.

Treatment for pregnant and breastfeeding women

In general, migraine treatment with medicines should be limited as much as possible when you're pregnant or breastfeeding.

Instead, trying to identify and avoid potential migraine triggers is often recommended.

If medicine is essential, your GP may prescribe you a low-dose painkiller, such as paracetamol.

In some cases, anti-inflammatory medicine or triptans may be prescribed.

Speak to a GP or your midwife before taking medicine when you're pregnant or breastfeeding.

Migraines are associated with a small increased risk of ischaemic strokes, and a very small increased risk of mental health problems.

Stroke

An ischaemic stroke happens when the blood supply to the brain is blocked by a blood clot or fatty material in the arteries.

Studies have shown that people who experience migraines (particularly migraine with aura) have about twice the risk of having an ischaemic stroke at some point compared with people without migraines. But this risk is still small.

It's not clear why ischaemic strokes are linked to migraine.

Contraceptive pill

The risk of having an ischaemic stroke is increased by using the combined contraceptive pill.

Medical professionals generally advise women who experience migraine with aura not to use the combined contraceptive pill.

Women who have migraine without aura can usually take the combined contraceptive pill safely, unless they have other stroke risk factors such as high blood pressure or a family history of cardiovascular disease.

If you take the combined contraceptive pill and experience aura symptoms, talk to a GP about alternative forms of contraception.

Mental health problems

Migraine is associated with a very small increased risk of mental health problems, including:

• depression
• bipolar disorder
• anxiety disorder
• panic disorder

There are a number of ways you can reduce your chances of experiencing migraines.

Identifying and avoiding triggers

One of the best ways of preventing migraines is recognising the things that trigger an attack and trying to avoid them. 

You may find you tend to have a migraine after eating certain foods or when you're stressed, and by avoiding this trigger you can prevent a migraine.

Find out more about possible migraine triggers

Keeping a migraine diary can help you identify possible triggers and monitor how well any medicine you're taking is working.

In your migraine diary, try to record:

• the date of the attack
• the time of day the attack began
• any warning signs
• your symptoms (including the presence or absence of aura)
• what medicine you took
• when the attack ended

Medicines and supplements

Medicines are also available to help prevent migraines. These medicines are usually used if you have tried avoiding possible triggers but you're still experiencing migraines.

You may also be prescribed these medicines if you experience very severe migraine attacks, or if your attacks happen frequently.

Some of the main medicines used to prevent migraines are outlined below.

Topiramate

Topiramate is a type of medicines originally developed to prevent seizures in people with epilepsy, but is now much more commonly used in migraine.

It's been shown to help prevent migraines, and is usually taken every day in tablet form.

Topiramate should be used with caution in people with kidney or liver problems.

It can also harm an unborn baby if taken during pregnancy and can reduce the effectiveness of hormonal contraceptives.

GPs should discuss alternative methods of contraception for women who are prescribed topiramate.

Side effects of topiramate can include:

• decreased appetite
• feeling sick
• being sick
• constipation or diarrhoea
• dizziness
• drowsiness
• problems sleeping

Propranolol

Propranolol is a medicine traditionally used to treat angina and high blood pressure, but it's also been shown to effectively prevent migraines.

It's usually taken every day in tablet form.

Propranolol is not suitable for people with asthma, chronic obstructive pulmonary disease (COPD) and some heart problems.

It should be used with caution in people who have diabetes.

Side effects of propranolol can include:

• cold hands and feet
• pins and needles
• problems sleeping
• tiredness

Amitriptyline

Amitriptyline is a medicine originally designed to treat depression, but has also proved useful in helping prevent migraines.

It's usually taken every day in tablet form.

Amitriptyline can make you feel sleepy, so it's best to take it in the evening or before you go to bed.

Other side effects include:

• constipation
• dizziness
• a dry mouth
• difficulty peeing
• a headache

It may take up to 6 weeks before you begin to feel the full benefit of the medicine.

Find out more about amitriptyline

Botulinum toxin type A

In June 2012, NICE recommended the use of a medicine called botulinum toxin type A by headache specialists to prevent headaches in some adults with long-term migraine.

Botulinum toxin type A is a type of nerve toxin that paralyses muscles.

It's not exactly clear why this treatment can be effective for migraine.

NICE recommends that this treatment can be considered as an option for people who have chronic migraine (headaches on at least 15 days of every month, at least 8 days of which are migraine) that's not responded to at least 3 previous preventative medical treatments.

Under the NICE guidelines, botulinum toxin type A should be given by injection to between 31 and 39 sites around the head and back of the neck.

A new course of treatment can be given every 12 weeks.

Acupuncture

If medicines are unsuitable or do not help prevent migraines, you may want to consider acupuncture.

NICE states that a course of up to 10 sessions over a 5- to 8-week period may be beneficial.

Find out more about acupuncture

Preventing menstrual-related migraines

Menstrual-related migraines usually occur from 2 days before the start of your period to 3 days after.

As these migraines are relatively predictable, it may be possible to prevent them using either non-hormonal or hormonal treatments.

Non-hormonal treatments

The non-hormonal treatments that are recommended are:

• non-steroidal anti-inflammatory drugs (NSAIDs) – a common type of painkiller
• triptans – medicines that reverse the widening of blood vessels, which is thought to be a contributory factor in migraines

These medicines are taken as tablets 2 to 4 times a day from either the start of your period or 2 days before, until the last day of bleeding.

Hormonal treatments

Hormonal treatments that may be recommended include:

• combined hormonal contraceptives, such as the combined contraceptive pill, patch or vaginal ring
• progesterone-only contraceptives, such as progesterone-only pills, implants or injections
• oestrogen patches or gels, which can be used from 3 days before the start of your period and continued for 7 days

Hormonal contraceptives are not usually used to prevent menstrual-related migraines in women who experience aura symptoms because this can increase your risk of having a stroke.

Read about the complications of migraines for more information about this.

Advice and support

There are a number of organisations that offer advice and support for people with migraines, including The Migraine Trust.

The Migraine Trust can be contacted on 020 7631 6970 or by emailing info@migrainetrust.org.

You can also join The Migraine Trust's online community through Facebook.