Migraine is a neurological condition, usually described as headache pain that is accompanied by symptoms such as light sensitivity, nausea and vomiting. However, a migraine attack can also be characterized by its phases, which begin before the headache pain starts, and continue even after the pain has disappeared.
“I think we do…patients a disservice, with migraine, [when] we bookend an attack by the beginning and the ending of the pain. The prodromal phase could last hours to days; the postdromal phase could last hours to days. So when you consider the true start of an attack and the true ending of an attack, [that] which was an eight, ten-hour headache may now turn into a three-day attack.”3
In this article we will describe:
The four phases of migraine, their symptoms, and treatment options during each phase.
A fifth phase of migraine, known as the interictal phase, that occurs between migraine attacks, and what treatments are important during this phase.
Why it’s important to understand and identify the different phases of your migraine.
The variability and complexity of migraine phases.
Phases of Migraine
The four phases of migraine are:1
The prodrome phase refers to a set of symptoms that typically occur before the acute phase of the migraine attack. It begins anywhere from a few hours to a couple days before the migraine pain begins.2
Common prodromal symptoms of migraine include:1, 3, 4, 5, 6, 7
brain fog, trouble concentrating, or difficulty processing information
fatigue or tiredness
mood changes, such as depression, irritability, or elation
neck stiffness or pain
sensitivity to light (photophobia)
sensitivity to noise (phonophobia)
sensitivity to smells (osmophobia)
Did you know?
The prodrome phase is also known as the premonitory phase. Premonitory means “serving to warn or notify beforehand” – a premonition that something is about to happen.8
Approximately 75% of people experience migraine prodrome symptoms, but they may be even more common.3 Lack of awareness and recognition of the prodrome phase can contribute to these symptoms not being identified as warning signs of an upcoming migraine attack.
More often, individuals with migraine disease identify bright lights, smells, neck pain, and other symptoms as migraine triggers. Distinguishing between migraine triggers and prodromal symptoms can be difficult, as Dr. Andrew Charles discusses in the video below:
In addition, prodrome symptoms can vary from attack to attack, making it even more difficult to identify a pattern. Prodromal symptoms are sometimes easier to identify in retrospect, or for family members to observe and identify.1
“Patients often experience a change in mood, either a feeling of depression or irritability, well before the headache begins. In fact, partners often can recognize [the mood change] more than patients.”1
Dr. Charles recommends that patients try the following interventions during the prodrome phase to see what impact they have on the progression of their migraine:1
Take medication as soon as you recognize you’re in the prodrome phase. These may be over the counter anti-inflammatories (NSAIDs) or prescription migraine medications.
Try the following non-medicinal approaches, to see if they help:
eat food and drink fluids, even when you are nauseated
breathing or relaxation techniques
However, at this time, there is no evidence that treatment of a migraine during the prodrome phase is helpful.5 According to Dr. Charles, “There’s no evidence yet to tell us what we should be doing during [the prodrome] phase of the attack … mainly because, [in] almost all of the trials for acute migraine medications, the stipulation is that they’d be taken when the pain has already started.”1
The second phase of migraine is the aura phase. This phase usually occurs about 30 minutes before the onset of the headache pain, but in some instances it may begin sooner or even overlap with the onset of the headache pain.5
Aura symptoms are due to an electrochemical event in the brain called cortical spreading depression. It starts in the occipital region in the back of the brain, and spreads toward the front, at a rate of 2 to 3 millimeters per minute. As this event spreads across the cortex, the symptoms occur.3 By definition, aura are symptoms that are not permanent, and must resolve within an hour. Aura that lasts for more than an hour is uncommon, and is referred to as migraine with prolonged aura.12
Dr. Charles describes four categories of migraine aura:5
Visual aura, such as shimmering, zig-zagging, or colored lights, or blind spots in the vision. These visual disturbances spread across the field of vision over the course of 20 to 60 minutes.
Sensory aura, such as tingling or numbness in the hand or face.
Language aura, such as difficulty finding words or putting together coherent sentences.
Motor aura, such as clumsiness or weakness on one side of the body.
For some people who experience aura, cortical spreading depression can cause aura symptoms to shift from one category of aura to another – for example, visual aura symptoms can spread into sensory aura symptoms.1
Auras, similar to other migraine symptoms, are variable across individuals, and also across migraine attacks. Approximately 30% of individuals have experienced aura at least one time, but only 15% of people experience aura with every migraine attack.3,5
The aura phase, similar to the prodrome phase, provides individuals with a warning signal that a migraine attack is coming. This is important, as early intervention can help mitigate the pain in the next phase of the attack. Prescription migraine medications, such as triptans, or non-prescription pain medications, such as NSAIDS, should be taken as soon as symptoms occur.12
Unfortunately, there are no specific treatments that are targeted just for aura. A small study has shown that taking a triptan may shorten the aura phase, but other studies have shown that taking a triptan during the aura phase is ineffective.12
Did you know?
Aura symptoms are not always followed by headache pain. This is sometimes unofficially referred to as “silent migraine.” It is common for a person who experiences aura to occasionally have a silent migraine. Only 3-4% of people are diagnosed with acephalgic migraine, which is when every migraine attack is a silent migraine.12
The headache phase of migraine usually follows the prodrome and/or aura phase. This phase can last for up to 72 hours. As the name of this phase suggests, this phase is most often characterized by head pain, which usually begins as mild and progresses to moderate or severe pain if it is not treated. The pain is often only on one side of the head, and may be throbbing, sharp, or dull. Usually the pain level peaks within 30 minutes. Additional common symptoms during the headache phase are:2,3,11
insomnia or increased need for sleep
nausea or vomiting
neck pain or stiffness
sensitivity to light (photophobia)
sensitivity to smells (osmophobia)
sensitivity to sounds (phonophobia)
vertigo or dizziness
This phase of migraine is usually called the “headache” phase or “pain” phase because head pain is the most common symptom. However, not everyone experiences headache pain during this phase. For example, those diagnosed with vestibular migraine often experience intense vertigo instead of pain.11 To represent the migraine experience for those who do not experience pain, this phase is sometimes referred to as the “attack” phase.
Did you know?
The headache phase of a migraine is also known as the ictal phase. The word ictal originates from the Latin word ictus which means “a blow or a stroke.”10
As mentioned previously, studies have shown that the earlier you treat a migraine during this phase, the more likely that acute treatment will be effective. It is recommended to take acute treatments for headache pain and/or nausea immediately when these symptoms start.1 Early treatment is not only important in shortening the duration of the headache phase, but it is also important in preventing future migraine attacks.5
Treatments during this phase are usually focused on reducing the pain or discomfort. Migraine treatments may include, but are not limited to, the following categories, and are sometimes used in combination:4,9
over-the-counter medications, such as non-steroidal anti-inflammatories (NSAIDs) like ibuprofen or naproxen, or pain relievers like acetaminophen
prescription migraine medications, such as triptans, gepants, ditans, and ergotamine derivatives
anti-nausea medications (antiemetics)
cold therapy to treat neck pain or stiffness
However, frequent use of acute medications – more than 10-15 doses per month – can result in medication overuse headache. This is when regular use of acute pain medications triggers future migraine attacks.9
The postdrome phase occurs after the headache phase has resolved. This phase may be unofficially known as the “migraine hangover.” It’s dominated by cognitive symptoms, such as:2,4,11
disorientation or dizziness
fatigue, or feeling “washed out” or “hungover”
Migraine postdrome symptoms can last for a few days or in some cases up to a few weeks, and can be just as disabling as the headache phase.1,11
“It’s all about … returning [migraine patients] to normal function or near-normal function. … If I can’t function because I’m in a postdrome, it’s just as debilitating as if I’m having pain.”3
No specific treatments have been identified for the postdrome phase, though the following may be helpful in some cases:1,4
caffeine (unless it is a migraine trigger)
cold therapy or heating pads to treat neck pain or stiffness
prescription drug stimulants, such as drugs that address the neurotransmitter norepinephrine
rest or sleep
The time between migraine attacks – between the end of the postdrome phase and the beginning of a prodrome phase of the next attack – is known as the interictal phase. Migraine symptoms may still persist during this phase, such as:11,13
light sensitivity, especially in individuals with chronic migraine
lightheadedness or dizziness, especially in individuals with vestibular migraine
sensitivity to sound and/or odors
“We go back to the fact that migraine is not a headache. Migraine is a brain disease, and it impacts many different aspects of our brain and how we function. And so, an individual whose head pain is gone, still can have lingering symptoms in between.”14
Migraine symptoms during the interictal phase are an important indication of the progression of migraine disease. For example, untreated episodic migraine can progress to chronic migraine, as consecutive migraine attacks begin to overlap each other and the individual is unable to fully recover from one migraine attack before the next one begins. This is characterized by worsening interictal symptoms. As Dr. Lay explains in the video below, reducing migraine symptoms during the interictal phase can be a step toward improving a person’s migraine disease.11,14
The interictal phase is a time to focus on migraine prevention and lifestyle. Preventive medications may be necessary to decrease the frequency of migraine from chronic to episodic. However, preventive medications do not need to be taken forever; they can be used temporarily to “reset the brain” and break the cycle of frequent attacks.14 Then, the progress that was made with the preventive medications can be anchored by lifestyle modifications, such as:7,14
biofeedback, meditation, and relaxation techniques
consistent eating schedule
consistent sleep schedule, or good “sleep hygiene”
“Extremes of exposure tend to bring on headaches. …Deviations from your daily pattern tend to bring on a headache. …”
Individuals with migraine may instinctively focus on avoiding migraine triggers. However, as Dr. Vince Martin points out, trigger avoidance isn’t always practical, and there may even be some benefits in intentional trigger exposure to train the body to cope with migraine triggers:7
Your experience with migraine is unique and likely to change over time
You – and your migraine attacks – are unique. It’s important to emphasize that not everyone with migraine experiences all of the four phases of migraine, nor will they experience every phase, in the same order, with every migraine attack. These phases can blur together, change order, change duration, change intensity, or be skipped altogether.1,2,3,5 Every migraine condition is unique, just as every individual with migraine is unique.
However, understanding the phases of migraine can help us treat our symptoms more effectively, decrease our migraine frequency, and, as Dr. Lay explains, change our brain structure over time:14
“We definitely do see alterations in the structure of the brain [due to chronic pain], and it’s not completely well understood why those happen and what the physiology is to get patients there. But we do know that you can change it the other way. We don’t really fully understand how or why, but we do know that doing all the right things – so, lifestyle factors, nutraceuticals, getting out for a walk, mindfulness, meditation, treating your attacks when they come, getting on top of them early and looking at preventive therapy – all are really important to reverse from chronic migraine to episodic migraine, but also to reverse some of those brain changes.”
Nestled between sleep and wakefulness, a morning headache is a common occurrence among people with and without migraine. This painful and unwelcome experience uncovers sleep’s role in migraine, and simultaneously, migraine’s effects on sleep. Though this relationship may not be clear as day, creating an action plan to combat a morning headache is both accessible and effective.
Why You May Wake Up with a Headache
1. Poor Sleep Habits
Poor sleep habits can impact both the quality and duration of sleep. Common traps that could induce an early morning headache include:
Not managing stress: Tension, either from tight muscles, anxiety, or an improper sleep position can trigger an early morning headache. Similarly, teeth grinding or clenching can also contribute to facial or head pain.1
Under- or oversleeping: Both scenarios can disrupt the body’s natural sleep-wake cycle, resulting in an early morning headache.
Irregular sleep schedule: Whether erratic sleep is due to jet lag, shift work, or the weekend “catch-up”, inconsistent sleep can disrupt the circadian rhythms and impact the production and release of melatonin, a hormone responsible for inducing sleep.1,4
Electronic use: The blue light emitted from electronics interferes with the body’s natural release of melatonin, a sleep-inducing hormone.2
“Patients who don’t sleep well over time have trouble with pain control. So the less we sleep, the more likely we are to have pain.”1
2. Sleep Disorders
All sleep disorders constitute some level of decreased sleep quality or duration.
Sleep apnea: Marked by gaps in breathing, sleep apnea can affect oxygen levels. If a morning headache lessens as oxygenation levels improve throughout the course of the day, sleep apnea may be the culprit.1
Insomnia: Lack of sleep or delayed sleep can trigger migraine or tension-type headache.4
Restless leg syndrome: Movement during sleep can impact sleep quality and contribute to a decreased pain threshold and morning headache.1
Sleep bruxism: Clenching the jaw or teeth grinding can increase muscle tension in the facial and head region, increasing the likelihood of a morning headache.1
3. Circadian Rhythm Disorders
Circadian rhythm disorders refer to disturbances in the circadian rhythm, or internal biological clock. When this system is out of sync with the environment, sleep and other biological processes are impacted.5 Decreased alertness, daytime sleepiness, or a morning headache can all be caused by a circadian rhythm disorder.
4. Headache Disorders
Migraine: Migraine attacks can be triggered by poor sleep quality and inconsistent sleep schedules. Additionally, people with migraine may experience poor sleep prior to a migraine attack. This may be due to spikes in serotonin levels during the night, causing fragmented sleep.2
Medication Overuse Headache: When over-the-counter pain relievers or prescription headache medications are used too frequently or for too long, a nighttime withdrawal could result in a morning headache.1
Hypnic Headache: Hypnic headache is a prime example of a dysregulated sleep-wake pattern. Characterized by attacks that awaken someone from sleep at the same time each night, this type of headache often begins in middle age and can last from 30 minutes to 6 hours.6
Cluster Headache: This type of headache is marked by severe pain in or around the eye or on one side of the head, congestion, excessive tearing or redness of the eye, and restlessness. Attacks can be cyclic and awaken someone from sleep.7 Excess sleep is a reported trigger for cluster headache.4
Did You Know?
While many with migraine may experience poor sleep as a trigger, it could actually be part of the prodrome, or the first phase of migraine. In other words, your migraine attack may be triggering poor sleep, not the other way around.1
5. Mental Disorders
Depression and Anxiety: Common among individuals with migraine, depression and anxiety are often accompanied by physical symptoms, such as appetite changes, sleep disturbances, or headache.9
Maladaptive Behavioral Patterns: If mornings become synonymous with head pain, consider evaluating any mental health factors that may be preventing a restorative and deep night’s sleep. For example, catastrophizing and hypervigilance, common behavioral patterns seen in people with migraine, may cause unease throughout the day and before bedtime.9,10 As a result, if you aren’t able to wind down your body and mind, sleep could be impacted.
6. Other Medical Disorders
Intracranial Hypotension: If a morning headache occurs upon standing up, but is absent when lying down, intracranial hypotension could be playing a role. This type of headache is caused by low levels of cerebrospinal fluid, which cushion the brain and spinal cord. Without adequate cushioning, compensation occurs, causing vasodilation and increased pressure in pain-sensitive areas.11
Brain Tumor: Awakening from sleep with head pain in no way points to a brain tumor. However, if a severe headache in the morning is accompanied by other symptoms indicative of a brain tumor, speak to your doctor.12
7. Hormonal Factors
Female Sex Hormones: Fluctuating hormone levels are a common migraine trigger. In fact, hormones are believed to be a contributing factor in the three-fold higher prevalence of migraine among people with vaginas than those with penises. If you are experiencing morning head pain around menstruation, hormones may be a likely cause.13
Similar to sleep habits, these daytime habits can have a direct impact on sleep:
not staying well-hydrated
skipping meals or eating a large meal before bed
consuming caffeine past noon, or caffeine withdrawal
9. Environmental Factors
Allergens: Dysfunction of the autonomic nervous system, which controls involuntary processes, links migraine and allergies. Allergen-induced inflammation triggers congestion, sneezing, fatigue, and headache.14 Additionally, the release of histamine causes dilated blood vessels and a rise in nitric oxide levels, which is associated with migraine attacks.15
Mold: Mycotoxins, which are present in mold spores and released into the air, can cause headache, fatigue, or difficulty concentrating. While more research is needed in this area, bedrooms with mold may play a role in a morning headache.16
Chemicals: Sensory sensitivities are hallmarks of migraine disease. Synthetic fragrances or other chemicals found in some perfumes, air fresheners, or body products can trigger migraine. If you’re sleeping in a room with a triggering chemical or scent, it could be causing a morning headache.
Sleeping pills: Studies show that certain sleep medications can actually worsen headache.1 Talk to your healthcare professional for medical advice if you think a sleep medication may be causing a morning headache.
Overusing pain medication: Taking prescription or over-the-counter painkiller medication too frequently can cause medication overuse headache, which may be experienced upon awakening.1
Reasons Why You May Wake Up with a Headache
Common causes of morning headache may include issues related to:
sleep habits, including unmanaged stress, under or oversleeping, inconsistent sleep/wake times, or electronic use before bed
sleep disorders, circadian rhythm disorders, headache disorders, mental disorders, or other health conditions
lifestyle, hormonal, and environmental factors
Treating Migraine and Comorbid Sleep Disorders
While a morning headache may respond to over-the-counter medications, such as acetaminophen or ibuprofen, embracing a holistic approach can promote wellness and prevent future morning attacks.
“The most common [sleep disorder] really is just poor sleep hygiene. A third of us are guilty of that.”2
Sleep hygiene refers to the healthy habits, behaviors, and environmental conditions that aid in achieving quality sleep. Incorporating sleep-friendly practices and avoiding sleep-disrupting activities is key for migraine and sleep disorder treatment.
Start a Sleep Routine
Sleep schedule: Strive for regular and consistent sleep patterns, i.e., wake up and fall asleep at around the same time each day.
Sleep duration: Adults should aim for eight hours of sleep each night, while children and teens need eight and a half to ten hours of sleep.
Wind down time: Set aside time to wind down before bed, and include relaxing activities, such as meditation. Dimming the lights can also help cue the body for sleep.
Electronics: Avoid using electronic devices before bed, as the blue light emitted from electronics inhibits the release of melatonin. If complete elimination is not realistic, you can use the “night mode” function to reduce blue light and prepare the brain for sleep.
Did You Know?
Studies show that people who meditate before bed have enhanced melatonin levels, slow-wave (deep) sleep, and rapid eye movement (R.E.M.) sleep.17,18
Optimize Bedroom Conditions
Cool temperatures: Keep the bedroom between 65 and 68 degrees Fahrenheit, and avoid dressing too warmly.
Quiet environment: Use a sound machine if noise is an issue.
Dark bedroom: Use shades or blackout curtains to prevent light from peeking through windows.
Key Point How fast should I fall asleep?
Ideally, sleep onset should occur after 20 minutes of being in bed. Rapid sleep onset may be a sign of sleep deprivation or exhaustion, while delayed sleep onset could indicate various issues pertaining to sleep hygiene or a sleep disorder.1
As you optimize sleep hygiene, consider exploring how daytime habits may be impacting sleep.
Sunlight: Get your daily dose of sunshine to help keep the circadian rhythm functioning as nature intended.
Stress management: Reduce stress through meditation, deep breathing, talk therapy, or social support. If temporomandibular joint (TMJ) disorder or teeth grinding is present, talk to your doctor about using a mouth guard.
Diet: Eat regularly to keep steady blood sugar levels, and avoid a large meal before bed.
Hydration: Stay well-hydrated throughout the day, and avoid drinking too much water right before bed.
Caffeine and alcohol: Avoid caffeinated beverages past noon, and limit alcohol consumption.
Smoking: Don’t smoke—nicotine disrupts sleep, and smoking is a risk factor for snoring and sleep apnea.19
Exercise: Strive for daily sweat-inducing movement, but avoid exercising within two hours of bedtime.
Bedroom activities: Only use the bedroom for sleep or sex.
Napping: While a nap can help fight a migraine attack, it can also disrupt the circadian rhythm and cause more sleep problems. If you need to nap, limit them to no more than 30 minutes, or consider going to bed earlier.
Cognitive Behavioral Therapy for Insomnia
Cognitive behavioral therapy for insomnia (CBTI) is a first-line treatment option for people with insomnia. Drawing from cognitive behavioral therapy, CBTI explores the underlying behavioral issues that may be perpetuating sleep deprivation. It focuses on two facets: stimulus control and sleep restriction.1
Stimulus control addresses any environmental stimuli that could be preventing sleep onset and continuity.
Sleep restriction aims to eliminate nighttime awakenings by restricting the time spent in bed. For example, if someone is in bed for ten hours but only sleeps for five and a half hours, then their time in bed would be restricted to six hours. This process will repeat, until over time, their time spent in bed parallels their time spent sleeping.
Key Point Treat Sleep Apnea
Sleep apnea causes snoring, pauses in breathing, and daytime sleepiness. It also causes drops in oxygen levels throughout the night, making treatment especially important. If you think you may have sleep apnea, seek a sleep specialist to obtain a sleep study. Treatment often includes a CPAP (continuous positive airway pressure) machine to help keep the airways open for better oxygenation and better sleep.
Widely available and generally cost-effective, supplements can be a relatively simple addition to your migraine toolbox.
Magnesium: Magnesium is a critical mineral that aids in relaxation, stress reduction, and sleep. Magnesium deficiencies, which 50% of people with migraine have, can cause irritability, insomnia, tension headache, or migraine attacks.21,22 While this supplement can be taken in various forms, 400 mg in pill form is a great place to start.21
Iron: Ferritin is a protein that stores iron and releases it as needed. Low ferritin levels could indicate an iron deficiency and is a common cause of restless leg syndrome.1 If you experience this sleep disorder, speak to a healthcare professional about the possible benefits of an iron supplement.
Sometimes poor sleep and increased migraine attacks may require pharmacological intervention. In these cases, adding a sleep medication can help break that cycle and offer an emotionally corrective experience.
Zolpidem (Ambien) and eszopiclone (Lunesta) are commonly used for insomnia. These medications have less habituation and less tolerance than benzodiazepines. In addition, usually, the same dose can be taken for longer periods of time.2
Summary Treating Migraine and Comorbid Sleep Disorders
Treatment options for migraine and comorbid sleep disorders include behavioral intervention, supplements, and medications.
For better sleep, start a sleep routine that incorporates sleep-friendly habits:
Keep the bedroom dark, cool, and quiet, and avoid working where you sleep.
Aim for 8 hours of sleep every night.
Wind down before bed by meditating and limiting electronic devices.
Be mindful of how daytime habits may affect sleep:
Eat regularly and stay hydrated.
Limit caffeine and alcohol, and don’t smoke.
Exercise no later than 2 hours before bed.
Keep the bedroom for sleep or sex.
For those with insomnia, cognitive behavioral therapy for insomnia is a first-line treatment.
Additionally, supplements, such as melatonin, magnesium, or iron can aid in sleep. In some cases, medication may be necessary to break a poor sleep and migraine cycle.
Due to sleep’s highly impactful nature, there are numerous reasons why someone may wake up in the morning with a headache. Issues related to sleep, medical conditions, or lifestyle factors could be possible causes of a morning headache.
Improving sleep quality and consistency is key to the successful treatment of migraine and comorbid sleep disorders. Through behavioral intervention, supplements, and medications, a morning headache can be addressed, treated, and prevented.
I’m getting frequent morning headaches. What should I do?
Creating a sleep log is a great place to start. Take note of bedtime, wake time, and any activities that may be affecting good sleep, as outlined above. You may be able to identify patterns that are contributing to a morning headache.
Additionally, reach out to your doctor. They may refer you to a sleep or headache specialist who can treat underlying sleep or headache disorders.
Is an early morning headache a sign of a brain tumor?
It’s very rare that a morning headache is a symptom of a brain tumor. However, if you experience a severe new type of headache accompanied by other neurological symptoms, speak to your doctor or neurologist.
For individuals living with migraine disease and its psychological comorbidities, coping with both the physical and mental symptoms can be very challenging. Despite this variable experience, a ‘mind versus body’ approach is a false dichotomy. In actuality, migraine and mental illness pool from undercurrents infused with similar biological make-ups. This resulting interdependence marks migraine and mental illness as travel companions and comorbid conditions.
Migraine and Mental Health
The pain, isolation, and frustration of living with migraine disease is a burden shouldered by one billion people worldwide.1 When this burden becomes impacted by mental illness, disability rises, leaving many with mental illnesses interlocked with migraine, and subsequently migraine restricted to maladaptive mental states.
Occurring silently, invisibly, and often in the face of stigma, migraine and psychiatric disorders are underdiagnosed, undertreated, and misunderstood.2
Mental Illnesses Comorbid with Migraine
Although migraine is neurobiological in nature, psychological disorders may arise in conjunction with migraine due to shared genetic and environmental components. This overlap in origin, as well as presentation, accounts for the occurrence of several mental illnesses comorbid with migraine, i.e., occurring simultaneously at a higher than chance rate.3
Major Depressive Disorder
Major depressive disorder (MDD) is the medical term for what is typically referred to as depression. Like migraine, depression is one of the leading causes of global disability. Severe depression can incapacitate just like migraine, and individuals with migraine are five times more likely to develop depression than those without migraine.3
Those with MDD experience persistent feelings of sadness and loss of interest. Coupled with somatic symptoms, such as changes in appetite, sleep, and energy, depression interferes with daily life and produces general feelings of unhappiness or not wanting to live.4
Although “depression headaches” may be used as a descriptor of experience, it is not the medically used term. Nevertheless, migraine and MDD may present in a similar fashion, as both can impair cognitive and physical function.
Like migraine, bipolar disorder rests on a spectrum, and individuals with bipolar disorder experience a range of symptoms, both in type and severity.
Although intensity of symptoms vary, bipolar disorder causes shifts in mood, energy, and ability to function. Episodes of mania or hypomania involve elevated, expansive, or irritable moods, while depressive episodes are marked by sadness, hopelessness, or indifference.
The road to a bipolar diagnosis can take years, echoing the journey that many with migraine face. In addition, one third of people with bipolar disorder also have migraine, making bipolar disorder yet another migraine comorbidity.5
Generalized Anxiety Disorder
The hallmark symptom of generalized anxiety disorder (GAD)—excessive, uncontrollable, and persistent anxiety and worry—is not unfamiliar to those prone to frequent migraine attacks. GAD has a five-fold greater prevalence in the migraine community. The chronicity of migraine and GAD affects an individual’s participation in work, school, and social life. These impacts perpetuate a cycle of fear and anxiety.
Becoming increasingly sensitive to your own physiological cues ties both disorders together as well, and understandably so. Efforts to manage these disorders often leave people with migraine and GAD with heightened interoceptive awareness, or the ability to notice bodily sensations.5
Rises in stress can worsen both disorders, causing increased worry, withdrawal, and hopelessness.3 Individuals who experience migraine and co-occurring GAD often become so conditioned to negative outcomes that catastrophizing becomes a learned response, and one that affects treatment outcomes.7
The symptoms of panic disorder parallel many of the experiences people with migraine face, including severe, intermittent, unpredictable, and uncontrollable attacks. Rushes of adrenaline and anxiety accompanied by a range of mental and physical symptoms mark the frightening experience of panic attacks.5
Efforts to decrease the frequency and impact of these attacks often result in avoidance and hypervigilance, experiences not uncommon amongst those with migraine. These resemblances contribute to the increased prevalence of panic disorder in the migraine population, as individuals with migraine are three to ten times more likely to develop it than those without migraine.3
Post-Traumatic Stress Disorder
Feelings of fear or distress are natural responses to trauma. However, nine million Americans experience lasting negative emotional responses after exposure to a traumatic event. This prolonged problem is referred to as post-traumatic stress disorder (PTSD).8
Individuals with PTSD experience intrusive and distressing thoughts and flashbacks, and as a result, often engage in avoidant behaviors as a way to decrease the frequency and impact of these symptoms. In addition, feelings of self-blame and other negative emotions contribute to low moods and indifference. Like migraine, changes in arousal, such as cognitive difficulties, sleep disturbances, and hypervigilance, color the experiences of those with PTSD.8
Suicidal ideation refers to the broad range of thoughts, ideas, and desires related to death and suicide. From momentary passive thoughts to deliberate planning and intense fixations, suicidal ideations vary in intensity, length, and type.
Because the probability of suicidal ideation increases with the presence of depression, anxiety, or bipolar disorder (disorders which already coexist with migraine), suicidal thoughts are more common within the migraine population.5 Not only that, but suicide attempts occur two-and-a-half times more among people with migraine than those without.2,3
The Migraine, Anxiety, and Depression Relationship
Experiencing depression or anxiety alongside migraine is not uncommon—many individuals with these disorders have witnessed neurological dysfunction leak into new territory. This highlights a bidirectional relationship: people with migraine are more likely to develop depression or anxiety than the general population, and vice versa.3,5
Migraine, depression, and anxiety feed off of each other—having one may worsen the others. Conversely, successful treatment of one condition may, but not always, ameliorate symptoms of the other conditions.
They work in tandem, for better or worse, and in this way they often travel together. More often than not, though, this pairing starts with migraine, and the addition of depression or anxiety arises later.5
Did You Know?
People with depression are three times more likely to develop migraine than people without depression.3
Risk Factors for Developing Mental Illness Comorbidities
Although migraine and mental illness coexist separately, there are several factors that increase the risk of developing mental disorders alongside migraine.
Living with migraine is stressful. According to the Chronic Migraine and Epidemiology Outcomes (CaMEO) Study, people living with migraine experience notable amounts of stress and guilt.7 Heightened psychological distress, such as worry, fear, or hopelessness, not only trigger migraine attacks, but also the development of comorbid anxiety and mood disorders.3
This link is mediated through activation of the sympathetic nervous system, which is responsible for the “flight or flight response.” Changes in this neural circuitry creates physiological imbalances that can manifest as anxiety or depression. Cognition, decision-making, and mood all become indicated in maladaptive patterns, perpetuating a vicious cycle where migraine and mental illness become relational and intertwined.7
History of Abuse or Neglect
The long-term consequences of abuse or neglect result in dysregulation of the body’s response to stress, increasing levels of stress hormones and inflammation.
In addition to changes in stress reactivity, the emotional impacts of childhood trauma contribute to negative emotional states. Consequently, those with a history of abuse or neglect are at a higher risk of developing both migraine and mental illness.10
While all forms of abuse or neglect can contribute to the development of illness, emotional abuse in particular is associated with migraine. People who have experienced emotional abuse in childhood also experience more significant impacts from the typical stressors found in adulthood.10
Increased Headache Frequency
As the frequency of migraine attacks increases, so does the risk for developing anxiety and mood disorders.3,5
Individuals with chronic daily headache are seven times more likely to develop depression, while those with one or fewer attacks per week are only twice as likely.10
It is believed this correlation is two-fold:
Experiencing more pain and disability, which are unpredictable in nature, can cause heightened psychological distress and social isolation, and thus increased risk for the development of mental illness.3,5
Increased migraine attacks can cause central sensitization, or the hypersensitivity of the central nervous system to stimuli. These sensitized neural networks can cause further distress, both physical and emotional, thereby increasing the risk of developing a mental illness.11
Furthermore, similar to frequency, increased headache severity accounts for the rise in suicidal ideation within the migraine population.5
Migraine with Aura
Migraine with aura has been linked to both depression and panic disorder, and those who experience aura are three times more likely to develop bipolar disorder than the general population.11 In addition, migraine with aura has been shown to be associated with suicide attempts.12
People with migraine report more sleep problems than those without migraine.13 While sleep disturbances are symptomatic of many mental illnesses, they may also be a risk factor, as poor sleep quality can result in fatigue, both physically and mentally. Irritability and exhaustion negatively affect emotional regulation, leading to mood swings and other physiological manifestations as seen in anxiety and depression.2,4
The Bidirectional Relationship Between Migraine and Mental Illness
Migraine is comorbid with various mental disorders, including major depressive disorder, generalized anxiety disorder, panic disorder, bipolar spectrum disorder, post-traumatic stress disorder, and suicidal ideation.
These disorders co-occur with migraine at a higher-than-chance rate and have a bidirectional relationship with migraine. For example, people with migraine are more likely to have depression or anxiety than those without migraine, and vice versa.
In individuals with migraine, certain risk factors increase the chance of developing a mental illness. These include migraine with aura, increased stress and headache frequency, poor sleep, and a history of abuse or neglect, particularly emotional abuse.
Key Features of Migraine, Anxiety, and Depression
While a well-honed stress response has evolutionary advantages, repeated activation of the sympathetic nervous system can cause dysregulation and somatization. Somatization refers to the physical expression of symptoms arising from emotional distress. Because the body cannot distinguish external dangers from internal worries, this stress response can fire frequently in the presence of migraine and mental illness, where internal tension and uncomfortable emotions may run high.
The Hypothalamic-Pituitary-Adrenal (HPA) axis regulates the body’s response to stress through intricate feedback loops between the hypothalamus, pituitary gland, and adrenal gland. This neuroendocrine network modulates various processes involving the immune system, nervous system, and metabolism, all in efforts to regain stability and maintain homeostasis, or internal equilibrium.
Stressors of any nature—emotional, physical, or mental—activate the HPA axis and jumpstart a cascade of events that result in the release of various hormones, including cortisol, a stress hormone.
When efforts to maintain homeostasis through the HPA axis result in allostatic overload, or the negative consequences associated with constant sympathetic nervous system activation, the nervous system becomes hyperexcitable and easily aroused. Abnormal and heightened responses to stressors, such as pain and uncomfortable emotions, further dysregulate neural circuitry and increase stress reactivity.15
Living with migraine, anxiety, or depression can deleteriously restructure cognition and misalign behavior. These impacts interfere with the development of healthy coping strategies and positive self-talk.
Though dysfunctional and unhelpful, these behavioral patterns can be viewed as understandable reactions to untenable circumstances. Excruciating pain, debilitation, and uncomfortable moods and emotions, as seen in migraine and mental illness, challenge coping mechanisms and adaptability.
Negative Self-Talk: Catastrophizing
Becoming accustomed to negative outcomes when living with chronic diseases often leaves individuals with migraine or mental illness prepared for the worst case scenario.
Catastrophizing refers to the snowballing of thoughts that escalates current conditions into disastrous consequences. This thought process lowers self-efficacy and the belief that people have control over their disease. As a result, fear and increased stress thwarts successful treatment outcomes.
Common among individuals with migraine, anxiety, depression, PTSD, and panic disorder, catastrophizing fuels feelings of hopelessness, helplessness, and worry. Rumination and heightened preoccupation with uncomfortable emotions or sensations accentuate symptoms of migraine, anxiety, and depression. In addition, frequent catastrophizing can propel the progression of episodic to chronic migraine.3,7
Anticipatory Anxiety and Hypervigilance
Inhabiting a body that experiences uncontrolled, unpredictable, and painful migraine attacks is inherently stressful. This is true for any chronic pain or disability with variable and acute attacks. Uncertainty of the future can lead people with migraine and mental illness to feel “on edge,” and understandably so.
Adapting to this erratic nature can result in a marked level of hypervigilance, and worry for the next migraine attack or the inability to be fully present and engaged can lead to anticipatory anxiety.5,6 Living constantly “on guard” can leave people with migraine and mental illness feeling stressed and exhausted.
Although understandable, these thought processes stamp the future as fixed. Attempts to control the uncontrollable can narrow one’s perspective, impair function, and shrink hope.
Due to the effects of anxiety and hypervigilance, people with migraine and mental illness can become increasingly sensitive to their own physiological cues.5
Developing anxiety sensitivity, or the fear of bodily sensations associated with anxiety or migraine, can increase the stress response and attack severity. It may also decrease the desired response to medication.5
Feelings of frustration and exhaustion can dampen the belief we have power over illness. Repeated stressful experiences can leave individuals with migraine or mental illness feeling trapped and unable to fulfill personal or professional obligations despite their best efforts. Over time, as functioning lessens, an individual’s spirits may follow.
Learned helplessness, or the conditioned belief that stressful situations cannot be changed despite being given opportunities to do so, is directly tied to migraine, depression, and anxiety. Believing one is incapable of affecting change lowers motivation, frustration tolerance, and self-esteem. Without belief in oneself, helpful intervention and treatment may remain distant and unutilized.6
What are the Similarities of Migraine, Anxiety, and Depression?
The key features of migraine and mental illness, increased stress reactivity and cognitive-behavioral patterns, are rooted in neurological dysfunction. This dysfunction appears physiologically through overactivity of the HPA axis, as well as behaviorally through self-defeating psychological patterns.
Examples of such patterns include catastrophization and anticipatory anxiety, in which people anticipate negative outcomes. Additionally, feelings of hypervigilance coupled with a heightened ability to sense bodily sensations, or anxiety sensitivity, is common amongst those with migraine, anxiety, and depression. Over time, feelings of discouragement and disappointment can potentially contribute to learned helplessness, or the belief that individuals are incapable of affecting positive change despite being given opportunities to do so.
Contributing Factors of Migraine and Mental Illness Comorbidities
Like migraine, the roots of mental illness cannot clearly be attributed to any singular cause. Nevertheless, these conditions share overlapping chemical imbalances, hormonal influences, and genetic susceptibilities.3,16
Neurotransmitters are chemical substances that the nervous system uses to transmit messages between nerve cells and target cells. They play an important role in a range of everyday functioning and behavior.2,3
Serotonin, dopamine, and noradrenaline (norepinephrine) are believed to be involved in mood, pain tolerance, motivation, and concentration. In addition, glutamate and GABA function as complements by acting as excitatory and inhibitory nervous system agents.19
Similar to neurotransmitters, hormones are chemical messengers that affect different bodily processes such as metabolism, sexual function, reproduction, and mood.
The association between female hormones and migraine is strong—fluctuations in certain hormones can cause spikes in migraine attacks, as well as anxiety, mood swings, fatigue, and irritability, as seen in premenstrual dysphoric disorder.18,33
The hormonal link may account for the increased prevalence of migraine and depression in people with vaginas as compared to those with penises.17
Genes affecting the function of some neurotransmitters, such as serotonin, dopamine, and GABA, may be implicated in migraine, anxiety, and depression.
This overlap in origin predisposes those with headache disorder to mental illness and vice versa.11,16
Environmental Stressors and Impacts
Stress is a normal state of humans. However, prolonged negative emotional, physical, or mental responses to stressors, or changes in the environment, has biological ramifications.10
Trauma and Adverse Childhood Experiences
Approximately 45% of the adult population have experienced adverse childhood experiences (ACEs) in the form of abuse or neglect. These traumatic experiences affect developing brains and bodies, causing increased risk for physical and mental health conditions.10
HPA Axis Dysregulation
Chronic activation of the sympathetic nervous system results in an interruption and dysregulation of the HPA axis, the body’s stress response system.10
Living in survival mode not only thwarts the ability to thrive, but also overloads the body with chemical substances called glucocorticoids which affect neural communication and connectivity. This can lead to a myriad of physical and mental symptoms.7,10
While optimal levels of glucocorticoids have anti-inflammatory effects, excessive levels of these hormones, which occur due to HPA overactivity, can actually increase inflammation. This maladaptive mechanism results in higher levels of inflammatory biomarkers, such as C-reactive protein. Elevated levels of C-reactive protein have been found in individuals with a history of abuse.10
The increased levels of glucocorticoids found in individuals who experienced high stress during childhood can cause shrinkage of the dendrites, or communicative branches of neurons, and its corresponding brain structure.
Volumetric changes to the limbic system, including the hippocampus and amygdala, which are involved in memory and fear, is associated with trauma and high childhood stress.10
Epigenetics refers to the relationship between the environment, behavior, and genes.
Exposure to trauma or ACEs affects the epigenome, which are chemical compounds that govern how a particular gene functions. With epigenetic changes, DNA sequence remains unaltered, but genetic expression undergoes modification, resulting in either up or down regulation of certain genes.10
Did You Know?
Due to the profound effects of early life stress, experiencing trauma and ACEs has the potential to affect multiple genes, and therefore multiple systems. Additionally, because epigenetic changes are hereditary, unresolved trauma can be passed down through generations. These devastating impacts of ACEs shed light on the reality of generational trauma.10
What Causes Migraine and Mental Illness Comorbidity?
While there is no singular cause for migraine and mental illness comorbidity, a variety of biological and environmental factors contribute to its concurrence.
Overlapping genetic associations, chemical imbalances, and hormonal influences can enable neurological dysfunction, thereby creating conditions ripe for comorbidity. Additionally, environmental factors, such as trauma and adverse childhood experiences can cause functional, structural, and epigenetic changes that contribute to migraine and mental illness onset.
These internal and external forces drive the genesis and progression of migraine, anxiety, and depression by affecting stress reactivity and inflammatory responses.
Treatment of Migraine and Co-occurring Anxiety and Depression
The most effective medications to preventively treat both depression and migraine are antidepressants.
Antidepressant medications work by affecting certain neurotransmitters that play a role in mood and pain, such as serotonin, dopamine, and noradrenaline.3,18,19
There are several classes of antidepressants that may be considered:
Tricyclic antidepressants, such as amitriptyline (Elavil) and nortriptyline (Pamelor)
SNRIs (Serotonin Norepinephrine Reuptake Inhibitors), such as venlafaxine (Effexor) and duloxetine (Cymbalta)
SSRIs (Selective Serotonin Reuptake Inhibitors), such as fluoxetine (Prozac)
When used appropriately, antidepressants can be effective treatment. Efficacy will vary depending on the individual patient and tolerability to side effects.
“…if you don’t treat the whole person, you’re oftentimes not going to succeed in treating each aspect of the person.”2
Due to the increased stress present in neurological dysfunction, realigning the body’s stress response is a cornerstone of migraine and mental illness management.
Fortunately, this can be achieved in a number of ways, and integrating multiple behavioral therapies and techniques can decrease stress and recalibrate our emotional response.
Psychotherapy with a trained mental health professional provides a safe space to process and address the challenges of living with migraine and comorbid depression or anxiety. Although there are numerous therapeutic modalities, two have strong evidence for migraine and mental health issues:
Cognitive behavioral therapy (CBT) addresses the relationship between emotions, thoughts, and behaviors. The focus of CBT lies in what can be controlled and adjusted, which is our reaction and response to the unpredictable and uncontrollable aspects of migraine and mental illness.3,7,20
Acceptance and commitment therapy (ACT) helps individuals accept uncomfortable emotions while staying present and nonjudgmental. By developing more productive approaches to cope with stress, people can commit to take action in ways that better align with their values and goals.4,21
Biofeedback is a therapeutic technique that trains people to control physiological processes that usually occur involuntarily, such as heart rate, blood flow, and muscle tension. Sensors attached to the scalp, hands, and chest provide visual or auditory feedback, allowing the individual to see in real-time how their thoughts affect bodily functions.
By increasing self-awareness and self-regulation, sympathetic nervous system activity can drop, thereby decreasing the body’s stress response. This relaxation process can then be applied to real-life circumstances that trigger or provoke migraine attacks or depressive and anxious symptoms.5,6,7
Although stress is unavoidable, relaxation training can help us modify how we respond to stressors. By slowing down the body’s stress response, calmness and rest can be achieved through regular practice.16
A few examples of relaxation therapies include:
Breath work: slow, abdominal, diaphragmatic breathing has evidence-backed benefits for migraine and anxiety disorders.
Progressive muscle relaxation: this technique involves contraction followed by relaxation of muscle groups. It helps people gain better awareness and ability to release muscle tension.
Guided imagery: by envisioning helpful mental images, individuals can learn to navigate uncomfortable terrains with positivity and openness.
Meditation is an ancient practice that redirects attention and awareness by grounding the senses in a thought or activity, such as the breath. As breathing slows and regulates, internal chatter fades, and a sense of clarity and calmness can be achieved.
By noticing thoughts and letting them pass, individuals can learn to quiet their mind, decrease stress, and regulate their emotions, all of which can positively affect migraine and co-morbid mental illness.
Mindfulness Based Therapies
“They say that depressed people live in the past; anxious people worry about the future. So, the role of mindfulness is to be in the present.”2
Mindfulness is a technique that focuses on the present moment in a nonjudgmental way. Mindfulness-based approaches nourish acceptance and understanding of a negative experience, thereby ushering in appropriate action.
Mindfulness-based therapies beneficial for migraine and comorbid mental illness include:
Mindfulness-based stress reduction (MBSR): MBSR includes a variety of approaches, such as yoga or meditation, that decrease stress and increase resilience.
Mindfulness-based cognitive therapy (MBCT): This modality combines the pillars of CBT and MBSR and is especially helpful for the prevention of depression relapses.
In order to integrate behavioral therapies and maximize their benefits, healthy lifestyle changes should be prioritized.
Addressing Physiological Needs
“If you don’t sleep well, if you don’t eat well, it’s hard to feel well.”2
Developing healthy habits facilitates brain plasticity, or the brain’s ability to adapt and change. Nourishing food, adequate sleep, ample hydration, and accessible movement can help promote neuroplasticity by releasing the patterns and stress responses present in migraine comorbid mental illnesses.3,24
Increasing Social Support
“…a lack of social support is inherently stressful. We need support from the people around us.”20
When the impacts of migraine are compacted by those of depression or anxiety, social support may wither, and individuals may experience increased isolation and disconnection.
Social support can take various forms. Compassion, helpful advice, and support groups can all provide the much needed connection that bolsters self-esteem and buffers against stress, one of migraine and mental illness’s biggest triggers.6,16
How is Migraine and Comorbid Depression and Anxiety Treated?
Effective management of migraine and comorbid depression and anxiety involves a combination of pharmacological and nonpharmacological treatment options.
Antidepressants and psychotherapy are often used simultaneously to recalibrate chemical imbalance and regulate stress. Other modalities such as biofeedback, meditation, mindfulness, and relaxation therapies aid in realigning physiological and emotional responses to stress, especially when used concurrently with healthy lifestyle changes and social support.
Using varied approaches, medicinal and behavioral, offer individuals the best chance of successful treatment.
Challenges of Living with Migraine, Anxiety, and Depression
Misconceptions and Stigma
“Migraine is not your fault. Migraine is a disease of the nervous system.”25
Migraine and mental disorders share more in common than neurological dysfunction. The misconceptions, judgments, and negative biases surrounding both disorders contribute to stigma, or the unfair and harmful labeling associated with a group of people who have a particular trait or disease.
The resulting self-blame, guilt, and shame compound the difficulties those with migraine and mental illness already face. These hardships lead to increased isolation, disability, and psychological distress.1,26,27
Increased Risk of Developing Other Medical Conditions
When people experience the far-reaching impacts of migraine disease in conjunction with mental illness, their quality of life may decrease. As a result, increased stress and isolation can contribute to the development of other health conditions.28
In particular, people with migraine and a history of trauma are at an increased risk for developing cardiovascular disease, PTSD, suicidal ideation, as well as revictimization.10,29
Worsening of Migraine and Mental Illness
People who have experienced stigma or discrimination may hesitate sharing health concerns with their physician. Delays in treatment can make migraine harder to manage, and within the time that passes until treatment is received, mental health issues and migraine can worsen.30
Moreover, people with episodic migraine and a history of abuse or comorbid psychiatric conditions are at a greater risk of developing chronic migraine.10,16 Not only that, but the risk of developing medication overuse headache also increases with the presence of depression or anxiety.2
In addition to chronicity, encountering stigma can lower self-esteem and provoke symptoms of depression or anxiety, contributing to negative cognitive-behavioral patterns.
Successful treatment of migraine and co-occurring mental illness requires patient engagement and participation. Apathy, lethargy, and indecisiveness, as often seen in depression, hinder a patient’s ability to incorporate new skills and healthy lifestyle changes. As a result, recovery and treatment outcomes can become stunted.
Due to stigma’s silencing effects, those experiencing migraine and mental health issues may refrain from disclosing the challenges they are facing. Although done out of self-protection, nondisclosure prevents individuals from receiving timely and appropriate treatment.31
What are the Challenges of Living with Migraine, Anxiety, and Depression?
Individuals living with migraine and comorbid anxiety or mood disorders are at risk for increased disability and a poorer quality of life.
Experiencing stigma can result in distress and nondisclosure. Consequently, delays in treatment can worsen symptoms of depression and anxiety and trigger the development of other health conditions.
Individuals with a history of abuse or psychiatric conditions are at an increased risk of revictimization and developing chronic migraine, as well as other diseases. A lack of patient willingness, engagement, and proactivity, as often seen in depression, can interfere with successful treatment outcomes.
Looking Ahead: Coping with Migraine, Anxiety, and Depression
Sitting in direct opposition to learned helplessness is learned optimism. In contrast to the pessimism and unwillingness that governs learned helplessness, optimistic people utilize adversity as a powerful weapon of growth to affect beneficial change through intentional and mindful thoughts and behavior.
By viewing setbacks as avenues of potential rather than dead ends, those who are optimistic tolerate and cope with stressors more effectively. They not only experience less stress, but are also able to recover from stressors more quickly. Additionally, less overwhelm and discouragement allow space for resilience: a key component of disease management.6
Resilience refers to the strategies and coping tools used during times of hardship. While innate personality styles may differ from person to person, resilience can be learned and cultivated regardless of background or circumstance.7
Building resilience, or resilience training, acts as a buffer against stressors, and the more resilient you become, the less suffering you may endure.
Ways to boost resilience include:
building your support system
implementing healthy lifestyle changes
incorporating behavioral therapies
developing passions and purpose outside of disease
engaging in advocacy
By releasing what no longer serves you and welcoming positivity, people with migraine, anxiety, and depression can navigate remission and relapse with increased confidence, thereby boosting resilience and optimism.
Migraine and mental illness share a bidirectional relationship driven by neurological dysfunction. Major depressive disorder and generalized anxiety disorder, the most common mental illnesses within the migraine community, are five-fold greater in the migraine population than the general population.
While certain physiological and environmental factors increase the risk of developing comorbid mental illness, underlying biological indications create conditions ripe for comorbidity. Trauma exposure and increased stress reactivity compound these implications, resulting in heightened disability and distress.
Realigning the dysfunctional stress response present in migraine, anxiety, and depression is paramount to successful treatment. Through medications and behavioral interventions, significant progress can be made, and new coping strategies can be developed. Cultivating resilience and learned optimism through this process bolsters our capacity to manage stressors and improves our wellbeing.
If I have depression, anxiety, and migraine, which should get treated first?
It’s important to treat these disorders concurrently, as each can feed off of the other. Building a well-rounded team of healthcare professionals who can appropriately address each issue gives you the best chance of success.2,7
I want to experience fewer migraine attacks, and less anxiety, and depression. Where should I start?
A great place to start is with your primary care physician, who can refer you to headache specialists, psychologists, psychiatrists, or other healthcare professionals. If cost prevents you from accessing medical treatment, free resources, such as books, websites, apps, and podcasts are available. Additionally, you can reach out to support groups, religious leaders, or other local groups that can provide support.2,6
Those who persevere through migraine know all too well the struggle that comes with living with this debilitating disease. The nausea, agonizing head pain, sensation disturbances, temporary cognitive impairment, and the general feeling of lost control over their own bodies. While there are many types of migraines, those living with vestibular migraine live a unique struggle when it comes to managing their attacks.
What is Vestibular Migraine
Migraine is considered a complex neurological condition. Vestibular migraine is unique within this class. Vestibular migraine is often referred to by its nicknames, “dizzy migraines” or “migraine-associated dizziness,” also “migraine-associated vertigo,” and “brain stem aura” by patients who suffer from pronounced vestibular symptoms associated with their migraine.1
The term “vestibular” refers to the sense of balance, spatial orientation, and more specifically, the structure of the inner ear.
Symptoms of Vestibular Migraine
Similar to classic migraine, vestibular migraines have a multitude of debilitating symptoms. Recent literature has classified these symptoms into two classes: ictal and interictal. This classification system is synonymous with the categorization of chronic migraine symptoms as primary and secondary. Ictal symptoms tend to occur during a migraine attack, while interictal symptoms trigger during remission of an attack.2
The most common symptom associated with vestibular migraine is vertigo or dizziness. Most patients also report dizzy sensations, such as constant falling, rocking back and forth, out-of-body experiences, and spatial disorientation. “Alice in Wonderland Syndrome” is a clinical term that refers to a severe perception of viewing the world from a shrunken standpoint due to spatial disorientation.3
It is important to distinguish that vertigo can occur with or without a headache. It is also crucial to understand that vertigo can coincide with common migraine symptoms such as:
polyuria (increased urination)
sensitivity to sounds and smells
problems with hearing
problems with taste and/or smell
body aches (i.e., shoulder pain, and neck and back pain)
The rate of the brain’s recovery, from vestibular migraine, is the same as a classic migraine patient: it takes time for the brain to recover from any migraine attack and the time period of recovery is variable for every person.2
What Causes Vestibular Migraine
If getting a proper diagnosis is enervating enough, pinpointing the triggers and the exact origin of vestibular migraine is just as perplexing, even to the experts in the field of migraine research. Over the years, many competing theories have emerged to try to explain the pathophysiology of this devitalizing condition. The triggers, however, have gathered more of a consensus among the experts.
Vestibular migraine has similar triggers to those of typical/classic migraine, such as:
changes in weather patterns
menstruation/menstrual cycle changes
intolerance to certain foods/food triggers
lack of sleep
The truly unique triggers of vestibular migraine are:
exposure to a lot of head movement
overload of visual stimuli2
Over the years, there have been many competing theories that have emerged to try to explain the pathophysiology of this devitalizing condition. The three leading theories that surround the common cause of this type of migraine are:
structural problems found in the inner ear
coexistence with Meniere’s disease and BPPV (Benign Paroxysmal Positional Vertigo)
dysfunction of the vestibular pathway
Structural inner ear problems
In the structure of the inner ear, there are microscopic crystals that help us maintain our balance. Just the same as our bodies constantly replenish us with new blood cells and skin cells daily, crystals found within the inner ear eventually fall off, get dissolved, and are soon replaced with new ones. However, as we age, the rate at which we lose these crystals becomes higher and occurs much more often, which leads to an accumulation of loose crystals rattling in the ear canal, which is regarded to be the cause of vertigo.
In patients with vestibular migraine, the process of losing crystals at an accelerated rate seems to occur in young patients rather than normal crystal loss seen in older patients. The shedding of these crystals seems to cause injury to the part of the inner ear called the otolith organ. Once these crystals become loose, they can trigger bouts of vertigo, as seen in patients with a similar condition known as BPPV. The clinical implications suggest that the displacement of these crystals could lead to mild hearing loss at later stages of life.2
Coexistence with Meniere’s disease and BPPV
Meniere’s disease, BPPV, and vestibular migraine are similar in many ways, but the statistics that surround them are not to be mistaken as a coincidence. Experts have found the following statistics:
Meniere’s disease statistics
56% of Meniere’s patients, within the general population, have migraine
85% of patients with Meniere’s disease, found in both ears, have migraine
This theory suggests that there could be a possible spectrum in which patients could fall between these two conditions. Some patients may suffer specifically from inner ear issues, while other patients, with migraine, suffer a fall during an attack, which then could turn into Meniere’s disease.5
The statistics surrounding BPPV in migraine patients also suggest a clinical trial relationship. Around 22% of patients with vestibular migraine are found to have loose crystals. In one clinical trial, of 500 vestibular migraine patients, 47% were found to have BPPV. However, experts also found 22% of that group actually had been diagnosed with BPPV at the same time of their vestibular migraine initial diagnosis.5
Dysfunction of the vestibular pathway
Similar to classic ordinary migraine, disruptions in the neural pathways are commonly cited as a cause for vestibular migraine is a common explanation. The consensus, among this theory, suggests that the disruptions seen in the vestibular pathway are not solely caused by injury, but rather by poor functionality.4This theory also suggests that, similar to how there are changes seen in the visual processing center of the brain in classic migraine patients, which produce a visual aura, the changes seen in the vestibular processing may be triggered by change because of activity in the vestibular nuclei. Other interconnected pathways seem to be affected (vestibular nuclei, other structures, and blood vessels).5
Diagnosis of Vestibular Migraine
Vestibular migraine is often misdiagnosed due to its symptoms masquerading as other vestibular disorders.
Vestibular migraine often misdiagnosed as
BPPV (Benign Paroxysmal Positional Vertigo)
PPPD (Persistent Postural-Perceptual Dizziness)
BPPV (Benign Paroxysmal Positional Vertigo)
BPPV is a condition characterized by brief sessions of mild to severe dizziness, often triggered by changes in head position.6 This condition’s origin is set among the crystals in the structure of the inner ear that become loose and get lodged in canals of the ear that maintains balance. The difference between BPPV and PPPD is the length of vertigo spells. A patient with BPPV typically experiences about 30-40 seconds worth of episodic vertigo while PPPD patients’ vertigo seems unrelenting.
PPPD (Persistent Postural-Perceptual Dizziness)
PPPD is a condition that is closely related to BPPV. The main difference between the two is that with PPPD, the patient has persistent dizziness, unsteadiness, and disequilibrium that can be triggered by any condition that causes vertigo. The condition is also associated with vestibular migraine because of the repeated attacks of vertigo.2
Meniere’s disease affects the inner ear and can cause the patient to experience episodes of dizziness and hearing loss. The cause is unknown but is believed to be attributed to fluid imbalance or accumulation in the inner ear. Its symptoms overlap with sinusitis with patients reporting fullness or pressure in the ear and changes in hearing levels, and tinnitus (ringing in the ear.) Similar to migraine patients, those with Meniere’s disease also report phonophobia (aversion to loud noises) and photophobia (aversion to bright lights).
Vestibular migraine differs from Meniere’s, PPPD, and BPPV as the dizziness associated with this disease tends to occur along with the neurological symptoms that are typically seen with migraine.
Sinusitis is the inflammation of the membranes found within the sinus cavity. Because 90% of patients report facial pressure, this could lead to the improper diagnosis of sinusitis or sinus headache rather than what could most likely be vestibular migraine.7
Tinnitus is defined as a condition where a patient hears a constant ringing sound without the presence of an accompanying external sound. The prevalence of vestibular migraine in conjunction with tinnitus is high enough that most clinicians would consider there to be possible links between them.2 About half of people who are diagnosed with vestibular migraine also report tinnitus symptoms while another study found 80% of patients reported a spinning sensation.
At the extreme end of the diagnostic spectrum, vestibular migraine could be misdiagnosed as a concussion. Of course, the likelihood of this diagnostic mistake is considerably low without the instance of a head injury. People who suffer a concussion can have dizziness or vestibular symptoms of ringing or other sounds within the ears.8
Given the overlapping symptoms in many vestibular conditions and vestibular migraine, getting a proper diagnosis can be challenging. To make matters worse, many patients experience another hurdle in getting an accurate diagnosis: how to find the right specialist?
Neurologists and Ear, Nose, and Throat specialists (ENTs) are the most common specialists who receive patients who report vertigo and dizziness. However, one of the main issues with this referral paradigm, while it seems innocent, is that ENTs are not adept at managing vestibular migraine patients’ treatment plans in an ever-changing treatment landscape. And the other is that while neurologists are familiar with how to navigate the medication landscape, vestibular migraine is still a relatively poorly misunderstood condition, even among the experts in this field of specialists.2
The best answer for which specialist a patient fitting the criterion for vestibular migraine should seek out is one who has training in ear medicine and ear neurology. This specialist may go by the following names, depending on the department in which they work:
otoneurologist: A neurologist who also specializes in ear conditions
neurotologist: A specialist who specializes in both otology and neurological conditions pertaining to the ear.5
Unfortunately, there is no specific test for diagnosing vestibular migraine. Researchers currently classify it as following a “classic migraine pattern of disease.” Meaning a patient goes to their doctor reporting an increase in headaches and other neurological symptoms, including dizziness.5
Recently, as of 2019, the International Headache Society constructed the term “vestibular migraine” in order to ensure stricter diagnosing criteria and to continue the study of vestibular migraine in greater depth. Unfortunately, while criteria like this are useful in biological and clinical efficacy trials, it presents a problem when people use the criteria as means to learn about the disease further. However, vestibular migraine is still a relatively new condition. So much so, in fact, it is surprising that most medical schools don’t teach vestibular disorders in their curriculum.2 As a result, the hallmark symptoms of vestibular migraine, i.e., dizziness and vertigo, are unfortunately not widely hot topics in the medical community. Thus, the diagnostic criteria are still relatively new as the condition is still coined as “new” based on its low understanding by experts.2
The next question would then be if getting an accurate vestibular migraine diagnosis is not any easier than managing symptoms, are there consequences of not getting a proper diagnosis early? Well, the answer is simple: the consequences would follow a similar trajectory as any other chronic condition that is ignored. The patient is likely to experience worsening symptoms relating to their vestibular migraine, particularly their interictal symptoms.
Who Gets Vestibular Migraine?
Previous studies’ statistics have observed the following conclusions:
Young women in particular, who have recurrent vertigo, migraine is the most likely diagnosis.4
Vestibular migraine tends to occur in people who are in their late 30s and older.2
Vestibular migraine tends to affect people following menopause. While patients tend to suffer from migraine headache attacks during their reproductive years, the headaches tend to improve once menopause occurs, then manifestations of vertigo and dizziness tend to set in soon after menopause.
The prevalence rate of vestibular migraine in children is between 0.7%- 15%.9
Migraine disease is tricky to pinpoint susceptibility. But common consensus agrees that the diagnosis of migraine largely has to do with certain pathophysiologic mechanisms. If we are to approach this from the nature versus nurture epidemiological debate, science has determined that the genetic and environmental factors are split either 50-50 or 60-40. However, the genetic expression of migraine can vary even within an individual’s family, where it is possible this expression can be very different.5 It bears noting that patients with migraine have a low threshold for certain stimuli. In the case of vestibular migraine patients, the sensitivity of balance and tilting tends to be greater compared to individuals without migraine.5
Treatments for Vestibular Migraine
Luckily for those who are afflicted with vestibular migraine, there is a wide range of treatments available to ease symptoms and improve quality of life.
Healthcare providers advise patients to establish an ACTION plan to manage and treat their migraines. The ACTION plan is broken down into five categories.
A (alternative therapies)
T (therapeutic options)
I (interictal symptom management)
O-N (planning to move “on”)
Step “A” (alternative therapies)
The first part of developing an ACTION plan is to consider alternative therapies (Step “A”). Alternative therapies include vitamins, herbs, nutraceuticals (a substance that is a food or a part of a food that has medical or health benefits), and exercises that are fitted to the individual.
Step “C” (changes)
Part two of the ACTION plan is to implement changes (Step “C”). This stage of the sequence involves two parts. It is necessary to identify triggers and avoid them in this step. The changes that take place can be little or big changes. Examples of this would be creating a diet that you can stick to or one that is specifically tailored to be anti-inflammatory, reducing the number of stress triggers, and avoiding food triggers.
Step “T” (therapeutic options)
Part three is to explore therapeutic options (Step “T”). This involves finding preventive and acute medications that fit your symptoms and lifestyle. This is the step with the most trial and error. This could be the most frustrating part of the sequence that can span years. Even if a medication is effective, it can become less effective over time, which could lead to searching for a new option.
Step “I” (interictal symptom management)
Part four is specifically catered to treating/managing interictal symptoms (Step “I”). This is the step that requires a dispelling of stereotypes around migraine. The ongoing challenge in managing migraines is a reminder that symptoms are truly more than the sum of their parts. It’s never “just a headache” or “dizzy spells.” Migraine attacks are much more complex than many realize. Learning to manage migraine symptoms is also the key to preventing other comorbidities (the presence of two or more diseases or medical conditions) that are more likely to occur with a migraine diagnosis, such as anxiety, depression, insomnia, sleep apnea, and motion sensitivity, also known as motion sickness.
Steps “O-N” (planning to move on)
The final part of the ACTION plan is a simple reminder to have faith that things will get better (Steps “O” and “N”). Now granted, that’s easier said than done. While it can seem migraine takes center stage in most people’s lives, it can be managed in a way that it takes occasional precedence. This part of the plan also encourages the need to make steps toward planning a life with migraine, rather than planning life around it. While migraine is chronic, establishing an optimistic future for yourself (e.g., manageable goals, lifestyle changes, future aspirations) and a solid support system are the golden tickets to living positively with migraine.2
Experts agree that when exploring drugs to combat vestibular migraine, the treatment of vestibular migraine is not that different from treating chronic migraine. Similar to chronic migraine, vestibular migraine needs to be treated with preventive medication. The medications to treat chronic migraine are divided into four classes, but vestibular migraine includes a few categories of its own.
The typical course of treatment for vestibular migraine follows the same trajectory as classic migraine utilizing various drug modalities. Current treatment option categories include:
sodium versus calcium channel blockers
selective serotonin reuptake inhibitors (SSRIs)
Classification of drug treatments for vestibular migraine
How it works
Type of treatment
Common side effects
Commonly prescribed examples
Serotonin Receptor Agonists; shrinks swollen blood vessels in the brain
Dizziness, weakness, nausea, sleepiness, pain at the injection site, pain in nasal passages
Anti-seizure medication; slows or blocks the sodium channel
Dizziness, nausea, vomiting, problems with coordination, balance, and speech, double or blurred vision, rash, itching, headaches, changes in blood pressure, weight gain or loss, fatigue, sleepiness, insomnia, hair loss, tremors
Although drug treatments tend to become the go-to approach in managing migraine symptoms, therapies used in conjunction tend to provide another layer of protection and assurance.
Clinical trials have examined several types of therapies that have been used to treat vestibular migraine but are not limited to:
cognitive behavioral therapy
physical therapy/vestibular rehabilitation.
Psychometric physiotherapy is a type of rehabilitation therapy in which the client works with a physiotherapist in order to better manage their condition.17
Sessions typically follow a client-centered therapeutic approach where the patient takes control over their healing as the therapist creates an atmosphere of safety and non-judgment.
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy, or CBT, has been an effective therapeutic approach that has been utilized across a breadth of topics in mental, physical, and emotional health. CBT combines both a cognitive and behavioral focus to develop healthy self-esteem, behaviors, personal coping skills, problem-solving, and regulation of emotions in the face of personal adversity.
Previous studies have cited CBT as an effective therapy to use simultaneously with drug modalities in the treatment of migraine.5
Both CBT and psychometric physiotherapy allow for honest, open forums between the therapist and client about the emotional struggles that come from managing migraine/vestibular migraine.
Vestibular rehabilitation, or vestibular rehabilitation therapy, on the other hand, demands more physical actions on the part of the patient. Vestibular rehabilitation is a type of physical therapy that specializes in treating or improving the symptoms that surround vestibular disorders, such as dizziness, vertigo, visual disturbances, and refining balance and posture.18
This type of therapy usually is administered by a physical therapist by referral from a physician. The outcomes of sessions are dependent on the type of vestibular symptoms present. Thus, the length and overall prognosis of the sessions could span months to years in some individuals. Similar to traditional physical therapy, the therapist utilizes different procedures to address the patient’s concerns and will require the patient to practice building their new skills with at-home exercises. Examples of the typical procedures in treating vestibular symptoms include but are not limited:
gaze stabilization exercises
otolith repositioning maneuvers18
Most people don’t consider physical therapy when trying to find a viable solution to abating their vestibular symptoms. Dr. Teixido elaborates further on the purpose and benefits of incorporating physical therapy into a vestibular migraine treatment plan:5
Aside from rehabilitation, medication, and therapeutic approaches, there are more cost-effective treatment options for vestibular migraine patients to access to decrease the number of episodes and severity of their symptoms.
If the sage old advice of partaking in exercise isn’t ringing a dead, broken bell, it’s only because clinical data has proven its whole body benefits. In terms of neurobiology, exercise has been proven to desensitize the brain to certain stimuli.2 While it may seem counterintuitive for vestibular migraine patients to engage in movement as a part of migraine management, in fact, engaging in moderate to high-impact exercises should not be discounted. Exercises such as jogging, running, cycling, hiking, playing various team sports, and many others are commonly cited as triggers in those with vestibular migraine, and, especially among those who are also diagnosed with exercise-induced and/or heat-induced migraine. However, the benefits of engaging in this level of exercise far outweigh the cons. Movement can release endorphin-inducing benefits.
Popular, low-impact exercises to consider are yoga, Tai Chi, walking, and vestibular therapy.2 It has been noted that people who suffer from vestibular migraine may find it difficult to engage in yoga or pilates due to certain head movements.
Adriane Dellorco also has some advice about how to avoid triggering a vestibular attack during an exercise routine:10
Experts have noted that there are ways to abate the negative side effects of exercise, specific for migraine patients.
These techniques include but are not limited to:
Performing warm-up exercises before engaging in moderate to high-impact activities.
Scheduling exercise routines at cool points in the day.
Exercising in shaded areas.
Staying hydrated before and after exercising.
Being mindful of your limits; pushing oneself with caution.
Consulting with a physician to determine whether or not moderate to high-impact aerobic exercises will be beneficial.
In the same vein as vestibular therapy, there are talks among experts about whether or not neuroplasticity training could provide some additional support in improving patient quality of life. Neuroplasticity refers to the brain’s potential to grow, change, and rewire itself. For example, engaging in everyday tasks such as learning a new skill, seeking positive social interactions, participating in novel experiences, taking up an exercise routine, and practicing mindfulness are all examples of neuroplasticity as they help establish and build neural connections.
Clinical neuroplasticity training is different. It shares some overlap with vestibular therapy; however, its aim is to help patients at the cellular level by creating and restructuring neuronal connections to improve cognitive functioning, decrease chronic pain signals, and help improve neural pathways to achieve better mental and physical health. This type of therapy can also help decrease sensitivity to vestibular stimuli that could contribute to dizziness and balance problems.2 The targeted area of study in the brain is the limbic system, and more specifically, the amygdala. The idea is that the limbic system is involved in the “fight or flight” response to certain emotional stimuli and past negative experiences can create, within the pathway, overactive neural signals of chronic pain.19 The goal of this therapy is then to rewire, at the neural level, how the limbic system responds to negative triggers to decrease chronic pain levels.
Other methods of treatment
There are new treatments developing outside the realm of drugs and therapy. A prime example of this are electronic neuromodulation devices. There are currently four neuromodulating devices on the market:
E-TNS– an external trigeminal nerve stimulator (Cefaly)
nVNS – a noninvasive vagal nerve stimulator (Gammacore)
sTMS– a single-pulse transcranial magnetic stimulator (sTMS mini)
REN – a remote electrical neuromodulator (Nerivio)20
These devices are great options for patients who have exhausted medication options or who show sensitivity to certain medications. Each of these devices shows promise and works to stimulate different cranial nerves to block pain signals.
Although living with a chronic disease as debilitating as migraine can seem like a lifelong burden, there is a break in the storm clouds. The field of migraine research is an ever-changing landscape with many advancements being made every year. Studies are also being replicated to better answer the questions that plague researchers as well as patients. The path to understanding migraine, in all its tangled web of complexity, is being studied now more than ever. It’s truly a time to feel hopeful, especially for vestibular migraine patients.
Dr. Beh offers a ray of hope to those seeking an end to their debilitating symptoms.2
While finding a permanent solution to vestibular migraine, and chronic migraine in general, is still in development, it is reassuring to know that it might be on the horizon. There are many chronic and debilitating conditions, but none are as misunderstood and stigmatizing as chronic migraine, which the general consensus considers a “silent disease.” With every demographic being susceptible, it makes the name silent disease all the more disheartening. But, as always, the more awareness raised, the greater the quality of living for those who are waiting for the day they can finally rid themselves of their symptoms and bring order back into their lives.
Individuals with and without migraine share a fundamental need for meaningful experiences and deep connection. While these ideals may be attainable to the status quo, people with migraine may be deprived of these core needs due to the stigma surrounding migraine.
Support, validation, and feelings of purpose and contentment strengthen our identity to self and community. Without these basic needs, becoming empowered and visible members of society becomes a goal, not a reality.
What is Stigma?
Stigma refers to the harmful labeling, stereotypes, biases, judgements, and prejudices that become attached to a certain group of people based on a diagnosis or trait, and in this case, migraine.1 8 It is a socially and culturally informed process, fueled by the constructs, values, and beliefs given at a specific place in time.
Migraine: A Stigmatized Disease
Contrary to public perception, migraine is a major public health issue with extensive impacts, both personal and economic.
One billion people worldwide have migraine.1
Migraine costs $30 billion a year in healthcare costs and productivity.1
In 2016, migraine was the second leading cause of global disability and neurological disease burden.2
Migraine is real, migraine is pervasive, and the people who have migraine matter.
Underrecognized, Underfunded, and Misunderstood
Despite these realities, the world at large remains tethered to false, outdated, and sexist perceptions of migraine, complacently allowing further stigma to ensue. As a result, stigma has extensively infiltrated and dictated migraine recognition, diagnosis, and treatment.3 4 5
Consequently, people with migraine are commonly subjected to societal disproval and discrimination. They may be forced to navigate environments unwilling to accommodate their needs which are deemed insignificant. This lack of visibility and validation spoils identity, leaving those with migraine with marred personhoods and diminished social connections. In conjunction with the trivialization of migraine that occurs within social systems, medicine, and legislation, it is widely reported that migraine is underrecognized, underfunded, and misunderstood.25 8
Measuring Migraine Stigma
The Stigma Scale for Chronic Illness (SSCI) is used to assess stigma among people living with chronic illnesses. Utilizing this assessment, chronic migraine was shown to have more stigma than epilepsy, which had a score similar to that of episodic migraine.20 25
Did You Know?
Ability to work was shown to be an indicator of stigma in migraine—increased work-related disability correlates with stigma for people with chronic migraine.20
Types of Stigma
Migraine does not exist in a vacuum. At the interface of migraine and society exists stigma.8 Layered over time and filtered through cultural lenses, stigma permeates society, and influences our thoughts, feelings, and actions. Due to its pervasive nature, there are three types of stigma:1
Summary What is Migraine Stigma?
Stigma refers to the harmful labeling and negative biases that are attached to a certain group of people based on a trait or diagnosis, in this case migraine. Despite migraine being an established debilitating, neurological disease that has profound personal and economic impacts, stigma has infiltrated perception, awareness, and treatment.
Migraine stigma has deleterious effects on quality of life, policy making, and accessibility to treatment.
Stigma can be broken down into three categories: structural, public, and self-stigma.
Structural stigma refers to the policies and laws that discriminate against people with migraine, while public stigma is the stereotypes and prejudices enacted by the general public. When those with migraine internalize and perceive the prejudices and negative biases they’ve experienced to be true, self-stigma results.
Contributing Factors of Stigma in Migraine
Marginalization and Dismissal
Migraine is an equal opportunity disease—all ages, ethnicities, abilities, and socioeconomic classes can have migraine. However, due to racial disparities and lack of access to care, migraine disproportionately affects more Black, Indigenous, and People of Color (BIPOC) as compared to white people. Despite this, BIPOC are often excluded from research and discouraged from seeking help.7
Minorities’ pain is often not validated or respected. The notion that BIPOC can tolerate pain better than white people can be traced back to slavery. Minimization and suppression of pain was expected when being auctioned, as smiling through physical abuse made slaves more auctionable. This psychology still exists within the healthcare system, and BIPOC are more likely to be stigmatized.7
Cultural scripts can dictate acceptable expressions and communication of pain. Some cultures value stoicism and encourage silence when experiencing pain. The resulting cultural dissonance between patient and physician increases the likelihood of dismissal and stigma.7
Validity of Migraine as an Invisible Illness
Migraine is an invisible illnesson two levels:
It cannot be seen by others.1 2
Labs or scans cannot provide proof of its existence amongst patients.1 2
Diagnosis of migraine is symptom-based and dependent upon patient evaluation. Neuroimaging or biomarkers cannot confirm a diagnosis, and though it is disabling, migraine’s invisible nature often leads others to disregard it as a valid disability. 8 As a result, many fail to validate its presence, and assume those with it must be fakers. 9
Denial of Migraine
The denial of migraine as a legitimate disease is central to the stigmatization of migraine.2 Without tests to justify migraine’s impacts, patients become responsible for providing the “proof”. As a result, migraine’s validity falls on the character of patients, and specifically their character flaws.10
Blaming Migraine on Character Flaws
Because migraine is viewed as a minor personal issue rather than a legitimate disease, the people with migraine are often judged as having character flaws which are to blame for their affliction.11 The dialogue therefore shifts from a framework of disease to one of blame, influenced by stereotypes and misinformation.10 11 18
Stereotypes and Misinformation
Negative stereotypes of migraine discredit the reality of the disease and the challenges faced by those experiencing it.
Common stereotypes attached to people with migraine and the resulting statements made include:¹¹
“What an easy life you have staying in bed all day.”
“When I don’t feel good, I still go to work. It’s what you do.”
“Stop complaining, you should just be grateful.”
“It could be worse.”
Overly sensitive or weak
“You’re just too sensitive, you need to toughen up.”
“Why can’t you just do [insert activity]? It’s not that hard.”
“Well, you still have to do [insert activity].”
Drug seekers incapable of coping with pain
“If you can work, it must not be that bad.”
Fakers who overexaggerate
“That’s your excuse for everything.”
Neurotic and excessive worriers
“Mind over matter, right?”
In addition, online representations often depict migraine as an “annoyance.” Google searches of migraine show adults, mainly women, simply touching their heads and wincing in pain. This depiction is rarely the reality, and it reinforces inaccurate stereotypes that minimize migraine.²
Other media representations use migraine as a metaphor for devaluation, comparing annoyances or stressful events to being a “migraine” or “headache”.²
The genderization of migraine has contributed to its delegitimization and subsequent stigma. In the past, historical narratives and pharmaceutical advertisements have contributed to sexist attitudes towards migraine, downplaying its severity and placing blame on the individual experiencing migraine.¹¹
Migraine stigma has changed throughout the centuries, reflecting the beliefs, attitudes, and values of society.
Throughout the 16th- and mid-17th century, migraine was treated as a legitimate disease, bolstering its existence within the medical sphere and garnering compassion and effective treatments (for that time period).¹²
During the 18th and 19th centuries, public perception of migraine transformed to a more genderedillness, one experienced primarily by poor, exhausted women, and scientific and intellectual men.¹²
This transformation from legitimate disease to minor affliction continued into the 20th century, which ushered in the rise of “migraine personality.” This “type A” personality categorized migraine as a character flaw held by highly sensitive, elite women (often housewives) who overthink and worry excessively.¹¹
Freud even postulated women’suncontrolled impulses were to blame for migraine attacks. Consequently, those with migraine were treated as being hysterical, and the doctors who treated them “enablers”.5
Role of Pharmaceutical Industry
The “Typical Migraine Patient”
When marketing migraine treatments, some pharmaceutical companies have portrayed the typical migraine patient as a white, privileged, professional, upper-middle class woman withchildren. Specifically, these advertisements emphasize this woman’s inability to care for her children during a migraine attack.¹¹
While this scenario may ring true for some, it is not the epitome of, nor does it do justice to, the migraine experience.
By fixating on white women as the primary target, i.e., gendering migraine, the pharmaceutical industry has unilaterally misrepresented the migraine community, both in identity and experience. Marginalization of BIPOC and lower-income patients reinforce the notion that migraine only afflicts white women of a certain class. This exclusion and biased perception perpetuates stigma and discrimination.¹¹
Silence Perpetuates Stigma
When faced with structural, public and self-stigma, nondisclosure is the unfortunate consequence experienced by many.¹³ While this silence may be an impact of stigma, it is also a cause, yielding a Catch-22 situation.
Summary What Causes Migraine Stigma?
Migraine stigma is caused by a variety of factors, all of which are tied together by dismissal and a lack of validity.
Because migraine is an invisible illness and diagnosis is symptom-based, many do not view migraine as a legitimate disability. Blaming migraine on perceived character flaws (being neurotic, weak, lazy, overly sensitive) compounds this issue of denial and reinforces negative stereotypes.
Misrepresentation in the media (such as pharmaceutical ads) excludes BIPOC, who often experience dismissal due to racism and cultural barriers.
Fear of rejection and shame may prevent people with migraine from speaking up, and the silence and nondisclosure that result further perpetuates stigma.
Impacts of Migraine Stigma
Psychological Distress and Nondisclosure
Self-stigma negatively affects self-esteem and mood, and triggers a hiding reflex in individuals with migraine so as not to expose the parts of themselves of which they feel ashamed.1 14
Guilt, self-blame, and fear of rejection compound these feelings and discourage individuals with migraine from speaking out, resulting in silence and nondisclosure.4 10 13 14
When enacted, stigma devalues and isolates those with migraine.8 Exclusion within social circles has negative impacts on individuals who are already forced to retreat due to repeated migraine attacks.
The subsequent discomfort with being one’s true self depletes energy and increases disability.11
Lack of Visibility and Validation
People with vaginas are often not believed or heard when sharing their experiences with migraine, and this contributes to the lack of visibility and validation experienced by people with migraine.15 16
Worsening of Migraine
Due to self-stigma, some people with migraine may not feel comfortable seeking a diagnosis or treatment. As a result, migraine may worsen.3
Delays in Treatment
On average, it takes 18 months to receive a correct diagnosis. Within this time frame, upwards of $12,000 may be spent in health care costs, not including work-related expenses.3
Incorrect diagnoses and inappropriate medications make treating migraine more difficult. Without support, migraine may worsen, as delays in treatment make migraine harder to manage.3
In addition, cultural barriers may affect the relationship between physician and patient, making it more difficult for BIPOC to feel connected and heard within the healthcare system. Consequently, trust becomes harder to build, and BIPOC experience obstacles in receiving diagnosis and treatment.7
Did You Know?
A diagnosis of migraine colors the professional opinions of employers—4 out of 5 employers thought migraine was an invalid reason to call out from work.8
Lost Jobs and Increased Employer Costs
Ninety percent of people with migraine cannot continue working during an attack, and the remaining 10% who do continue are only half as productive.10
Without appropriate accommodations and support in the workplace, people with migraine may experience a worsening of migraine or may need to quit altogether.10
Both possibilities are costly to employers, whether it be through increased health care costs, or an increased need for recruiting, training, and hiring—all of which decrease morale and productivity.10
Did You Know?
Thirty four percent of individuals with migraine have experienced discrimination or hardships at work due to stigma.21
Stigmatized disorders receive less funding than non-stigmatized disorders. Consequently, migraine receives a fraction of research funding relative to its impact in disability adjusted life years (DALYs). DALYs are a measure of disease burden assessing years of life lost due to disability and mortality.2 11
Comparatively, arthritis, breast cancer, and digestive diseases all have similar DALYs as migraine. As of 2015, these diseases received appropriate funding relative to their impact: $214 million, $674 million, and $1.6 billion, respectively. Migraine, on the other hand, only received $20 million.2
Without proper funding, less research can be conducted, and without research new medications cannot be developed.2
Fewer clinicians may view migraine research as a successful career option, limiting the number of research scientists advancing migraine care, which further shunts migraine awareness.2 8
Barriers to Care
Lack of Specialists
Due to a lack of available research grants, medical students and residents may feel hesitant entering a field with slim prospects of a successful career.2
As a result, there are fewer than 700 certified headache specialists available to treat the 55 million Americans with migraine.26
This lack of appeal is even exchanged amongst established physicians, who may view headache medicine with condescension, holding a “courtesy stigma” towards the physicians who treat migraine.2
Furthermore, without adequate funding, publicly funded laboratories, which invent two-thirds of new migraine medications, are not able to discover new medications.2
Did You Know?
Medical students generally only receive a few hours of education in headache medicine. Exposure to headache cases often does not occur until clinical training, most likely in the third or fourth year.22
Structural stigma discriminates against people with migraine through unfair policies, causing coverage impediments.2
For instance,receiving medication or treatment can be more difficult for people with migraine due to unfair insurance policies governing migraine.4
In addition, there is currently no listing for migraine in Social Security’s Blue Book, despite being the second leading cause of global disability. As a result, applying for Social Security disability benefitsis more difficult for people with migraine.2 8
Did You Know?
Migraine has existed for centuries, but criteria for diagnosis didn’t exist until 1989.3
Lastly, employers may not acknowledge migraine’s severity and impact, impeding the process of applying for worker’s compensation.2
Summary What Are the Impacts of Migraine Stigma?
Individuals with migraine exposed to stigma may experience increased disability and psychological distress. Shame and isolation may prevent people with migraine from speaking up and seeking treatment, which can worsen migraine.
Structural stigma results in structural inequities. Workplace discrimination and a lack of accommodations put individuals with migraine and employers at risk for lost jobs and increased costs. Lack of research funding and specialists in the headache field limit the development of new medications and treatments, and unfair policies create coverage impediments and barriers to care.
Combating Stigma in Migraine
Due to stigma’s silencing effects, advocacy necessitates courage. 1 8 11Effective advocacy is rooted in empathy and is patient, not pharmacy, led.11 14 18
Disclosure within healthcare settings helps establish an honest relationship between patient and doctor, and transparency aids physicians in choosing the most appropriate treatment for each patient. 4
Likewise, disclosure at work benefits the person with migraine in the following ways:
It makes employers aware of migraine.10
It gives employers the opportunity to provide accommodations.10
It allows employers to be more understanding of any migraine related absences.10
In order to stamp out migraine stigma, we must change the language used to describe it.10
Validating the Person with Migraine
“…Disentangle migraine from personhood, so I suggest we talk about people having migraine. Let’s not talk about migraine sufferers, let’s not talk about ‘migraineurs”, let’s talk about people who have migraine. We’re full human beings with lots of interest, lots of things we do in our lives, and we have migraine.”11
Appropriate language should acknowledge people with migraine as human beings first and foremost. Extracting migraine from personhood to reveal and celebrate the humanness of each person with migraine will lay a foundation of basic human dignity and respect.1118
Validating Migraine as a Disease
”We tend to define words by how we use them. If two-thirds of the time the word headache means annoyance, and we associate the word migraine with headache, then migraine becomes a different annoyance.”2
Language chosen that will acknowledge and validate migraine as a legitimate disease is fundamental to breaking the stigma.2 The Coalition of Headache and Migraine Patients (CHAMP) offers the following guide to facilitate validation through language:24
In order to become better advocates, people with migraine and their supporters must understand the disease. Educating yourself and others allows us to build more effective and articulate dialogue.4 14 18
One avenue worth considering is social media, which offers a substantial influx of information and support. It facilitates a sense of community and growth, and online support groups establish camaraderie among fellow migraine patients.17
People with Migraine
In order to establish migraine as a legitimate disease, those with it must be acknowledged appropriately. Common labels circulating society devalue and isolate those with migraine. A new script is needed—one that validates the true experience of migraine and acknowledges those with migraine as strong and heroic.6 One with migraine could be likened to a warrior—a “migraine warrior”—i.e., strong individuals who display bravery and perseverance in the face of disabling disease.
Furthermore, people with migraine can rewrite their own perception of their experience. Relinquishing self-blame and guilt allows the individual with migraine to embrace compassionand acceptance for themselves and others with migraine.6
Sharing how migraine impacts a patient’s life takes tremendous courage and authenticity, especially when instances like these may have been met with disbelief and invalidation in the past.11
Doctors should be sensitive to the lifetime of stigma their migraine patients may have endured. Listening and believing that their pain is real will help reframe physician’s perception of migraine, which will help break the stigma.11
The pharmaceutical industry strongly influences migraine perception through medication advertisements.11
Advertisements highlighting the diversity within the migraine community, as well as the spectrum of impactspeople with migraine face will assist in reframing migraine.11
Likewise, a more realistic portrayal of the lived experience of migraine can help guide others in viewing migraine with a more compassionate and understanding lens. Doing so will allow people with migraine to be their authentic selves.11
Receiving increased visibility from government entities combats stigma by establishing migraine as a legitimate disease worthy of federal government attention.8
In order to boost migraine visibility at the structural level, Congress must allocate more funds to the National Institutes of Health (NIH) for migraine research. By doing so, headache medicine will garner more interest from doctors and researchers, which will grant people with migraine better access to care.2 11 As a result, migraine will have a greater presence in medical curricula,and neurology departments will seek more headache specialists.2 11
Summary Combating Migraine Stigma
Advocacy is key. Patient participation and community involvement can challenge stigma and reframe migraine as a legitimate disease worthy of visibility, validation, and federal government investment.
Speaking up and educating others increases awareness and challenges stereotypes and misconceptions. Mindfully choosing language that validates both migraine warriors and the disease itself will garner more respect, compassion, and empathy for the migraine community.
Legislative action and policy reform will provide increased structural support in the form of research and medications.
Looking Ahead: Destigmatizing Migraine
Advocacy in the Community
Those with migraine who are comfortable advocating can begin in smaller settings amongst family, friends, neighbors, and coworkers. Doing so will increase visibility in social circles, and others will be more apt to offer validation.18
Helpful tips to keep in mind include:
Honesty and openness: Self-advocacy can be as simple as sharing how one truly feels when asked “how are you?” By honoring and expressing your needs, it helps others to understand migraine’s impacts. Sugarcoating a true experience in order to avoid discomfort may mislead the general public and strip those with migraine of social support.18
Have resources available to share with others: Unfortunately, honest expressions may fall on disbelieving ears. In these cases it’s helpful to have a list of websites available to assist others in understanding migraine disease.16
Non-combative and non-accusatory: It’s especially important to steer any justified emotional reactions toward advocacy. Remaining objective and non-accusatory will help communicate messages more clearly. By creating a welcoming and nonjudgmental space for others it allows them to reevaluate their biases and preconceived notions.11
Self-advocacy can be frightening, especially when past attempts have been disregarded. Not feeling ready or able to advocate is completely valid and should be honored.11
Advocacy at Work
Gaining accommodations in the workplace simultaneously acknowledges migraine’s impacts and increases productivity.10
Key points to keep in mind when disclosing migraine to employers:
Disclosure in writing is preferred.10
Disclose as soon as possible.10
Keep documentationof what was exchanged between employer and employee, as well as dates.10
Informing employers of any known triggers and/or worsening of migraine attacks will help maintain transparency.10
Provide a doctor’s letterormedical records to aid this process.10
Advocacy in the Government
The United States Federal Government is the largest funder of biomedical research in the world.11 Members of Congress are responsible for the allocation of funds to the NIH, who in turn fund public research laboratories.2 19
Lobbying members of Congress to allocate more funds for migraine research will allow public research laboratories to perform more research and discover new migraine treatments.2
Stigma is a serious problem with significant personal and structural impacts. To the detriment of the migraine community, stigma has warped public perception of migraine with sour representations and negative associations, discrediting both the experiences and identities of individuals with migraine.
Despite these impacts, stigma can be addressed and challenged through advocacy and patient mobilization strategies. Speaking up and raising awareness is key to affecting communal and legislative change. With proper research funds and increased visibility and validation, destigmatizing migraine is possible.
I feel like I’ve experienced stigma from other people with migraine. How is this possible? Shouldn’t we all be on “the same page”?
Stigma is painful, especially when it originates from a group you identify with. Experiencing stigma from other people with migraine is possible, due to self-stigma, or the internalization of public and structural stigma.1
In addition, because migraine is a spectrum disease, people with mild migraine may be confused when others experience more severe impacts and disability. As a result, they may not believe others’ experiences and, unfortunately, may perpetuate harmful stereotypes.23
Why is “I have migraine” and “I am having a migraine attack” preferable to “I get migraines” and “I have a migraine”?
Referring to migraine in the singular establishes migraine as a disease, much like asthma is singular. Likewise, labeling an acute episode of migraine as “a migraine attack” rather than “a migraine” sheds light on the reality of living with a spectrum disease, as acute attacks are only one aspect of migraine disease—managing triggers, lifestyle modifications, and seeking treatment are also central to living migraine disease.
How do I cope with migraine stigma? Other people do not understand or believe me.
You are not alone! Getting more informed, and receiving support from others with migraine is empowering. The migraine community is here to help you in your journey as a patient and as an advocate. Join a migraine support group, find a counselor, or participate in walks/races. Resources are available to help you cope.17 18 19
Remember that stigma is widespread and that many people with migraine have experienced stigma and possibly discrimination. Shame and self-blame are all too common in the migraine community, but know that this narrative can change, and authentic and affirming connections can be created.6
I have migraine disease and I’ve encountered stigma at work. How do I address this?
Individuals with migraine are protected under the Americans with Disabilities Act (ADA), which allows people with disabilities to request accommodations in the workplace. 10
In the event an employer denies accommodations that aren’t due to undue hardship, a complaint can be filed with the Equal Employment Opportunity Commission (EEOC). This federal agency will determine if an employer is discriminating or unfairly denying accommodations to an employee. If the EEOC denies the complaint, a lawsuit can then be filed. 10
An additional resource for individuals with migraine is the Family and Medical Leave Act (FMLA), which allows employees to take additional unpaid time off. 10
Rebound headache can be caused by the medication that we’ve been advised to take for migraine disease. It’s a debilitating disorder, with at least 15 headache days per month, and in severe cases, daily migraine attacks. Approximately 1-2% of the world’s population experience rebound headache, yet the majority don’t know they have it and are not informed on how to prevent it.
As an individual’s migraine or cluster or tension headache disease worsens, they may take medication more frequently. This temporarily lessens the pain, but when it wears off, and they again experience headache pain, they may take another dose, which again wears off, and they may take more. The rebound phenomenon develops when this cycle happens over a period of at least three months. The rebound headache is often worse than their original headache disorder because of the increased frequency triggered by the frequent use of pain relievers and other acute medications.11
What is Rebound Headache?
Rebound headache is referred to as medication overuse headache (MOH) by the International Headache Society’s (IHS) International Classification of Headache Disorders. Rebound headache is a term used by many and is perhaps more well-known than MOH.
Patients taking medication(s) for their primary headache disorder may develop rebound headache, a secondary headache disorder, because of that medication. This generally happens after taking more than the recommended number of doses of acute medications for at least three months.2
Secondary headache disorders are headaches due to an underlying illness or condition condition such as sinus infection, meningitis, brain tumor, brain hemorrhage or head trauma, and in this case, medication:3
There are three main categories of primary headache disorders:
trigeminal autonomic cephalalgias, such as cluster headache
Rebound headache can happen with any of these primary headache disorders.4
Migraine occurring 15 or more days a month is known as chronic headache or chronic migraine, regardless of whether it’s the medication-induced rebound phenomenon or has developed without frequent acute medications. So by definition, rebound headache is chronic headache, but not all chronic headache is rebound headache.1
Note that the same medications that initially relieve the headache pain can trigger chronic, and sometimes daily headache attacks if used more than the 10 or 15 days per month. See specific guidelines below (Medications and Frequency Thresholds).
Some clinicians and patient advocacy organizations have taken issue with the fact that rebound headache is classified as medication overuse headache or “MOH” by the IHS International Classification of Headache Disorders. They believe the MOH term places a stigma on the individual with migraine disease.
A person with migraine disease should not be blamed for using the medication prescribed or recommended by their physician, especially when they have not been informed by their healthcare provider about rebound headache. Often a healthcare provider will say “take this medication as needed.” It’s important to give the right parameters for each individual medication.15
Whereas rebound headache is not a perfect term because it does not indicate the role that medication does indeed play, it’s generally accepted by the medical community, and it does not place undue blame on people with migraine disease.
“Medication Response Headache” and “Medication Adaptation Headache” are alternative non-stigmatizing terms suggested by the Coalition for Headache and Migraine Patients (CHAMP). These terms are not yet widely used, but they more accurately reflect the causal nature of medications in this type of headache.5
The phenomenon of rebound headache was first described in the 1930s by physicians with migraine patients who used ergotamine, an early migraine treatment extracted from the ergot fungus. Physicians noted exacerbation of migraine in patients was associated with ergotamine overuse, and improvement occurred after the drug was stopped.
In the 1970s physicians began noting increased headache frequency in association with barbiturates and opiates, specifically, codeine.
In 1988 the first edition of the International Classification of Headache Disorders (ICHD) introduced “drug-induced headache” to describe “headache induced by chronic substance use or exposure.”
Later, when triptans were used for migraine treatment, they were added to the list of drugs that could “transform” episodic migraine to chronic, if used more than 15 days per month.
In 2004 the ‘“medication overuse headache” and “MOH” terms were first introduced to describe the disorder, along with acute medication and frequency thresholds that existed.6 7
What causes Rebound Headache?
Medications and Frequency Thresholds
15 Days Per Month
Taking only over-the-counter (OTC) medications, for 15 days per month, to relieve migraine pain will trigger this chronic/rebound headache condition.
The OTC non-steroidal anti-inflammatory drugs (NSAIDS) and analgesics are pain relievers that fall into the 15-day-per-month threshold. Ibuprofen, naproxen (Aleve), aspirin, and acetaminophen (Tylenol) are just a few in this drug class.
Since these OTC medications are readily available without the need for a prescription, and are relatively inexpensive, it is easy to unknowingly trigger a rebound headache. Although they may temporarily lessen or relieve the pain, more medication is often required to treat increasingly frequent attacks as the primary headache disorder worsens. This can lead to a vicious cycle of rebound headache. All anti-inflammatories and analgesics can potentially trigger rebound headache when used 15 days per month.1 2
10 Days Per Month
Triptans are another common class of drugs used to treat migraine. These include brand names such as Imitrex, Relpax, and Zomig, and can transform migraine to chronic/rebound with 10 or more doses per month. Since these are prescription drugs, physicians and insurance companies generally won’t approve a number high enough to cause rebound headache. However, patients may have extra tablets from months when they experienced fewer migraine attacks. Without being informed about the phenomenon of rebound headache, taking 10 or more doses in several consecutive bad months could unwittingly trigger this condition.
Ergotamine was the first migraine medication associated with rebound headache when taken 10 or more days a month, and is still in use today.
Multiple drug classes,including over-the-counter Excedrin, or use of triptans, along with NSAIDs or analgesics, can trigger rebound headache at 10 days of usage per month.1 2
Few individuals with frequent migraine are taking just a single acute medication. When taking some days of triptans and some days with combination analgesics and some days with nonsteroidals, it’s probably best to assume that if one is taking 10 or more days of acute treatment per month — putting barbiturates and opioids aside — that one is likely to get medication overuse headache and transformation into chronic migraine.1
1 or 2 Days Per Week
Opioids and barbiturates are most likely to cause rebound headache when taken for relief of migraine pain. They are also highly addictive. Fioricet and Fiorinal are brand names for medications containing barbiturates as well as other pain medications. Just one day per week of barbiturate use, or two days of opioid, regardless of the type of opioid, are associated with high-frequency rebound headache. These subtypes of rebound headache are extremely debilitating and difficult to treat.1 2 11
Almost all acute medications used to treat migraine disease can cause rebound headache.1
One exception is dihydroergotamine or DHE.This particular derivative of ergotamine is used by injection or nasal spray to terminate migraine. Most headache specialists believe it does not cause rebound headache.1
Another exception is the newer group of medications, the gepants. Gepants include ubrogepant (Ubrelvy),andrimegepant (Nurtec), which do not appear to cause rebound headache. In fact, in a one-year rimegepant trial, more frequent doses of rimegepant resulted in fewer migraine days. The study showed that gepants work acutely for attacks, but also can be used preventively for migraine.1 10
Other substances and drugs can contribute to rebound headache for those individuals with an existing primary headache disorder. These include:1
caffeine at 100 or 200 milligrams per day
over-the-counter antihistamines (not including newer ones like cetirizine (Zyrtec)
benzodiazepines (anti-anxiety agent such as Prozac) – are thought by some clinicians to trigger rebound headache
sleeping pills – most can trigger rebound headache
lasmiditan (REYVOW) – a new drug, is a selective serotonin agonist. Preclinical studies suggest that it may trigger the rebound phenomenon similar to the triptans.8
Who gets Rebound Headache?
Did You Know?
The estimates vary, but approximately 1%-2% of the general population have rebound headache. That makes it about as common as epilepsy. It’s an extraordinarily common phenomenon.2 Worldwide, only 10% of people that experience rebound headache are professionally diagnosed.16
The following are risk factors for developing rebound headache:1 9
High frequency episodic migraine – eight to 14 migraine days per month.
Migraine that doesn’t respond to various acute medications.
Comorbidities – a person with other pain disorders, such as arthritis, fibromyalgia or pain due to injury, in addition to their primary migraine disease.
In these situations, a person with migraine disease is more likely to take frequent medications to relieve headache and/or other pain over a period of months, resulting in triggering rebound headache.
The use of opioids or barbiturates(Fioricet, Fiorinal) for pain relief poses a strong risk for developing rebound headache. Taking these drugs for just one or two days a week often triggers rebound headache. Additionally, these drugs are addictive which makes them easy to overuse.
What happens when you have Rebound Headache?
Neurology experts do not yet understand all the pathophysiology associated with rebound headache. It’s believed that over time, when taking acute medication for headache, the brain starts to think this is part of the normal chemistry, and it upregulates receptors for those drugs. When that drug isn’t present, perhaps after a long night’s sleep, the brain thinks that something is missing. The brain communicates that with pain. Taking more medication relieves the pain temporarily but doesn’t treat the underlying disorder.3
How do you know if you have Rebound Headache?
Generally, you experience a pattern of starting with relatively frequent migraine symptoms (eight to 14 days per month), taking an acute medication to get headache relief, obtaining the relief, and then over time the pattern becomes one of increasing headache frequency and increasing medication usage, with headache reoccurring when the dose wears off. It’s common to wake with head pain in the early morning hours. In this scenario, once you have exceeded 15 migraine days per month for three months, you have likely developed rebound headache.2
Rebound headache symptoms vary. It doesn’t matter if the head pain location is front, back, right, or left side. It can be mild, moderate, or severe. It’s not the type of headache symptoms, it’s the number of headache days. It must be 15 or more headache days per month according to the International Classification of Headache Disorders’ criteria. And there must be the frequent use of acute medications for at least three months.1
Table depicts medication thresholds when used for at least 3 months, regardless of dose.
It’s important to maintain a headache diary or calendar to track the number of days you are experiencing migraine symptoms, along with the acute medications that you are taking each day. It can be as simple as noting this information on a calendar, or downloading a free app on your smartphone. This will prepare you for partnering with your doctor to accurately diagnose and treat the disorder.1
Your doctor can diagnose rebound headache based on your history of a primary headache disorder, recent headache frequency, and medication use. Tests are usually not necessary. Your headache calendar records will be extremely helpful.1
The typical recommendation is to limit acute medications for migraine to no more than two, or at most, three days per week and avoid opioids and barbiturates. This plan of action will generally prevent rebound headache.
Headache specialists often tell their patients, “This medication will work best if you take it early in your attack. Try to take it while your pain is mild, but don’t take too much.” In reality, that can be difficult to adhere to. Patients trying to avoid rebound headache often delay treatment that may make their disease harder to manage long term.2
Taking steps to reduce headache frequency by combining different types of preventive methods are key. Partner with your physician to determine which may work best for you. These include:1 2 11 12 15
Behavioral methods including Cognitive Behavioral Therapy (CBT) to help identify and avoid headache triggers.
Physical therapy, massage, chiropractic treatment, especially for those with comorbidities such as back pain, fibromyalgia, and arthritis.
Neuromodulation device therapy.
Preventive medications include several varieties that are taken on a daily basis.
Botox or the CGRP monoclonal antibodies can be used to reduce headache frequency.
The gepants are offering much hope for use as both preventive and acute treatments without triggering rebound headache.10
”The most important treatment is education of the patient. If you came in to see me and you had this problem and you were using Excedrin 6 [days] a week for a year, and I explained to you what you’re doing wrong and I said to you, I need you to come off. You can stop it tomorrow. You can stop it over a 2-week period. It doesn’t really matter. You’re going to feel worse for a little bit of time. At the end, you’ll feel at least the same and most probably better, and then I’ll have other medication for you to try as well. If you buy into that and you do it, I think that you’re going to get better.”11
Breaking the cycle of rebound headache requires restricting your pain medication. The process to do that depends on the types of medications you’re taking. Your doctor may recommend stopping the medication right away or gradually reducing the dosages. They may recommend adding or changing preventive treatments.
Most people with rebound headache are able to eliminate their acute medications with some increased pain, but fairly easily, once they understand the goal and why it’s necessary.11 15
For some people, rebound headache becomes such a trap that medication withdrawal has to be done in the hospital or in an outpatient center under close supervision of a headache specialist. Protocols are in place for keeping the patient comfortable using intravenous therapies until any withdrawal symptoms have disappeared and the process is complete. That can be necessary if, as medication is withdrawn, severe pain results, or the patient is unable to stop their acute medications.2
Inpatient treatment provides particular value to the 30% of patients experiencing depression as a result of rebound headache. The frequent headaches make people feel hopeless and helpless, unable to escape the downward cycle. If discharged and headache-free for the first time in years, that often relieves those hopeless feelings.2
The recent availability of the gepants offers promise, and already significant success, for prevention and acute treatment of rebound headache, eliminating what could otherwise be a difficult withdrawal period. 1 10
How soon does Rebound Headache respond to acute treatment?
Overall prognosis for recovery
The majority of patients with rebound headache are able to stop using their acute medications which typically breaks the cycle within a few weeks.
Patients that struggle most with medication withdrawal and require intravenous therapies usually see a quick improvement. However, the relapse rate is typically 25% within the first year. It’s important to be vigilant with effective preventive treatments to keep from falling back into the rebound cycle. It’s also important to partner with a headache specialist to ensure you are on the preventive treatments that work for you. If something doesn’t work for you, be willing to keep trying until you find effective therapies.2
Why is it important to recognize and treat Rebound Headache?
The problems with frequent use of the acute medications are not just the headaches and the worsening of the headaches. These medications can cause a lot of associated medical problems.
The anti-inflammatories and the combination analgesics are not so benign when taken frequently. They can cause:
exacerbation of blood pressure problems
Though frequent triptan use can cause rebound headache, it’s not generally a problem in terms of overall health.1
Opioids are narcotics that alter the pain regulatory system. Use of opioids in migraine patients worsens overall health including frequency of headaches, cardiovascular health, depression, and anxiety.
Butalbital, a potentially dangerous barbiturate, causes sedation. Withdrawal from butalbital can cause seizures. People may be at risk when they’re not aware they’re at risk. It can cause cognitive problems, as well as exacerbating depression. It’s been withdrawn from most markets worldwide including Europe, South America, Asia, and most of Canada, however it’s still available in the U.S.1
When to see a healthcare provider?
If you suspect you have rebound headache, and are experiencing more than two headaches a week, you will need to partner with your primary physician or headache specialist to officially diagnose and put together a treatment plan. The treatment to reduce your need for acute medications by reducing the frequency of your headache days will vary based on the medications you have been taking and your health history.1 11
”If you’re taking more than two days [per week] of acute pain medication for anything, maybe you’re not taking it just for your headache, you’re taking it for something else, I would seek medical attention and try to find out are there different strategies that work for you that you can do that gives you the relief that you need to carry on and have a high quality of life.”15
Bring your headache diary/calendar to your appointment. Come prepared to talk about your headache symptoms, frequency, and any other pain history.1 11
Inform yourself about migraine disease. Keep up-to-date with new treatments being offered. Partner with your physician and take control of your disease.
Seek out a headache specialist, especially if you feel trapped in a cycle of frequent migraine days. Partnering with a headache specialist will ensure you are getting the best treatments, including the newer migraine-specific drugs if appropriate. Note that not all neurologists are headache specialists so be sure to check credentials.
Do not give up. There are many preventive treatments. Keep trying until you find what works for you. The last few years have finally brought forth migraine-specific CGRP and gepants medications. Consider lifestyle and other non-medication preventive options.
Know that you aren’t alone. There are one billion people with migraine disease world-wide.14 You can find support through your local or national migraine patient advocacy organization.
Can the pain relievers I take for back pain cause Rebound Headache?
If you have a primary headache disorder such as migraine or cluster or tension-type headache, then yes, unfortunately the pain medication you take for other conditions such as back pain or arthritis or fibromyalgia are likely to cause rebound headache if used for a period of three months or more. Consult your healthcare provider for alternatives to the acute medications that are known to cause the rebound headache phenomenon, including non-drug alternatives like exercise or physical therapy.11
It seems like no matter what I do, my headaches and other migraine symptoms get worse, not better. It’s impacting my life in every way, yet my doctor seems to have given up on me. Should I look for a new doctor?
The common goal of the patient and physician should be an improvement of function and improvement of quality of life. If you, as a patient, don’t feel that your physician agrees with the fundamental statement that you deserve better, then it may be a good time for you to let them know. If you find it intimidating to let them know in person, send them a letter; let them know that you didn’t feel heard. You may need to fire your doctor and find another physician that can help meet your needs.12
Calcitonin gene-related peptide (CGRP) inhibitors represent a new class of drugs uniquely designed to treat migraine. There are two types of CGRP inhibitors: monoclonal antibodies which are designed for migraine prevention, and gepants which can be used as both preventive and acute migraine therapies. Several options are available within both categories. While these treatments are not a cure for migraine disease, they have proven to be safe and effective.
What is CGRP?
CGRP is the acronym for calcitonin gene-related peptide. CGRP is a small molecule made up of 37 amino acids that is produced naturally by the body.1 CGRP is involved in body functions in the gut, the reproductive tract, and blood vessels.2
CGRP may be helpful in protecting against cardiovascular issues, such as high blood pressure and heart disease. For example, in the midst of a heart attack or a stroke, CGRP may be released to help prevent such an event.1
While CGRP is found in everyone and is helpful to some of our body functions, the effects of CGRP can also contribute to migraine attacks.
What is the role of CGRP in migraine?
CGRP is released into the body during the migraine process.18 CGRP affects the trigeminal nerve, which communicates pain and sensitivity to touch and temperature. It is released throughout the peripheral and central nervous systems during a migraine attack. When CGRP attaches to its receptors in the brain, it perpetuates the migraine process, leading to inflammation and headache pain.3 4In patients who have chronic migraine disease, CGRP levels remain elevated during a migraine attack, as well as between attacks.19
Did You Know?
The trigeminal nerveis the largest of the 12 cranial nerves that connect the brain to the body. Specifically, the trigeminal nerve connects to sensory and motor functions in 3 areas:
upper part of the face, including the forehead, scalp, and upper eyelids
middle part of the face, including the cheeks, upper lip, and nasal cavity
lower part of the face, including the ears, lower lip, and chin, controlling the movement of muscles in the jaw and ear.20
Clinical studies have shown that when CGRP is injected into the body it causes moderate to severe headaches in people who have not been diagnosed with migraine disease, and migraine-like headaches in people who have migraine disease.1 18 This information suggests that people with migraine disease may be particularly sensitive to CGRP.18
The initial development and studies of drugs that target and reduce the amount of CGRP in the body began in the late 1990s.18 The first CGRP inhibitors to prevent, reduce, and or treat migraine attacks were approved by the FDA in 2018.3
Did You Know?
Migraine medications that block CGRP may also be known as:
CGRP receptor antagonists
CGRP monoclonal antibodies for migraine
What are CGRP Inhibitors?
CGRP inhibitors generally fall into two classes of drugs: Monoclonal antibodies and receptor antagonists.3
Monoclonal antibodies work by blocking the CGRP pathway. They are a preventive treatment due to the longer duration they remain in the bloodstream.1Monoclonal antibodies are FDA approved for migraine with and without aura.6
The following monoclonal antibodies work by binding to the CGRP molecule itself, “mopping up” the CGRP in the body.7 They are FDA approved for the preventive treatment of migraine in adults.
Fremanezumab (Ajovy) is self-administered as a subcutaneous injection every month or every 3 months, depending on dosage.8
Galcanezumab (Emgality) is self-administered as a subcutaneous injection every month for the preventive treatment of migraine. A different dosage is approved for the treatment of episodic cluster headache.9
Eptinezumab (Vyepti) is administered in the doctor’s office as a 30 minute intravenous infusion every 3 months. It is approved for the preventive treatment of migraine in adults.10
A fourth FDA approved option, erenumab (Aimovig), works by binding to the CGRP receptor, so that the CGRP cannot be activated and result in a migraine attack.7 Aimovig is self-administered as an injection every month, and is approved for the preventive treatment of migraine in adults.11
Gepants are small molecule CGRP receptor antagonists that bind to and block CGRP receptors. Gepants are generally marketed for acute migraine treatment due to the shorter length of time they stay in the bloodstream, but some gepants may be used daily as a preventive treatment.1 4 5 12 13
The following gepants are FDA approved for the acute treatment of migraine in adults:
Rimegepant (Nurtec ODT) is a disintegrating 75 mg single dose oral tablet. It is also approved for the preventive treatment of episodic migraine.14
Ubrogepant (Ubrelvy) is prescribed as a 50 or 100 mg oral tablet. A second tablet can be taken in 2 hours if the migraine pain returns. The maximum dose is 200 mg per day.13 It is approved for the acute treatment of migraine attacks with or without aura; it is not approved for the prevention of migraine headaches.15
A third option, atogepant (Qulipta) is FDA approved for the preventive treatment of episodic migraine in adults. It is prescribed as a daily 10 mg, 30 mg, or 60 mg oral tablet.16 At this time it is not FDA approved for acute migraine treatment.
Did You Know?
A key attribute of gepants is that they do not cause rebound headache (medication overuse headache).12 Learn more about rebound headache.
What are the side effects?
Side effects of the CGRP monoclonal antibodies include:
high blood pressure11
injection site reactions, such as pain, redness, or swelling8 9 10 11
Side effects of gepants include:
nausea14 15 16
Who is contraindicated?
CGRP inhibitors are generally well tolerated and can be used safely by patients who do not have an allergic reaction to the drug or its ingredients.
Before taking the drug, patients should tell their healthcare provider about all medical conditions and medications, as some interactions may exist.
CGRP inhibitors have not been adequately studied for safety in pregnant women, unborn infants, or their presence and effect in human milk, milk production, or breastfeeding infants.13 19 Patients should tell their healthcare provider if they are pregnant, breastfeeding, plan to become pregnant, or plan to breastfeed.
Safety and effectiveness in children has also not been established.19 None of the CGRP inhibitors discussed in this article have been approved for the treatment of migraine in children.
How much relief can be expected?
In clinical trials, more than half of people found that their migraine days and/or severity of their migraine attacks dropped by 50% when using a CGRP inhibitor.4 Fortunately, about 70% of people see some level of improvement.17
Some people may need to take the medication for three to six months to achieve an optimal response.4 6There is currently no method to predict who will have good results, and which drug within the treatment class will be the most effective.2 If a patient does not find relief on one CGRP inhibitor, or has not tolerated it due to side effects, it is advisable to try another drug.12
CGRP inhibitors can be an equally effective option regardless of whether you have:
Failed to see migraine improvement on one or dozens of other preventive therapies.
Been using or overusing acute medications.
Been newly diagnosed with migraine disease or have had migraine for a lifetime.
With a new class of medication such as CGRP inhibitors, there may be challenges for patients to access these treatments. Commercial insurance companies in the U.S. generally require failure of at least two, if not three, preventive medications from three different classes before providing prior authorization to cover these new medications. This is usually due to the high cost of the CGRP inhibitors.6 Without insurance coverage, a year of treatment with a CGRP inhibitor can cost a patient several thousand dollars.13
To assist patients in obtaining these medications, some drug companies offer programs that offer free trial doses, temporary coverage of medication, or copay assistance. These programs may not be available to patients who have government insurance.4
CGRP inhibitors are the first medications specifically designed for the prevention and treatment of migraine attacks. They have few side effects, and a high degree of efficacy in reducing migraine frequency and/or severity. While cost and insurance coverage of these new medications may pose a challenge for some patients, there are payment assistance programs available. CGRP inhibitors bring new hope to many patients who have struggled to find an effective migraine treatment.
Links to outside organizations and articles are provided for informational purposes only and imply no endorsement on behalf of Migraine World Summit.
Anyone who has ever experienced an ocular migraine can probably recall their very first episode. They might have been sitting at their desk, feeling perfectly normal, then suddenly started seeing flickering lights, zigzagging lines, or a rash of colorful, kaleidoscopic waves. To say that the experience can be alarming would be an understatement. The good news is: it’s not dangerous.
Some people experience these “light show” symptoms regularly, usually before the onset of a painful headache. Others experience the symptoms alone – without the accompaniment of a classic migraine headache. And some may have experienced them only once or twice, never to be repeated again.
Ocular migraine is a term commonly used to describe certain visual disturbances associated with migraine. The symptoms are varied and can include:
flashing lights, or kaleidoscope- or prism-like visual sensations
blind spots or scotomas
The condition – a type of migraine with “aura” – can be disturbing, but symptoms are generally benign and most last less than an hour.
Aura is a term that refers to sensations other than head pain that can accompany a classic migraine. Visual symptoms are the most common type of migraine with aura, though aura can affect other senses and cause symptoms ranging from numbness and tingling in various parts of the body, nausea and vomiting, or even altered motor and language skills.
These visual disturbances usually affect both eyes and can occur with or without a headache.
Approximately one-third of migraine patients will experience migraine with aura. Some may have only one or two in their life, others may have a couple a month, and some may have an aura with every attack. About 15% of individuals who experience aura have one with every attack.1
The term “ocular migraine” is considered a misnomer, in that the visual disturbances associated with it occur in the brain, not in the eye or in the retina.
Though many people – including some medical specialists – continue to use the term “ocular migraine” to refer to a migraine with visual disturbances, it is more accurate to refer to ocular migraine as “migraine with aura” or “migraine with visual aura.”
Ocular migraine is sometimes referred to as “retinal migraine,” and although some of the symptoms overlap, the two diagnoses are not the same. Retinal migraine is a different and much rarer type of migraine.
On occasion, ocular migraine is also called “visual migraine,” “ophthalmic migraine” or “eye migraine,” but these are vague, general terms that refer to any migraine displaying visual impairments.
But ocular migraine, I don’t use that term at all, because it’s too confusing. I don’t know if the person is talking about retinal migraine or migraine phenomenon or migraine with aura, so we try to stick with migraine with aura and and get rid of ocular migraine or eye migraine, because it really isn’t specific. It’s kind of a slang term.2
What Causes Ocular Migraine?
Ocular migraine – or migraine with visual aura – is generally thought to be caused by electrical disturbances in the brain, triggered by a phenomenon called cortical spreading depression. This refers to electrochemical waves that spread slowly across the cortex, the outer surface of the brain. Most of the time, these disturbances occur in the occipital lobe, the part of the cortex that controls vision, causing visual symptoms.1,2
How Does Ocular Migraine Differ From Retinal Migraine?
Though the terms “ocular” and “retinal” migraine are frequently used interchangeably, the two are not the same. While both types of migraine generally involve unusual temporary visual phenomena, ocular migraine symptoms generally involve both eyes. Symptoms can occur with or without a headache.
Retinal migraine is a very rare cause of temporary vision loss in one eye (monocular), and can be – but is not always – followed by a headache within an hour of the onset of symptoms.
The transient vision loss experienced in retinal migraine can range from partial to full. Symptoms may include flashing lights and scintillating blind spots.
A retinal migraine diagnosis is made only after excluding other possible causes of single eye vision loss. An eye doctor should be able to make the diagnosis after conducting a comprehensive eye exam with dilation, including a formal visual field exam.
Vision impairment is quite common during migraine, so it’s not surprising that they’re going to end up in an eye doctor’s office…
Ocular Migraine Triggers
Ocular migraine attacks can be triggered by the same symptoms that trigger other migraine attacks and vary from person to person. Common triggers include:
weather (including excessive heat or barometric pressure changes)
alcohol (including red wine)
certain foods (including aged cheeses, or foods containing additives such as nitrates, MSG, or artificial sweeteners)
family history of migraine
bright lights, including sunlight
lack of sleep
Additional triggers may include activities that involve:
extended computer screen use
Which Specialist to See When Experiencing Visual Symptoms?
A person experiencing visual disturbances, such as flashing lights, zigzagging lines, or even blind spots may first go to an eye doctor, who can conduct a comprehensive eye exam with dilation and rule out other causes of the symptoms before diagnosing migraine. An ocular migraine diagnosis does not mean the symptoms are occurring in the eye or caused by some dysfunction of the eye. The visual activity is caused by electrical disturbances in the part of the brain that controls vision. These symptoms can occur with or without headache. Patients who experience these symptoms are generally referred to a neurologist for ongoing migraine management.
When to Seek Immediate Medical Attention
Because a number of migraine-related symptoms can affect vision, it is not always easy to determine which are unrelated, but persons experiencing the following should seek medical attention right away to rule out stroke or another diagnosis that could lead to irreversible vision loss:
Any significant change or increase in duration of usual visual symptoms.
New floaters or flashes of light or dark spots in one eye that do not go away within an hour.
Episodes of temporary vision loss in one eye.
Vision loss that presents as darkness or complete blindness.
Experiences of tunnel vision or inability to see out of one side of one’s vision field.
Treatments for Ocular Migraine
Drugs that treat regular migraine symptoms may be used to treat ocular migraine attacks. These include over-the-counter pain relievers, including:
Prescription medications that may be used to treat an ocular migraine include many of the same medications used to treat classic or common migraine attacks, such as:
triptans, such as sumatriptan (Imitrex) or rizatriptan (Maxalt)
ergotamine derivatives, such as DHE (dihydroergotamine)
prescription NSAIDS, such as diclofenac or celecoxib
neuromodulation devices, such as Cephaly, Nerivio, or Gammacore
Whether an individual is using over-the-counter or prescription medication, early-onset treatment is more effective than waiting until after the migraine attack has had a chance to build up.
Patients who experience more frequent visual aura symptoms may consider medications designed to prevent classic or common migraine, including:
antidepressants, such as amitriptyline (Elavil ), nortriptyline (Pamelor), or venlafaxine (Effexor)
blood pressure medications, such as beta blockers or calcium channel blockers
anti-seizure drugs, such as valproic acid (Depakene, Depakote) or topiramate (Topamax, Qudexy XR, or Trokendi XR)
monoclonal antibodies, such as erenumab (Aimovig), galcanezumab (Emgality), fremanezumab (Ajovy), eptinezumab (Vyepti)
gepants, such as atogepant (Qulipta), rimegepant (Nurtec ODT)
Other practices/treatments that may be helpful
Get regular exercise – any kind – including walking, swimming, bicycling.
Eat regularly – try not to skip meals.
Develop good stress management strategies.
Consider mindfulness practices, such as meditation, tai chi, yoga, etc.
Maintain a regular sleep pattern (7-9 hours per night).
Consider testing for apnea if sleep is frequently interrupted.
Ask your healthcare provider if supplements may be helpful.
Join a migraine support group for tips and fellowship.
Consider FL-41/tinted lenses, which help block color wavelengths that bother persons with light sensitivity.
Roughly one-third of people with migraine experience some kind of aura, and many of those experience some kind of visual aura. The symptoms can be unsettling, but they are generally benign. It is important to note that effective options are available to treat attacks and help prevent future ones, as discussed above.
While there is no cure for migraine, many new treatment and prevention options are now available – and more are in the pipeline. Work with an experienced healthcare professional to find what management techniques work best for you. And consider joining a migraine support group to help you on your healthcare journey.
Migraine, and migraine with aura, is more than just a headache. In fact, for many people it’s not a headache at all. Bouts of vertigo, waves of nausea, vision loss, and the inability to speak or walk are just some of the symptoms that those with migraine with aura can experience.
What is Migraine With Aura?
Aura occurs due to a spreading electrochemical event on the surface, or the cortex, of the brain. This electrochemical event spreads slowly, two to three millimeters per minute, across the cortex, and as this event progresses, the aura symptoms commence.
Most of the time, 90% in fact, the aura begins in the occipital cortex which controls vision, explaining why patients often complain of hallucinations in their vision. They’ll see spots, sparks, stars, lightning bolts, or even colors or prisms that will grow. Oftentimes it starts in the periphery, but it can also begin in the center of the vision. Then it expands over a period of time. The International Headache Society classifies migraine with aura as having reversible symptoms that resolve within an hour. If it goes on longer than an hour, that’s called prolonged aura and is less common.1,5
The duration of symptoms depends on which area of the brain the spreading electrochemical event is occurring. Some people may start to feel numbness in their tongue, in their face, in their hand, in their arm, or even in their leg. They may think they’re having a stroke. Sometimes people will develop a language aura, so they’ll not be able to find words, or express themselves properly. They may slur their speech, or they might not understand speech (also known as aphasia). The type of dysfunction experienced corresponds to the physical part of the brain involved during the migraine attack. There are different types of symptoms, but they usually happen for a short period of time, and should be fully reversible.
Approximately one third of migraine patients will experience migraine with aura. Among those with aura there is great variability. Some may have a couple of auras in their life, others may have a couple of auras a month, and others may have an aura with every single attack. Of those individuals with aura, about 15% will have an aura with every attack.
Types of Migraine with Aura
1. Migraine with typical aura
Migraine with typical aura refers to the most common symptoms associated with aura such as numbness, weakness, trouble with language, and visual disturbances. In addition to this combination of symptoms there are other types of migraine with aura with their own set of symptoms although some overlap with typical aura is common.
2. Migraine with brainstem aura
In migraine with brainstem aura, a distinct set of symptoms can be experienced and produced by the brainstem itself which sits underneath the hemispheres of the brain.
Individuals may experience double vision, slurred speech, unsteady gait, dizziness, vertigo, ringing in the ears, or tingling on both sides of the body.
With all these symptoms an individual may have one, some, or all of them during a migraine attack.2
About 10% of those who experience migraine with aura will have migraine with brainstem aura. It’s more common than hemiplegic migraine, but it’s still not common.2
3. Hemiplegic migraine
Hemiplegic migraine can cause paralysis and/or weakness. The name “hemiplegic” comes from the fact that during the aura or the neurological symptoms that precede the migraine attack, the patient is weak on one side of the body hence the term “hemi” meaning half and “plegia” meaning weakness.
Clinicians should determine if patients are describing numbness when perhaps they actually mean weakness. For instance, Dr. Dodick, at the 2017 Migraine World Summit, commented, when someone says numbness, “What do you mean by that? Do you mean that there’s no sensation? Do you mean that it’s tingling and prickling, or do you mean that it’s actually clumsy and weak?” It’s a very important distinction.
Hemiplegic migraine causes weakness, and that weakness can involve the face, the hand, the arm, the leg, or all of the above. When patients with hemiplegic migraine develop weakness on one side of the body, they will almost always have either a visual aura and a sensory aura, and sometimes a language aura.
Symptoms may include:
tingling and numbness
visual illusion (visual aura)
they may not really understand what you’re saying or have trouble processing information
they may have trouble speaking.2
Hemiplegic migraine patients can present with hemiplegia, or weakness on one side of the body, which can mimic a stroke.
Sometimes there’s a motor aura, where people will develop weakness on one side of their body and that can mimic a stroke as well.
4. Retinal migraine
There is a form of migraine called retinal migraine, which is truly in one eye, but it’s an extremely rare form of migraine and it’s very difficult to diagnose.3
Some of the people who have been examined during what they call a retinal migraine actually have a vasospasm of their artery in their eye causing the visual phenomenon. It’s always in one eye and they can get a headache right behind their eye.
What about ocular migraine?
If patients are experiencing black holes in their vision, spots in their vision or the symptoms of aura without headache, they typically see an ophthalmologist or eye doctor. Fortunately, most eye doctors will recognize migraine and be able to distinguish it from ocular disease.
Eye doctors may refer to this as “ocular migraine” but it’s not a problem in the eyes itself. Dr. Dodick at the 2018 Migraine World Summit, asked, “Remember the spreading electrochemical event in the occipital cortex of the brain producing those visual symptoms? So ‘ocular migraine’ is a misnomer, it’s not the eyes causing the problem, it’s the brain causing the problem. So we call it migraine with aura whether or not it’s accompanied by headache.”
“Eye migraine” or “ocular migraine” are commonly used to describe this type of migraine but they are technically vague and unclear and not terms used by headache specialists for diagnosis. A headache specialist will refer to the condition either as migraine with aura or retinal migraine – which is a rare condition.
Migraine With Aura Symptoms
Let’s look at the four phases of migraine and see where the aura phase fits in.
The four phases of migraine are:
Premonitory or Prodrome phase
The premonitory phase refers to the symptoms that occur in the hours before pain begins.
In the aura phase a variety of symptoms may occur more immediately before the headache phase, but may also overlap with the headache phase.
The headache phase is the point at which a moderate to severe headache is experienced.
The postdrome refers to the phase after the headache resolves. Symptoms experienced in this phase may outlast the headache for hours to days.4
Prodrome symptoms refer to pre-headache signs and symptoms. These include fatigue, yawning, nausea, thirst, irritability and needing to use the bathroom frequently.
Sometimes symptoms that occur during the painful headache phase itself can occur during the prodrome such as sensitivity to light, sensitivity to sound, neck pain, depression, feeling down, changes in mood, changes in one’s ability to concentrate and to process information.
You might think, “I’m just in a little bit of a fog today, I’m not firing on all cylinders,” but it could be a prodromal phase. So you can see why all of those things reflect a problem in the brain itself versus in the blood vessels. Blood vessels couldn’t possibly cause all of those symptoms.1
Cravings are another common feature of prodrome cited by patients. These are sometimes interpreted as triggers. Cravings for certain foods like chocolate or other processed foods that are eaten and then followed by an attack lead a person to believe it may be a trigger. That isn’t necessarily the case. It may simply be part of the prodrome. Where migraine is thought to begin in the brain is an area that’s responsible for appetite and could plausibly be causing these food cravings.4
Vomiting and nausea can occur in the prodrome phase but it usually occurs in the head pain phase as the attack has progressed. Oftentimes the nausea is associated with the intensity of the pain, so the worse the pain, the worse the nausea, the more likely you’ll vomit. Not always, but often they tend to track together, but patients can remain nauseated in the postdrome phase, after the head pain has disappeared.
There’s overlap with these symptoms and phases. There are not always clear lines of division between each phase or its symptoms.
Visual symptoms are the most common characteristic during a migraine with aura. A visual aura is a discrete neurological event that causes disturbance in the vision. It often will start like a little flickering or kaleidoscopic, and then will build up and grow as it moves across an individual’s field of vision. They are often a warning sign preceding the head pain phase of the migraine.
Many people think something is wrong with their eye, but really it’s happening in the brain, and if they cover the eye that they believe has the problem, they can still see little zig-zaggy lines or spots from the other eye.
We know that this disruption is coming from the brain. We also believe that it is triggered by cortical spreading depression. This refers to an electrical disturbance in the brain.
There are other types of auras, such as dizziness or vertigo auras, or numbness around the face and hand followed by a headache, but the visual aura is the most common.3
Other visual symptoms include blurred vision, blind spots (scotoma), and/or temporary loss of vision as part of their migraine with aura.
For both living with migraine with and without aura, visual sensitivity in between their attacks is common. This sensitivity extends beyond just light but includes visual sensitivity to stripes, flickering lights and lights that are moving. In those people who are vulnerable, peripheral movement in the visual field may sometimes even trigger a migraine. Bright lights could trigger a migraine. People with migraine, in general, are visually sensitive and this can continue between attacks.3
Numbness or tingling are common sensory symptoms that can occur during the aura.
Most of the time, people will experience numbness or tingling that begins in maybe a couple of fingers, or maybe the digits of the hand, and then it will gradually creep up to involve the hand, and then maybe move up to the arm. It can jump to the face and occur around the mouth. Sometimes it will go inside the mouth and involve the gums and the tongue. Sometimes it will involve the whole body.
People can also experience weakness during the aura phase. Weakness can occur in the arm or leg, and face drooping can also be associated with their attacks.
People may be cognitively affected during a migraine attack. A recent study has shown that cognitive symptoms were the second most disabling symptoms behind the head pain itself.2
Brain fog is a common cognitive symptom. An individual might just feel off on a particular day and not really understand why they feel off. Particularly, if they have frequent migraine attacks. Even though they’re not experiencing a headache, they might normally associate that with headache, but it looks like that symptom clears up, that brain fog clears up when they’re effectively treated.
Dr. Dodick has been seeing this for many years, when a patient is effectively managed on a preventive regimen, they feel better. They feel better because they’re not having as many headaches. “Even when I’m not having a headache, I feel better. I feel like a cloud has been lifted, or a fog has been lifted.”2
Like many symptoms of migraine, they can occur alone or in combination with other symptoms. As you know, you don’t even need to have headache, to have migraine. Dr. Dodick refers to it like a wheel with multiple spokes, and each spoke is a symptom.
Sometimes you’ll have one spoke. Sometimes you’ll have five spokes. Sometimes you’ll have all the spokes on the wheel.
You can get dizziness, or vertigo associated with a typical migraine attack, which accompanies a headache, and sometimes not. It can occur in isolation or it can occur in conjunction with other migraine symptoms, like sensitivity to light and noise and nausea.
Can you have a migraine without headache or an aura without headache?
Yes, it is possible, however it is rare to only ever have a migraine aura without headache. This type of migraine is referred to as acephalgic migraine attacks.
Another term used to describe this type of migraine is silent migraine. It occurs in perhaps 3-4% of people living with migraine.
Some of the people who have migraine headache and have a visual aura can sometimes only have the visual aura without their usual headache. This combination is more common.
Migraine With Aura Causes
There are different theories but the truth is scientists still don’t really know what causes migraine with aura. One risk factor is having one or two parents with migraine with aura. There is a genetic link. We do know that it occurs in the brain after it is triggered.
After head trauma, we know that there can be massive changes in depolarization in the brain, but there are people sitting normally, having a depolarization in the brain. The cortical spreading depression seems to occur for no good reason.
There may be certain migraine triggers for some people that make them more susceptible, for instance if they haven’t slept enough. Altitude may play a role in making people more susceptible to aura. But the initiation point is not really known.
Migraine With Aura Diagnosis
Diagnosis is typically made by a clinician taking a history from the patient who describes their symptoms. Some clinicians may perform a physical exam to rule out other conditions. Scans and tests are not typically required but may be requested in certain cases.
Migraine itself is defined by the International Headache Society criteria as a headache which can be of moderate to severe intensity. It can be on one side of the head or on both sides of the head, and it has certain features associated with it.
The features, for example, include nausea and/or vomiting; light and sound sensitivity; and difficulty in moving. These symptoms are common with migraine without aura.
Migraine with aura often has those features as well, but has separate features that clinicians can diagnose from listening to patients tell them about visual symptoms of flashing lights, numbness or tingling in the face or hands, and trouble with articulation and understanding others’ speech.
Migraine With Aura Treatment
We know that early intervention, not just in migraine but other headache disorders and other diseases, help to prevent the downstream effects. The prodrome or premonitory phase sets itself up as an ideal opportunity for early intervention, with treatments that are safe and well-tolerated.
If people recognize the premonitory or prodromal phase they may be able to more effectively prevent or reduce the downstream effects, the onset of the pain and all the other symptoms.
Once the headache phase begins, many people will reach peak headache intensity within about 30 minutes, so there isn’t a large window of opportunity within which to intervene.2
Acute treatments are medications used to treat an oncoming migraine attack. These include:
pain relievers available over the counter, including acetaminophen, ibuprofen, naproxen, diclofenac, celecoxib oral solution, and aspirin
triptans such as sumatriptan or rizatriptan
ergotamine derivatives such as DHE (dihydroergotamine)
devices (Cefaly, Nerivio, Gammacore)
Triptans are specifically designed to be taken when you have a migraine attack.
“There was initially some suggestion to say that you should avoid triptans during an aura. There’s a myth there that it’s dangerous to take a triptan during aura because you’re going to cause a stroke.5 There’s no evidence for that. There was one — an older study — that suggested it wasn’t effective. Then there’s also been other studies that suggested it can be effective. So I actually tell people to take it as soon as they feel the onset of their migraine coming on. But different people may have different opinions on that. With regards to other drugs like nonsteroidal anti-inflammatory drugs — and again you take it as soon as possible, as soon as you get these symptoms.”
Triptans are contraindicated in patients with hemiplegic migraine. That’s based on an old hypothesis that the aura, which is the weakness, is due to a lack of blood supply to the brain, and Triptans can cause constriction of blood vessels. There isn’t a lot of research to support whether triptans are indeed safe or not so it’s best to avoid triptans in this group until there is more evidence and data to suggest it’s safe.2
Migraine With Aura Prevention
If people have frequent aura and migraine or migraine with aura, many of the same preventatives that we use for migraine without aura will work with migraine with aura.
If attacks are so frequent that people are disabled by them, they should be on a preventive medication. People who experience migraine should probably talk to their doctors about what’s right for them, because not everything is going to work for everybody.
I’ve found that baby aspirin is really good for aura. Sometimes aura without headache, to prevent that, and also to prevent migraine with aura. But you have to know whether your system can tolerate baby aspirin or not. And that should be a conversation between a person and their primary provider. I’ve also found calcium channel blockers can be very helpful. Things like Verapamil sometimes are very good for people with migraine with aura.
Other preventatives that are helpful preventing migraine with aura include:
antidepressants, such as amitriptyline (Elavil)
blood pressure medications, like beta blockers or calcium channel blockers such as candesartan (Atacand), propranolol (Inderal), timolol (Timoptic)
anti-seizure drugs, such as topiramate (Topamax), valproate sodium (Depacon)
Calcitonin Gene Related Peptide (CGRP) monoclonal antibodies:
There’s some data to suggest that some medications may be helpful for aura. There’s some small studies on a drug called Lamotrigine which suggests that maybe that had some beneficial effect on aura. There’s a drug called Flunarizine which is used quite widely throughout Europe, and there’s again anecdotal evidence from a pediatric study that it was more effective in hemiplegic migraine groups, so maybe a bit more effective in aura.5
If you’re light-sensitive, sometimes FL-41 or the tinted lenses can be really helpful in preventing migraine attacks, in-between attacks.
Polarized sunglasses are not considered a preventive for those with a light sensitivity unless used outdoors to help reduce glare. People can wear sunglasses outside, because it blocks the light on all wavelengths. The FL-41 and some of these light filters can block certain wavelengths, especially the blue wavelength that seems to be more bothersome to people indoors.
What about other visual phenomena noticed by people living with migraine?
There are some people with migraine who can also get other visual phenomena. For example, there’s an entity called visual snow. Visual snow is very different from an aura. Aura is a discrete neurological event that occurs, typically followed by the headache. Visual snow is a persistent visual phenomenon. It’s like little, tiny dots in the field of vision, like in the old TV sets showing a static snowy pattern. People see visual snow commonly and they can see through it. Their vision can be 20/20, but they continuously see these little visual dots. Some people have blobs of color that they constantly see.
Dr. Digre has seen people who feel like they see little things floating around in their vision. People with migraine can have floaters. Lots of people have floaters and people with migraine seem to notice those floaters a little bit more readily. Floaters can be seen easier on a blank wall or in the blue sky.
People with migraine also have other strange symptoms such as image recurrence. They can look at an object, and then they can look away and they might see the same object sitting next to them, and that’s called palinopsia. Or they can have their hand go in front of a target and they can almost see their hand trailing across space.
It’s these unusual visual phenomena that people with migraine are more prone to, that are so different from our normal visual world, which makes it challenging for patients to explain to an ophthalmologist or eye doctor for example.3
Migraine aura later in life
What’s interesting about this aura is as people get older, sometimes they lose the headache but keep the aura, and sometimes that is called later-life migraine accompaniments. It’s still a migraine aura, but it doesn’t trigger the headache.3
White Matter Lesions Associated with Migraine with Aura
MRI scans in people with migraine with aura may show T2 hyperintensities which might be concerning for some who ask if they are lesions and what they mean.
These are white-matter lesions, and they do not cause dementia.6
A study done in the Netherlands took several hundred patients, some that have migraine with aura, and they compared them versus a research control group of healthy people. MRIs were conducted on their brains and they measured the dots. Nine years later they found those patients again and then re-measured the dots on the MRI, specifically looking to see if there were cognitive changes that would occur over time. They found that women were more likely to have these dots, but there was no effect on cognition or neurological effects.
There’s actually data that shows that these white-matter lesions are not a cause for concern. We do not think that they’re causing any damage.6
Patent Foramen Ovale and Migraine
Some people are born with an open passageway between the two top chambers of their heart called the atria. If this passageway is open it’s referred to as a patent foramen ovale (PFO). Learn more about the link between the PFO and migraine in this article.
Risk of Stroke
Some patients are worried about the risk of stroke as they may have heard that migraine with aura is associated with an increase in risk. Typically the increase in risk is minimal. Learn more about migraine and stroke risk, in this article (coming soon).
When to see a healthcare provider?
How to talk to them about migraine with aura
Here are a few tips to get the most out of your doctor visit if you suspect you may have migraine with aura:
Keep a record of your migraine attacks. How often do they occur? How long do they last?
Record what happens during your attacks including sensory disturbances. Do you experience a visual aura? How long does that typically last? Describe the symptoms you may experience such as zigzag lines, flashing lights, or any other classic migraine with aura symptoms.
Tell the doctor what treatments you’ve tried already and ask him/her about both acute and preventive options for your migraine.
Another tip is to take a friend or family member with you to your appointment to help you remember questions you wish to ask and also to help you recall the answers provided. There’s a lot that happens in a relatively short period of time and if you’re in pain or tired or experiencing side effects from treatments it is easy to lose track of what is said.
What to expect from your doctor?
It’s important to recognize that patients with migraine will end up in many different physicians’ offices, especially because one-third have visual symptoms. These symptoms will most likely take them to an ophthalmologist or optometrist.
Sometimes patients with migraine have well-formed visual aura, so it’s very clear what’s going on. But at least half of patients who have migraine without aura will have something wrong with their vision during an attack, such as blurred vision. They can’t quite explain it, they can’t see as clearly, their vision is not as crisp. Things appear blurred or indistinct or something is affecting their vision. Vision impairment is quite common during migraine, so it’s not surprising that they’re going to end up in an eye doctor’s office.
For migraine with or without aura, most people will be treated and managed by the primary care physician. Primary care doctors vary widely in their understanding and interest of migraine. Going to your appointment prepared and informed with questions and requesting a comprehensive treatment plan once a diagnosis is confirmed will help ensure you get the most of our visit.
Migraine with aura affects a significant proportion of people with migraine. Its symptoms can feel strange and unsettling and even mimic those of a stroke. But there are effective options to manage migraine and help prevent attacks.
Tips for migraine with aura are similar to those with general migraine:
1. Review your lifestyle triggers.
2. Ensure you have a regular sleep pattern.
3. Make sure you are not missing meals.
4. Practice good stress management.
5. Treat early. There’s evidence that you shouldn’t wait for your migraine attack to build up before you treat it. An established migraine attack is less responsive to treatment than treating at the onset. If you’re going to treat it, treat it at the onset of the attack.
6. Prevention isn’t just for chronic migraine. If you have more than six days of any migraine symptoms per month, consider prevention strategies to stop the migraine attack from occurring in the first place.
While there is not yet a cure for migraine, it can be effectively managed and controlled. It takes time to learn how migraine affects you and which treatment options and management plans work best for you. Working in partnership with your health care professional is a critical part of your migraine care.
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