Migraine: Types, Symptoms, Triggers

Brief overview

  • What is a migraine? Headache disorder with recurring, severe, usually one-sided attacks of pain
  • Forms: including migraine without aura (with subtypes such as pure menstrual migraine without aura), migraine with aura (e.g. migraine with brainstem aura, hemiplegic migraine, pure menstrual migraine with aura), chronic migraine, migraine complications (such as migraine infarction)
  • Causes: not yet fully known; a genetic predisposition is suspected, on the basis of which various internal and external factors (“triggers”) trigger the pain attacks
  • Possible triggers: e.g. stress, certain foods and stimulants, certain weather conditions, hormonal fluctuations (e.g. during the menstrual cycle)
  • Diagnostics: medical history (anamnesis), physical and neurological examination; additional examinations (e.g. MRI) if necessary
  • Prognosis: not curable, but intensity and frequency of seizures can be reduced; often improves with age, sometimes disappears in women after the menopause.

Migraine: Description

People who suffer from migraines experience headache attacks at irregular intervals. The pain usually only affects one side of the head and is described by sufferers as pulsating, hammering or drilling. It intensifies with physical exertion. Migraine headaches are often accompanied by various other symptoms such as nausea, vomiting or visual disturbances.

Migraines are the second most common form of headache after tension headaches. According to a 2016 Global Burden of Disease Survey, it is the sixth most common disease of all.

Types of migraine

The International Headache Society (IHS) differentiates between various forms of migraine. These include

1. migraine without aura, with three subtypes:

  • Purely menstrual migraine without aura
  • Menstrual-associated migraine without aura
  • Non-menstrual migraine without aura

2. migraine with aura, with various subtypes such as…

  • Migraine with brainstem mura (formerly: basilar migraine)
  • Hemiplegic migraine
  • Retinal migraine
  • Purely menstrual migraine with aura
  • Menstrual-associated migraine with aura
  • Non-menstrual migraine with aura

3. chronic migraine

4. migraine complications such as…

  • Status migraenosus
  • migraine infarction
  • Epileptic seizure, triggered by migraine aura

5. probable migraine with or without aura

6. episodic syndromes that may be associated with migraine, for example…

  • Recurrent gastrointestinal disorders (e.g. abdominal migraine)
  • Vestibular migraine

Migraine patients do not always have to suffer from one and the same form of migraine. For example, someone who often experiences migraine attacks with aura can also have attacks without aura.

Below you will find more detailed information on selected forms of migraine:

Migraine without aura

Migraine without aura in menstruating women

In a few women, these migraine attacks occur in connection with menstruation. This makes it possible to differentiate between subtypes of the disease. The above criteria for “migraine without aura” are met in all cases, but the following also applies:

  • Purely menstrual migraine without aura: The migraine attacks occur exclusively two days before to three days after the onset of menstruation, in at least two out of three menstrual cycles. The rest of the cycle is always migraine-free.

Migraine attacks that occur during menstruation are generally of longer duration and accompanied by more severe nausea than attacks outside the menstrual cycle.

Menstruating women with migraine attacks that fulfill the criteria of “migraine without aura”, but neither those of purely menstrual nor menstrual-associated migraine without aura, are also referred to as non-menstrual migraine without aura.

Migraine with aura

This form of migraine, formerly known as “migraine accompagnée” (from the French “accompagner” = to accompany), is much rarer than migraine without aura.

Doctors use the term “aura” to describe visual disturbances and other neurological symptoms that usually precede the headache phase, but can also occur together with it. Sometimes there is just the aura alone – without an accompanying or subsequent migraine headache (subtype “typical aura without headache”, formerly also called “migraine sans migraine”).

  • Visual disturbances (such as flashes of light, flickering, seeing jagged lines, visual field loss = scotoma) – are the most common symptoms of a migraine aura
  • Speech disorder (aphasia)
  • Abnormal sensations (sensory disturbances) such as numbness or tingling (e.g. in one arm)
  • Incomplete paralysis (paresis)
  • dizziness

Aura or stroke?

The symptoms of a migraine aura are also temporary and, unlike a stroke, do not leave any permanent damage.

In hospital, computer tomography (CT) or magnetic resonance imaging (MRI) can be used to determine exactly whether it is a stroke or migraine – or more precisely, symptoms of an aura.

Migraine with aura in menstruating women

Migraine with brainstem aura

Migraine with brainstem aura is a form of migraine with aura in which the aura symptoms can be clearly assigned to the brainstem. Motor and retinal symptoms, on the other hand, are absent.

Symptoms of brainstem aura can be

  • Speech disorder (dysarthria)
  • Dizziness (no drowsiness!)
  • Ringing in the ears (tinnitus)
  • Hearing loss
  • Double vision (no blurred vision!)
  • Disturbance of movement coordination (ataxia)
  • Disturbance of consciousness

Hemiplegic migraine

Another form of “migraine with aura” is hemiplegic migraine (also known as “complicated migraine”). It is characterized by motor weakness as part of the aura. In addition, there are symptoms in the area of vision, sensitivity and/or speech or language.

The motor weakness in a hemiplegic migraine attack usually disappears completely within 72 hours. However, it can sometimes persist for weeks.

Subforms

Sporadic hemiplegic migraine (SHM) is present in patients in whom no first or second-degree relative (e.g. mother, child, grandfather, brother) also suffers from this form of migraine.

If, on the other hand, at least two first or second-degree relatives have migraine attacks with motor weakness, doctors diagnose familial hemiplegic migraine (FHM).

Retinal migraine

Retinal migraine (retinal migraine) is rare. It is characterized by repeated attacks of unilateral visual disturbances such as flickering in front of the eyes, visual field loss (scotoma) or – very rarely – temporary blindness. In addition, at least one of the following three criteria is fulfilled in this migraine of the eyes:

  • The symptoms develop gradually over five or more minutes.
  • They last for five minutes to an hour.
  • Accompanying or within 60 minutes, migraine headaches also occur.

Not a migraine: ophthalmologic migraine

When talking about eye migraines, the term “ophthalmoplegic migraine” (ophthalmoplegia = eye muscle paralysis) is often used. This old name stands for a condition that is no longer classified as a form of migraine by the International Headache Society, but is instead included in the group of neuropathies and facial pain. It is now known as “recurrent painful ophthalmoplegic neuropathy”.

According to some research data, the headaches can also occur up to 14 days before the eye muscle paralysis.

Chronic migraine

If someone has headaches* on at least 15 days per month for more than three months and if these have the characteristics of migraine headaches on at least eight days per month, the doctor diagnoses chronic migraine. It can develop from a migraine without aura and/or a migraine with aura.

Status migraenosus

Status migraenosus (status migränosus) is a migraine complication that can occur in both migraine with aura and migraine without aura. The affected person suffers a migraine attack that lasts longer than 72 hours and in which the headache and/or the associated symptoms severely affect the affected person.

Migraine infarction

Epileptic seizure triggered by migraine aura

Another possible complication of migraine with aura is an epileptic seizure that occurs during or within an hour of a migraine attack with aura. Sometimes this rare migraine complication is also called migralepsy.

Recurrent gastrointestinal disorders

A subtype is abdominal migraine, which mainly affects children. This is characterized by recurring, unexplained, moderate to severe abdominal pain attacks that last between two and 72 hours. They are accompanied by at least two of the following symptoms: loss of appetite, pallor, nausea and vomiting. Headaches do not occur during these attacks. In the period between two attacks, those affected are symptom-free.

Vestibular migraine

This includes, for example, spontaneous dizziness, where you have the deceptive feeling that you yourself are moving (internal dizziness) or that what you see around you is turning or flowing (external dizziness). Positional vertigo is also an example of a vestibular symptom – as is dizziness with nausea triggered by head movements (dizziness in the sense of impaired spatial orientation).

  • Headache with at least two of the following four characteristics: localized on one side, pulsating, moderate to severe intensity, worsened by routine physical activity
  • Aversion to light and sound (photophobia and phonophobia)
  • Visual aura (i.e. visual disturbances such as flashes of light)

Old names for vestibular migraine are migraine-associated vertigo, migraine-related vestibulopathy and migrainous vertigo.

Overlaps with inner ear disease

There are also many patients who exhibit characteristics of both diseases. The relationship between the disease mechanisms of vestibular migraine and Meniere’s disease is still unclear.

Migraine in children

In children, migraine headaches often occur on both sides and mainly affect the forehead and temples. However, there are other differences to migraines in adults:

This different symptom pattern means that migraines in children often go unrecognized for a long time. This is aggravated by the fact that young children are not yet able to adequately express their symptoms.

Often triggered by stress

Migraines in children are very often triggered by stress. This can be physical, for example due to fatigue, exhaustion, overstimulation, lack of hydration or not eating enough. Emotional stress, such as conflicts at home or arguments with classmates, can also trigger migraine attacks in children.

Little medication

If supportive medication is necessary, doctors often prescribe different preparations for children than for adult patients.

You can find detailed information on this topic in the article Migraine in children.

Migraine: symptoms

The most important migraine symptom is a severe, usually one-sided headache. Other symptoms such as photophobia or noise aversion also occur. In addition, various neurological deficits (also known as aura) can precede or accompany the migraine headache. Migraine headaches are rarely absent.

Migraine symptoms in four phases

  • Pre-phase (prodromal stage)
  • Aura phase
  • Headache phase
  • Regression phase

Symptoms in the preliminary migraine phase (prodromal phase)

Sometimes there are signs hours to two days before a migraine that herald the coming attack. These include, for example

  • Mood swings, changes in mood
  • Cravings or loss of appetite
  • Difficulty reading and writing
  • Increased yawning
  • increased urination (polyuria)
  • Increased thirst (polydipsia)

Migraine symptoms in the aura phase

Visual symptoms: Such visual disturbances are the most common aura symptoms. Sufferers often see a jagged figure, the shape of which is reminiscent of former fortifications (forts) and is therefore called fortification. The zigzag figure spreads slowly to the right or left. While the peripheral zone flickers, a visual field loss (scotoma) can occur in the center – i.e. a black or grey “spot”. In the affected area of the field of vision, the patient can either not perceive objects at all (absolute scotoma) or only to a lesser extent (relative scotoma).

sensory symptoms: After visual disturbances, sensory disturbances in the form of pinprick-like sensations (paresthesias) are the second most common aura symptom. These sensations spread slowly from the point of origin and can eventually affect a greater or lesser part of one side of the body (including the tongue, for example).

Symptoms with regard to speech and/or language

Brainstem symptoms: These are typical signs of migraine with brainstem aura (see above). These include ringing in the ears (tinnitus), double vision, speech and consciousness disorders. In familial hemiplegic migraine, brainstem symptoms are also very often present during the aura phase.

Retinal symptoms: In retinal migraine, the aura includes retinal symptoms such as sudden flickering in front of the eyes, visual field loss and even blindness.

Migraine symptoms in the headache phase

The duration of migraine headaches varies between a few hours and up to three days. The period can change from attack to attack.

Unilateral migraine headaches can change sides of the head during an attack or from attack to attack.

Nausea and vomiting: Nausea and vomiting are common accompanying symptoms of migraines. Scientists suspect that the reason for this is the disrupted serotonin balance in many sufferers. Serotonin is a messenger substance (transmitter) in the body that acts in the brain as well as in the gastrointestinal tract and in many other areas of the body.

Exacerbation through activity: Migraine symptoms can be exacerbated by physical activity, which is not the case with tension headaches – the most common type of headache. Even moderate exercise, such as climbing stairs or carrying shopping bags, can make migraine headaches and discomfort worse.

Migraine symptoms in the recovery phase

Take migraine symptoms seriously

As a general rule, anyone who has frequent migraine symptoms should see a doctor. They can recommend effective measures to treat and prevent migraines.

In some cases, it turns out that the symptoms are not due to a migraine at all, but to another illness – such as a vascular malformation (aneurysm) or a tumor in the brain. These must be treated at an early stage!

Migraine: causes

Genetic predisposition

According to experts, migraine is generally based on a polygenetic predisposition: changes (mutations) in several genes increase the risk of migraine. Some of these genes are involved in the regulation of neurological circuits in the brain.

Others are associated with the development of oxidative stress (increased concentration of aggressive, cell-damaging oxygen compounds). However, the exact biological mechanisms by which these gene mutations promote migraine have not yet been clarified.

Familial hemiplegic migraine (FHM) is not based on genetic changes in several genes, but only in a single gene – it is therefore a monogenetic disease. Depending on the affected gene, there are four subtypes of FHM:

  • FHM1: The CACNA1A gene on chromosome 19 is affected by mutations.
  • FHM2: Here the gene ATP1A2 on chromosome 1 is mutated.
  • FHM3: This is caused by mutations in the SCN1A gene on chromosome 2.

The genes mentioned contain the instructions for components of various ion channels. These are large proteins in the cell membranes that allow electrically charged particles (ions) to pass through the membrane.

Migraine triggers

Various migraine triggers can trigger a migraine attack if there is a genetic predisposition. Which factors “trigger” an attack in individual cases varies from person to person. Here are a few examples:

Changes in the sleep-wake cycle: they can cause a stress reaction in the body and thus become a migraine trigger. People with shift work or long-distance travelers, for example, are affected. The risk of a migraine attack is also increased after a very restless night.

Weather/weather changes: There is no specific “migraine weather” that triggers attacks in all patients. However, many migraine sufferers react sensitively to warm and humid thunderstorm air, strong storms, foehn winds or very bright light on a cloudless day. For some, on the other hand, cold triggers migraine attacks. Changes in climate due to travel (and the associated exertion) can also trigger migraines.

Migraine attacks often start when you have eaten too little (due to hypoglycemia).

Migraine diary reveals trigger factors

To find out your personal trigger factors, you should keep a migraine diary. You should document the following things there:

  • Time of day, duration and intensity of migraine attacks
  • any aura symptoms
  • any other accompanying symptoms
  • drinks and food consumed before the start of a migraine attack
  • physical exertion or stress before a migraine attack
  • other special events before a migraine attack (e.g. long flight, sauna visit)
  • Time and duration of menstruation
  • Hormone intake

These notes can often be used to recognize a pattern and identify personal migraine triggers – for example, if you tend to get a migraine attack after a long, stressful day at work or after drinking alcohol.

There are also ready-made headache calendars for one month at a time, in which the above information can be noted – available from us and from migraine/headache associations:

  • German Migraine and Headache Society: https://www.dmkg.de/patienten/dmkg-kopfschmerzkalender
  • Austrian Headache Society: https://www.oeksg.at/index.php/infos/praxismaterial-kalender

Migraine: What happens in the head?

As mentioned, not only the causes of migraine, but also the underlying disease mechanisms are not yet known in detail. However, there are hypotheses or theories about what happens in the head during a migraine.

How does a migraine headache develop?

  • Nociceptive nerve fibres (specialized for pain stimuli) in the meninges are activated – possibly by signals from the hypothalamus.
  • The activated nerve fibers release neuropeptides (= small proteins that are released by nerve cells as messenger substances). As a result, small inflammations occur and the blood vessels of the meninges dilate. According to current knowledge, the messenger substance CGRP (calcitonin gene-related peptide) plays a key role in this process.
  • The signals travel from the trigeminal ganglion to the brain stem and from there to the thalamus.
  • The signals then travel on to the cerebral cortex, which is where the pain is perceived.

How does the migraine aura develop?

With regard to the development of the migraine aura, many experts today assume a so-called “spreading depression” or “cortical spreading depression”:

Migraine: examinations and diagnosis

If you suspect that you are suffering from migraines, your family doctor is the right person to contact first. They may refer you to a neurologist or a doctor who specializes in headaches.

Taking your medical history (anamnesis)

The doctor will first ask you about your symptoms and any previous illnesses in order to establish your medical history (anamnesis). It is important that you describe your symptoms and their progression as precisely as possible. Frequently asked questions by the doctor during the medical history interview are, for example

  • How often do you have attacks of pain?
  • Where exactly do you feel the pain?
  • How does the pain feel (e.g. pulsating, throbbing, stabbing)?
  • Does the headache get worse with physical exertion?
  • Do other members of your family suffer or have suffered regularly or frequently from headaches?
  • Do you take medication, for example for headaches or for other reasons? If yes, which ones?

If you keep a migraine diary or a migraine calendar (see above) for a while before your visit to the doctor, you will be able to answer these questions particularly well. The doctor may also look at your notes himself.

Physical and neurological examination

A physical examination is generally required to diagnose headaches. Among other things, the doctor will measure your blood pressure, check the mobility of your cervical spine and test whether pressing and tapping on the top of your skull is painful.

In the case of a migraine, such examinations are normally unremarkable outside of an acute attack. If not, there may be another cause for the headache.

Further examinations

The medical history and physical neurological examination are often enough to diagnose a migraine. Only in certain cases are additional examinations necessary – for example, imaging of the head using magnetic resonance imaging (MRI). This may be indicated, for example, if

  • a migraine occurs for the first time over the age of 40,
  • the character of the headache changes or
  • unusual symptoms appear.

Another imaging procedure that can be helpful in certain situations is a computer tomography (CT) scan of the skull. For example, a sudden, severe headache with nausea, vomiting and photophobia may not only be caused by a migraine, but possibly also by a recent subarachnoid hemorrhage (SAH). This form of cerebral hemorrhage can almost always be detected in a cranial CT scan in the first few hours.

Migraine: Treatment

Even if a migraine cannot be cured, the right treatment can significantly reduce the frequency and intensity of the pain attacks. In addition to measures in acute cases, it also includes preventive measures to reduce the frequency of migraine attacks.

Measures in acute cases

The attending physician can also recommend alternatives if a patient does not respond to the analgesics. In such cases, as with (moderately) severe migraine attacks, other medications are chosen for acute therapy – so-called triptans (e.g. sumatriptan, zolmitriptan). If these alone are not effective enough, they may be combined with painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs) such as ASA.

If the headache attack is accompanied by nausea and/or vomiting, so-called antiemetics (metoclopramide or domperidone) can help.

Preventive measures

Various preventive measures can – if applied consistently – significantly reduce the number of migraine attacks and often also reduce their intensity. These include, for example

  • Avoidance of personal trigger factors (e.g. stress)
  • Endurance sports
  • Relaxation techniques
  • biofeedback
  • Psychological pain therapy (e.g. pain management, stress management)
  • Cognitive behavioral therapy if necessary
  • Medication-based migraine prophylaxis if necessary (e.g. beta blockers, valproic acid, topiramate)

Read on to find out how migraines can be prevented and treated in acute cases: What helps against migraines?

Migraine: course of the disease and prognosis

Migraines are a chronic illness that can significantly affect and restrict sufferers in their everyday lives. Some migraine sufferers are even completely incapacitated for a few days during an acute attack.

A glimmer of hope for patients is the fact that the frequency of migraine attacks often decreases with age. In women, migraines can also improve with the menopause. In principle, however, the course of a migraine varies greatly from person to person and is unpredictable.