A throbbing, recurring headache, typically affecting only one side of the head. Onset is sudden, and pain is usually severe. Visual, auditory, neurological, or gastrointestinal symptoms may appear 10 to 30 minutes before head pain or may accompany the headache. Duration may be from a few hours to several days. True migraine headaches affect approximately 11% of the population and are more common in females than males. True migraine is consistently present with aura, which provides warning of the upcoming attack. Migraines may begin at any age; they are most common between age 10 and 30 and may vanish after age 50 or, in women, after menopause.

Blood vessels to the brain and scalp constrict and then dilate, irritating surrounding nerves and resulting in pulsating or pounding pain with blood flow. The underlying etiology is not known. Possible causes include the following.

• Abnormal blood levels of serotonin, a neurotransmitter that may precipitate vasoconstriction
• Vasoactive medications such as drugs to treat hypertension, angina, and arthritis
• Hypersensitivity to certain foods or odors, missed meals, excessive sun exposure, altered sleep patterns, alcohol consumption
• Menstruation, hormonal changes
• Stress
• Malformed cranial blood vessel (rare)

• Female gender
• Family history of migraine
• History of motion sickness, recurrent vomiting spells
• Patients who chronically suffer from migraine headaches have levels of blood magnesium well below normal levels
• Smoking

The following symptoms may vary between patients but usually remain consistent in individuals.

• Aura preceding headache, irritability, restlessness, hearing or vision disturbances, numbness, weakness, or tingling sensations may precede head pain by 10 to 30 minutes or may be present with headache
• Severe, throbbing, usually unilateral headache
• Headache accompanied by increased sensitivity to light and noise
• Headache persists for hours and if untreated may last days
• Pounding pain worsens with movement or bending
• Nausea, vomiting
• Near-syncope, vertigo
• Feet and hands may be cold and cyanosed
• Scalp arteries may be prominent

• Brain tumor or brain abscess
• Systemic disease
• Meningitis or meningeal irritation
• Seizure disorder
• Encephalitis
• Subarachnoid hemorrhage
• Subdural hematoma
• Hypertension

Patient describes migraine symptoms, without intracranial pathologic changes.

No laboratory tests are available to diagnose migraine. Lumbar puncture to rule out meningitis/encephalitis. Assessment of thyroid function is essential. Headaches, menstrual cramps, constipation, and depression are some of the hidden symptoms of functional hypothyroid, even in the presence of normal thyroid function tests.

Intracranial blood flow changes.

Usually not appropriate. Some migraines can mimic strokes, and cause one-sided numbness or paralysis. The first episode of these types of migraines should be evaluated with an MRI.

• Careful patient history should note characteristics of headache, timing, frequency, duration, and possible triggers.
• Positive response to a migraine drug will confirm diagnosis of migraine.

Treatment varies according to the severity of the migraine attack. Proper use of analgesics should be explained to patients to help prevent rebound headaches from overuse. Cold compresses to forehead and eyes, complete immobility, and minimalization of light, noise, and odor are management approaches.

There is no simple drug of choice.

For mild migraines: Aspirin (600 to 1,000 mg every four hours), ibuprofen (800 mg followed by 400 mg every 4 hours), naproxen (500 mg), and codeine may be sufficient if taken early in attack.

For moderate migraines: NSAIDS, ergotamines (dihydroergotamine—DHE, particularly ergotamine combined with anti-emetic), ergotamine suppositories (1/2 up to 2 suppositories per attack)

For severe migraines:

• First treatment: DHE by subcutaneous, intramuscular, or intravenous injection, or sumatriptan (orally or subcutaneous injection); if an IV line is used, 10 mg IV metoclopramide is recommended. If ineffective after 20 minutes, 0.5 to 1.0 mg of DHE may be added intravenously up to a maximum dose of 2 mg over three hours.
• Other options include: chlorpromazine (0.1 mg/kg intravenously) may be given over 20 minutes and may be repeated after 15 minutes, to a maximum dose of 37.5 mg; saline (5 ml per kg of body weight or 50 mg intramuscularly) should be given to prevent hypotension; prochlorperazine may be given rectally (25 mg), intravenously, or intramuscularly (5 to 10 mg); ketorolac (39 to 60 mg intramuscularly) or dexamethasone (12 to 20 mg intravenously) may be given in resistant cases.

Other treatment options include intranasal lidocaine.

These therapies may be quite useful in decreasing the frequency of migraines. Some homeopathics may be helpful in the acute stage, but most acute migraines require greater pain relief than alternative therapies have to offer. It is often helpful to differentiate migraines in treating them with complementary therapies. Diet and allergy elimination have offered great relief to some. Hormone balancing can be quite helpful for cyclic migraines. Just as the specific symptoms of a migraine are often unique to the individual, the specific treatments that are most effective may be a unique combination for each patient. A combination approach of drugs for pain relief and complementary therapies to reduce recurrence can offer effective management of migraines. Some patients receive significant relief with chiropractic treatment.

Biofeedback: to control vascular contraction and dilation and improve stress management; may influence both the frequency and the intensity of attacks.

• Allergy identification and elimination: Elimination/challenge diets have been shown to effect a 30% to 93% decrease in migraines. Patient eliminates suspected food allergens for two weeks and then reintroduces the foods and/or additives, noting the response. Once the offending agents are identified, they generally need to be eliminated for six months, and then they may be reintroduced. While effective, elimination/challenge diets are more challenging in hormonally influenced migraines. Some common allergens are alcohol (especially red wine), cheese, chocolate, citrus, cow's milk, wheat, eggs, coffee, tea, beef, pork, corn, tomato, rye, yeast, and shellfish. Food additives (preservatives and coloring) and nitrates are also common irritants.
• Caffeine should be avoided due to its vasoactive effects.
• Essential fatty acids (1,500 and 3,000 mg/day) regulate platelet aggregation and arachidonic acid metabolites, and may be very helpful for all migraines. Dietary manipulation includes reducing animal fats and increasing fish. Supplementing with fish or flaxseed oil (1 to 3 mg bid) may also be helpful.
• Magnesium (500 mg/day) minimizes nerve excitability and increases muscle relaxation. Since magnesium-deficient people are more subject to vascular headache, adequate intake from food or supplements is essential. Excess magnesium may cause diarrhea in sensitive individuals. The diarrhea resolves with cessation of magnesium. Patients with a heart block without a pacemaker should refrain from high doses of magnesium.
• Intravenous injection of 1,000 mg of magnesium by a physician can terminate an acute migraine headache within minutes (in up to nearly 100 percent of subjects in some reviews).
• IV injection of folic acid (15 mg) in one study achieved total subsidence of acute headache within one hour in 60 percent, with great improvement in another 30 percent. These two agents are strikingly successful.
• Omega-3 oils (EPA and DHA, average dose 14 g daily) greatly reduce intensity and frequency of migraines.
• Vitamin B2 (riboflavin) (400 mg/day for three months) has been shown to reduce migraine frequency by two-thirds.
• Vitamin C (2,000 mg/day), vitamin E (400 to 600 IU/day), vitamin B6 (100 mg/day), choline (100 to 300 mg/day), and mixed flavonoids (1,000 mg/day) all inhibit the tendency to high platelet adhesion rates in migraine.
• 5-hydroxytryptophan (300 mg bid) works as well as methysergide for prevention of migraine, enhanced by taking with 25 mg of vitamin B6.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Feverfew (Tanacetum parthenium): Studies show that feverfew cuts the frequency of migraines (25% to 70% in some studies); this may possibly be by suppressing the release of inflammatory prostaglandins and histamines. Feverfew also inhibits platelet aggregation. Feverfew helps with both frequency and intensity of migraines. Dose is two fresh leaves daily, dried herb capsules (250 to 300 mg bid), or 30 drops of tincture tid. It may take 2 months to show an effect. Feverfew may be taken in larger quantities to help reduce pain during a headache.
• Jamaica dogwood (Piscidia piscipula): anodyne, antispasmodic, anxiolytic, historic use is specifically for migraines
• Skullcap (Scutellaria lateriflora): sedative, antispasmodic, bitter digestive aid
• Gingko (Gingko biloba): inhibits lipid peroxidation, especially in the brain, prevents cerebral ischemia, stabilizes smooth muscle of blood vessels, affects platelet activating factor (watch with thrombolytics)
• Ginger (Zingiber officinale): anti-inflammatory, anti-emetic, choleretic
• Meadowsweet (Filipendula ulmaria): anti-inflammatory, contains salicylic acid, anti-emetic, astringent
• Total herbal treatment could include feverfew by itself. In addition, a combination of the above herbs may be useful. Dose is equal parts dried herb as a tea—1 cup bid to qid, or a tincture of equal parts 60 drops bid to qid.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until symptoms resolve.

• Iris versicolor for periodic migraines that begin with blurred vision, especially after eating sweets or after relaxing from a mental strain
• Lac defloratum for frontal migraine preceded by an aura of dim vision, marked nausea, vomiting and chills, that may be brought on by milk
• Natrum muriaticum for migraines "like hammers beating the head," that are much better lying down alone in the quiet dark, especially if the migraines are associated with menstruation
• Sanguinaria for right sided migraines that begin in the neck and move up, migraines with vomiting, especially if the vomiting provides some relief

Appropriate regular aerobic exercise—brisk walking, gardening, low impact aerobics, and water aerobics—are among the options that reduce the frequency and intensity of migraine episodes. Chiropractic adjustments and/or craniosacral therapy may be helpful.

May be very helpful, especially in migraines that are hormonally influenced. Acupuncture is one of the most effective treatments for migraines.

Stretching, yoga, massage and other stress management techniques can be quite helpful. Massage may help release chronic neck and shoulder tension that may exacerbate migraines.

Patient should seek medical assistance if headache begins after exercise, straining, coughing, or sexual activity, or is accompanied by changes in mental state or memory, confusion, or sleepiness. A sudden, severe headache may be caused by brain hemorrhage, or if accompanied by stiff neck and fever, meningitis or encephalitis.

• Patient should keep a headache diary to record migraine triggers. Identified triggers should be avoided.
• Antihypertensive drugs including beta-blockers and calcium-channel blockers help prevent attacks in some patients. Begin with low doses and increase if needed: propranolol hydrochloride 40 to 80 mg bid, increasing to 320 mg/day, with a maximum of 640 mg/day; atenolol 50 to 100 mg/day; metroprolol tartrate 100 mg/day, increasing to 400 mg/day; amitriptyline 75 mg/day, increasing to 150 mg/day.)
• Prophylactic antihypertensives are contraindicated with certain illnesses including asthma, chronic obstructive pulmonary disease, insulin-dependent diabetes mellitus, peripheral vascular disease, heart block or heart failure, hypotension, congestive heart failure, arrhythmias, and current or previous depressive illness.

Severe migraine may be so incapacitating it requires emergency treatment.

Migraines start suddenly, sometimes waking patient from sleep, and then usually last several hours but can persist for days. Headaches may occur repeatedly over several weeks or months, then may disappear for weeks or months. Frequency and severity may decrease with age.

Avoid prophylactic antihypertensive drugs and other medications or alternative remedies that are contraindicated during pregnancy.

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