Migraine is among the most frequent headache disorders in Germany and throughout the world. About 10-15% of the population suffers from migraine. Migraine can start in childhood. In children, migraine attacks are often less distinctive and shorter than in adults. Abdominal pain, nausea or dizziness may be the main symptoms. Before puberty, migraine affects boys and girls similarly. After puberty, three times more women than men suffer from migraine. Most often, migraine starts between 20 and 30 years of age. In many patients, there are significant fluctuations of migraine activity during lifetime, with good times and bad times. Often, migraine activity is highest between 40 and 50 years of age. In old age, migraine often becomes less frequent and less severe, and sometimes stops altogether. Most often, migraine is an episodic disease with recurrent attacks that may occur several times a month but usually not several times a week.

A small proportion of patients suffer from the chronic form of migraine. In this case, headache is present on 15 days per month or more, with typical migraine characteristics on many but not necessarily all of these days. Chronic migraine can be diagnosed only when there is no concomitant overuse of acute headache medication or if headache does not improve after withdrawal of acute headache medication.

How do I recognize a migraine attack?

Migraine is characterized by recurrent headache attacks. Migraine headache is often unilateral but in some cases may be bilateral. The pain is described as dull and pressing and usually becomes stabbing or throbbing with physical activity. Pain intensity is usually high enough to lead to a significant impairment in daily life. In adults, migraine attacks last for a few hours up to 3 days if not treated. Rarely, migraine attacks may last longer than 3 days. Migraine has typical accompanying features, such as nausea, vomiting, increased sensitivity to light, sounds and odours. Many migraine patients experience fatigue during their attacks. They are pale and want to be alone, preferably to lie down in a quiet, dark room. Sleep is often experienced as helpful.

What does migraine aura mean?

15-25% of migraine patients experience an aura, mostly before the headache starts. The aura is characterised by neurological symptoms, particularly visual disturbances with scintillations (flickering) or scotomas (parts of the visual field are missing). There may also be sensory disturbances on one side of the body or speech difficulties. Typically these symptoms develop slowly over minutes and regress within one hour. Many patients suffer from migraine attacks both with and without aura.

What is the cause of migraine?

Migraine is a disorder of the brain. During a migraine attack, pain-processing brain areas are activated and pain-related signalling molecules (neurotransmitters and neuromediators) are released. These signalling molecules lead to a sterile inflammatory reaction of the blood vessels in the meninges. The normal pulsations of the blood vessels then lead to stretching of the inflamed vessel wall, explaining the typical throbbing character of migraine headache. According to current knowledge, there is also a genetic predisposition for migraine. The brain of predisposed persons reacts to certain triggers or stress situations with a migraine attack. About two thirds of migraine patients have family members who also suffer from migraine attacks.

How is migraine treated?

Principally, one has to distinguish between treatment of the attack itself and preventive treatment. There are both pharmacological and non-pharmacological methods of migraine therapy. During the attack, common painkillers such as acetylsalicylic acid or ibuprofen are used, in combination with antiemetics (drugs to treat nausea) if necessary. Moreover, there are also migraine-specific drugs, so-called triptans. Most triptans are prescription drugs. All acute migraine drugs work best when taken early in the attack. Painkillers may not work when taken during the aura phase. Triptans should not be taken during the aura phase for safety reasons. In order for the acute medication to be most effective, it is recommended that patients take a break and lie down if possible. However, all painkillers, including triptans, may also lead to worsening of migraine when taken too regularly over a longer period of time. Therefore, common painkillers must not be taken on more than 10 to 15 days per month. Triptans must not be taken on more than 8 to 10 days per month.

If migraine attacks occur more than 3 or 4 times per month, or regularly last for more than three days, or do not react well to acute therapy, a preventive treatment (migraine prophylaxis) should be started. Daily intake of preventive medication may reduce migraine frequency and severity. This is sometimes the only way to prevent frequent intake of painkillers or triptans. The drugs used for preventive migraine treatment are drugs that are also used for treatment of arterial hypertension or epilepsy. Dietary supplements or magnesium may also be useful in selected patients. It is important to know that the effect of a preventive treatment may set in only after 4-6 weeks. The goal of preventive treatment is a reduction of migraine attacks by at least 50 %. It is usually not possible to completely stop migraine using preventive treatment. An effective preventive treatment should be continued for at least 6 to 9 months. After that, dose reduction and ultimately discontinuation of the drug can be attempted.

What can be done for non-pharmacological migraine treatment?

Non-pharmacological methods play an important role in reducing the frequency and severity of migraine. Scientific evidence indicates that migraine can be reduced by regular physical exercise, especially in the form of endurance sport and by muscle relaxation training. Biofeedback may also be helpful. Many patients know that there are certain factors, such as lack of sleep, irregular meals, dehydration or stress, that trigger their migraine attacks. In these cases behavioural interventions, such as cognitive behavioural therapy with the goal of stress reduction, may be very effective in reducing the number of migraine attacks.