Migraine headaches are repeated or recurrent headaches, possibly caused by changes in the diameter of the blood vessels in the head. Most people with migraines do not have any warning before it occurs. However, in cases of "classic" migraine headache, a visual disturbance called an aura happens before the headache starts.

Classic migraine is different from "common" migraines (which have no warning sign or aura) or "complicated" migraines (which occur with speech, movement, or other problems in the nervous system).

Migraine headaches are a common type of chronic headache. They affect about 6 out of 100 people.

• Classic migraine accounts for about one-sixth of all migraines.
• Common migraine and other (rare) forms account for the rest.

The causes of migraine are complex and somewhat controversial. One theory is that the symptoms are due to temporary changes in blood vessels. The blood vessels to the brain may become narrow, resulting in less blood flow to the brain. This could be what causes the visual changes before the headache.

Minutes to hours later, the blood vessels dilate (enlarge), resulting in the severe headache. Classic migraine specifically refers to migraines preceded by visual symptoms.

Migraines occur in women more than men, most often between the ages of 10 and 46 years. In some cases, they appear to run in families.

Attacks of migraine headache may be associated with:

• Allergic reactions
• Bright lights
• Loud noises
• Physical or mental stress
• Changes in sleep patterns
• Smoking or exposure to tobacco smoke
• Missed meals
• Alcohol
• Caffeine
• Hormonal fluctuations (related to menstrual cycles or use of birth control pills)
• Other conditions

Foods associated with migraine include:

• Foods containing the amino acid tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, some beans)
• Chocolates
• Nuts and peanut butter
• Fruits (avocado, banana, citrus fruit)
• Onions
• Dairy products
• Baked goods
• Meats containing nitrates (bacon, hot dogs, salami, cured meats)
• Foods containing monosodium glutamate (MSG)
• Any processed, fermented, pickled, or marinated foods

True migraine headaches are not a result of underlying brain tumors or other serious medical problems. However, only an experienced physician can determine whether headache symptoms represent migraine or some underlying medical condition that requires further tests. This assessment can only be made after a review of a patient's history and a thorough neurological examination.

A classic migraine begins with visual disturbances (aura). These warning symptoms may occur anywhere from a few minutes to 24 hours before the headache. The visual changes are common in one or both eyes. They may occur in any combination:

• Seeing zigzag lines
• Seeing flashing lights
• Other visual hallucinations
• Temporary blind spots
• Sensitivity to bright light
• Blurred vision
• Eye pain

Other symptoms that may precede or accompany classic migraine headache include:

• Loss of appetite
• Nausea
• Vomiting
• Chills
• Increased urination
• Increased sweating
• Swelling of the face
• Irritability
• Fatigue

The headache itself is often described as a "pounding" feeling that starts on one side of the head and may spread to the other side. For many patients, the headaches start on the same side each time. Many patients describe pain behind the eye or in the back of the head and neck.

The headache typically begins as a dull ache that progressively worsens over several minutes to hours to the point of disabling pain. The headache may last several hours to days, during which patients are sensitive to light or sound. Patients often wish to rest in a quiet, dark room.

Migraine Treatment   

To learn what may be triggering your migraine headaches, keep a headache diary. Write down:

• When your headaches occurred
• How severe they were
• Additional symptoms
• What you've eaten
• Sleep patterns
• Menstrual cycles
• Any other possible factors

For example, the diary may reveal that your headaches tend to occur more often on days when you awaken earlier than usual. Changing your sleep schedule may then result in fewer migraine attacks.

Some birth control pills and other medications may trigger headaches. Your health care provider should address questions regarding their use.

Even in the absence of a clear factor that triggers migraine attacks, try to keep a regular exercise and sleep schedule. Avoid smoking, caffeine, and alcohol. Some patients have found biofeedback and self-hypnosis to be effective at reducing the frequency of migraine attacks.

Although there is no cure for migraine headaches, numerous medications are available. These medications are used to:

• Prevent migraines from occurring
• Stop the migraine once early symptoms develop
• Treat the symptoms of migraine (e.g., pain, nausea)

All medications have potential side effects and may be incompatible with other medications you are taking. Also, many migraine medications are associated with birth defects and are therefore not safe to use during pregnancy.

Often, a physician will try several classes of medications before one (or a combination) is found to be effective.

Many medications can reduce the frequency of migraines. Generally, these need to be taken daily in order to be effective. These medications are less useful and tolerable to patients with infrequent headaches. Medications in this category include:

• Beta-blockers
  (e.g., propanolol)
• Anti-depressants
  (e.g., amitriptyline)
• Anti-convulsants
  (e.g., valproic acid)
• Calcium-channel blockers
  (e.g., verapamil)
• Serotonin re-uptake inhibitors

Other medications are taken when there is the first sign of an impending migraine attack. In the case of classic migraine, this is typically when visual disturbances are first noted. These medications can effectively stop the migraine in its tracks, preventing the progression to other migraine symptoms or reducing the severity of the attack.

Many of these medications cause constriction of blood vessels and cannot be given to patients at risk of heart attack or other conditions. These medications include:

• Ergots (e.g., DHE-45)
• Serotonin agonists / triptans (e.g., sumatriptan)
• Isometheptene

These medications come in various preparations to enable administration via different routes. For example, patients who experience vomiting and cannot keep pills down may benefit from a nasal spray or injectable dose.

Call for an appointment with your health care provider if taking an ergotamine-containing medication and you are likely to become pregnant (these medications can have serious side effects to a developing fetus).

Other medications are primarily given to treat the symptoms of migraine. Used alone or in combinations, these drugs can minimize pain, nausea, or emotional distress caused by the migraine. Some of these medications may also have some effect on the underlying process in addition to providing symptomatic relief. Medications in this category include:

• Anti-emetics (e.g., prochlorperazine)
• Sedatives (e.g., butalbital)
• Anti-inflammatories (e.g., ibuprofen)
• Acetaminophen
• Narcotic analgesics (e.g., meperidine)

Migraine headaches usually do not represent a significant threat to your health. However, in rare circumstances, people with migraine may be at risk of serious complications. A severe migraine may result in a stroke, possibly due to prolonged constriction of blood vessels. Some people may have side effects of medications. A physician should choose the appropriate medications based on symptoms and other conditions.

Experienced physicians can identify patients who may be at increased risk from these complications and can provide treatment that reduces such risk.

The large number of people affected by migraine has led to extensive research into finding effective treatment. In the future, expect that new medications will continue to be developed.

If a person has any of the following, call for an evaluation by a physician immediately:

• Speech, vision, balance, movement, sensation, and other neurological problems, particularly if the person has NOT had these symptoms with previous headaches
• Loss of consciousness
• A change in headache pattern
• The worst headache in one's life
• Headaches that are more severe when lying down
• A headache that starts extremely abruptly

Such headaches may be the result of stroke, intracranial hemorrhage, aneurysm, or other serious condition and require the immediate attention of a physician.

Depending on the history of the headache, a CT scan or MRI may be done to rule out any of the above conditions.

Also contact your healthcare provider if:

• Previously effective treatments are no longer helpful.
• Side effects of medications occur, including irregular heartbeat, changes in skin color (pale or blue), extreme sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain or cramps, dry mouth, extreme thirst, among others.

Most patients with migraine can identify certain foods that are closely associated with their migraine headaches. To find out which foods are responsible, avoid all of the above-mentioned foods and then gradually work each food back into the diet. An accurate headache diary helps determine which foods may be responsible.

Many people with migraine become familiar with their warning symptoms prior to a headache and may be able to take medication to lessen the oncoming headache.

Reviewed  09-05-2003

What is Migraine?
Is there any treatment?
What is the prognosis?
What research is being done?
Organizations
Related NINDS Publications and Information
Additional resources from MEDLINEplus

What is Migraine?

The pain of a migraine headache is often described as an intense pulsing or throbbing pain in one area of the head. It is often accompanied by extreme sensitivity to light and sound, nausea, and vomiting. Migraine is three times more common in women than in men. Some individuals can predict the onset of a migraine because it is preceded by an “aura,” visual disturbances that appear as flashing lights, zig-zag lines or a temporary loss of vision. People with migraine tend to have recurring attacks triggered by a lack of food or sleep, exposure to light, or hormonal irregularities (only in women). Anxiety, stress, or relaxation after stress can also be triggers. For many years, scientists believed that migraines were linked to the dilation and constriction of blood vessels in the head. Investigators now believe that migraine is caused by inherited abnormalities in genes that control the activities of certain cell populations in the brain.

There are two ways to approach the treatment of migraine headache with drugs: prevent the attacks, or relieve the symptoms during the attacks. Many people with migraine use both approaches by taking medications originally developed for epilepsy and depression to prevent future attacks, and treating attacks when they happen with drugs called triptans that relieve pain and restore function. Hormone therapy may help some women whose migraines seem to be linked to their menstrual cycle. Stress management strategies, such as exercise, relaxation, biofeedback, and other therapies designed to help limit discomfort, may also reduce the occurrence and severity of migraine attacks.

Taking a combination of drugs to prevent and treat migraine attacks when they happen helps most people with migraine to limit the disabling effects of these headaches. Women whose migraine attacks occur in association with their menstrual cycle are likely to have fewer attacks and milder symptoms after menopause.

Researchers believe that migraine is the result of fundamental neurological abnormalities caused by genetic mutations at work in the brain. Investigations of the more rare, familial subtypes of migraine are yielding information about specific genes and what they do, or don’t do, to cause the pain of migraine headache. Understanding the cascade of biological events that happen in the brain to cause a migraine, and the mechanisms that underlie these events, will give researchers opportunities to develop and test drugs that could prevent or interrupt a migraine attack.

American Council for Headache Education

19 Mantua Road
Mt. Royal, NJ 08061
achehq@talley.com
http://www.achenet.org
Tel: 856-423-0258 800-255-ACHE (255-2243)
Fax: 856-423-0082

National Headache Foundation

820 N. Orleans
Suite 217
Chicago, IL 60610-3132
info@headaches.org
http://www.headaches.org
Tel: 773-388-6399 888-NHF-5552 (643-5552)
Fax: 773-525-7357

Related NINDS Publications and Information

NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient's medical history.

Provided by:
The National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda, MD 20892

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If you suffer from migraine headaches, you know how painful and disruptive they can be. You may have been forced to explain to your boss and co-workers why you sometimes need to leave early or take days off from work. You might have missed social events, disappointing family and friends. You have probably tried many medications to try to stop the throbbing pain, nausea, and light sensitivity experienced in a migraine attack. And you may have tried to stop the migraines from happening in the first place by taking a preventative prescription medication.1,2

However, many of the prescription medications commonly used to prevent migraines can also cause troubling side effects including: weight gain, dizziness, low blood pressure, decreased sex drive, dry mouth, nausea, and insomnia. And if you have a co-existing health problem, such as high blood pressure or diabetes, some preventive medicines may actually be dangerous for you to take.2

However, there is very good news regarding migraine prevention. Standardized Butterbur Extract, an all-natural nutritional supplement, can effectively prevent migraines without serious side effects. This powerful herbal extract has been used in Germany for many years to successfully prevent migraines. Now avail-able in America, standardized Butterbur Extract’s effectiveness has been ali-dated in clinical studies. In fact, a recently completed large multi-center study involving hundreds of migraine headache sufferers determined that standardized Butterbur Extract significantly prevented migraine headaches with no serious side effects.3-5

This article we'll discuss migraine headaches and how to prevent them with powerful, all-natural, and safe standardized Butterbur Extract.

Butterbur is the common name of Petasites hybridus, a member of a large family of flowers, herbs, and shrubs. Petasin is one of the key compounds found in Butterbur. It is believed that Butterbur’s beneficial effect for migraine prevention is related to the antispasmodic and anti-inflammatory activity of petasin.6,7 The clinical trials of Butterbur have all used an extract standardized to contain 7.5 mg petasin per 50 mg of the extract, and to be free of pyrrolizidine alkaloids. We will talk more about the importance of a pyrrolizidine alkaloid free extract later in this issue.

According to the Journal of the American Medical Association Migraine Education Center, there are several differences in the two headache types.2 The chart below illustrates the differences:

Migraine headaches are caused by expansion of the blood vessels in the brain and inflammation of the surrounding tissue. While researchers know what happens in the brain during an attack, there is still debate and ongoing research regarding the underlying causes of migraines. Some feel it is related to sudden changes in blood vessel constriction; recently, more focus has been on the electronic changes that are more similar to seizures. Most people with migraines have family members who also have the disorder. Migraines often reoccur, meaning it’s very rare to only suffer with one single migraine headache episode. The attacks tend to become less severe as people get older.1,

Migraine sufferers sometimes have unique symptoms with individual variations. About 20% of individuals who have migraines experience an “aura” prior to an attack. Most auras are visual, appearing as flashing lights or zigzagging lines. These disturbances make it difficult to read a page or see a person's entire face. The disturbance lasts 15 to 60 minutes before fading, only to be followed by a migraine headache.1,2 There are certain foods, events, and changes called “trigger factors” that can initiate migraines. These include dietary factors such as chocolate, alcohol, and skipping meals; sensory triggers such as very bright lights and strong odors; environmental triggers like weather changes; stress triggers such as job loss or divorce; and hormonal factors related to menstruation. Trigger factors are different for each individual with migraine headaches.1,2

Scientists have discovered that standardized Butterbur Extract contains active compounds that not only prevent the blood vessel expansion of a migraine, but also prevent the inflammation, as well.3-5

To see how well standardized Butterbur Extract works for actual migraine suffer-ers, randomized, placebo-controlled, double blind studies have been completed. These types of studies provide the most accurate and verifiable results, and are considered the gold standard for valid scientific conclusions.

One of these studies examined Butterbur Extract standardized to contain 7.5 mg petasin in 58 people who experienced at least 3 migraines a month. The patients received either the standardized Butterbur Extract (50 mg) or a placebo twice a day for 12 weeks.5

Compared to the placebo, standardized Butterbur Extract significantly reduced the frequency of migraine attacks, the number of migraines experienced per month (see figure 1), as well as the frequency of accompanying nausea and dizziness. Patients who took the standardized Butterbur Extract had 46% fewer migraines at the 4th week of the study and 50% fewer migraines after 12 weeks.5

Most importantly, when each groups’ members were asked how they felt during the study, 74% of the patients taking standardized Butterbur Extract stated that it successfully prevented their migraines, compared to 27% of the placebo group.5

The results of a larger study were presented at the 54th meeting of the American Academy of Neurology held recently. Researchers compared Butterbur Extract standardized to contain 7.5 mg petasin to placebo in 202 migraine suffer-ers. On the average, these participants experienced at least 3 migraines a month prior to entering the study.3

Once the individuals were recruited into the study, they stopped taking all of their current migraine medicines. This so-called “washout period” eliminated the possibility of any effect from other migraine treatments.3

The participants were divided into two groups. Half got the standardized Butterbur Extract and half got a placebo. Those in the standardized Butterbur Extract group received either 50 mg twice a day (100 mg total) or 75 mg twice a day (150 mg total). The treatment period of the study lasted 16 weeks.3

The table below represents the number of attacks each group experienced, per month, both at the beginning and at the conclusion of the study.

For the individuals taking 150 mg of standardized Butterbur Extract per day, this meant a 62% reduction in the number of migraine attacks they experienced each month.3

Even more importantly, when the people taking the 150 mg of standard-zed Butterbur Extract per day did experience a migraine, it did not last as long as those people in the placebo group. The average number of days the migraine lasted in the 150 mg group dropped to 1.6 compared to the placebo group who were experiencing 2.2 days.3

Based on the results of these studies, the recommended dosage of standardized Butterbur Extract is 150 mg per day for the first month (which can be taken as 50 mg three times per day), and then 100 mg per day (divided into two doses of 50 mg each) thereafter.

Yes, standardized Butterbur Extract can be taken with other migraine medicines, even prescription medications used to prevent migraine attacks.3,5 Because migraine sufferers often take several medications, standardized Butterbur Extract is an excellent addition to your migraine regimen because it has very few side effects.

However, you need to be patient. Standardized Butterbur Extract prevents migraines from happening, so it takes a little time to be effective. Generally, people see results after 4 weeks.

While the previously discussed studies examined the effectiveness of standard-zed Butterbur Extract as a preventative for people who experienced three or more migraines a month, researchers are also investigating its ability to help people who have migraines once a month or less. Preliminary data suggests that the following dosage is helpful in treating an acute migraine attack. Take 100 mg of the standardized Butterbur Extract as soon as you feel a migraine developing. This is followed by 50 mg of the extract every two hours (but not exceeding 250 mg in one day). On the second day, take 50 mg three times a day.

This method of taking standardized Butterbur Extract is useful even if you only have one or two migraine headaches a year.

To date, there have been no studies that have directly compared feverfew and standardized Butterbur Extract for migraine prevention. However, the studies of feverfew in the prevention of migraines have been mixed.9,10 The double-blind, placebo controlled studies of feverfew reported less effectiveness in migraine attack frequency than were found in the standardized Butterbur Extract studies.11 Feverfew is not nearly as potent as standardized Butterbur Extract.

Butterbur Extract standardized to 7.5 mg petasin is very safe; there are very few side effects. In one of the studies, mild gastrointestinal upset was noted in a few of the patients.

Pyrrolizidine alkaloids, or PAs, are toxic compounds that can harm the liver. Some lab studies have suggested PAs might be linked to cancer. PAs are found in the plant family to which the butterbur plant belongs, so it is essential to make sure the standardized Butterbur Extract you buy is free of PAs.

You should take standardized Butterbur Extract for 4 to 6 months and then stop. Standardized Butterbur Extract continues to work even though you aren’t taking it. If your migraines return, you can once more resume taking the standardized Butterbur Extract for another 4 to 6 month cycle.

According to the Migraine Education Center, migraines affect between 11 to 18 million Americans.1 While there is no known cure, there are treatments available to help manage the problem. Standardized Butterbur Extract is both safe and effective and can be a part of your migraine treatment regimen. You have nothing to lose except the pain.

1. Journal of the American Medical Association. Migraine Information Center. Accessed February 20, 2002. Available at: www.ama-assn.org/special/
migraine/migraine.htm.

2. American Council for Headache Education. Prevention of Migraine Headaches: What Every Patient Should Know. Accessed on February 20, 2002. Available at: www.achenet.org/prevention/.

3. Lipton RB, Gobel H, Wilkes K, Mauskop A. Efficacy of petasites 50 and 75 mg for prophylaxis of migraine: results of a randomized, placebo-controlled study. Der Schermerz 2000;15:S61.

4. Monograph. Petasites hybridus. J Altern Med Rev. 2001;6:207-209.

5. Mauskop A, Grossman WM, Schmidramsl H. Petasites hybridus (Butterbur root) extract is effective in the prophylaxis of migraines: results of a randomized, double blind trial. Headache. 2000;40:420.

6. Mauskop A. Petasites hybridus: ancient medicinal plant is effective prophylactic treatment for migraine. Townsend Letter. May, 2000 (Issue 202).

7. Thomet OAR, Weismann UN, Schapowal A, Bizer C, Simon H-U. Role of petasin in the potential anti-inflammatory activity of a plant extract of petasites hybridus. Biochem Pharmacol. 2001;61:1041-1047.

8. Hamelsky SW, Stewart WF, Lipton RB. Epidemiology of migraine. Curr Pain Headache Rep. 2001;5:189-194.

9. Murphy, J.J., Heptinstall, S., and Mitchell, J.R.A. Randomised double-blind placebo-controlled trial of feverfew in migraine prevention. Lancet. 1988;23:189-192

10. Palevitch, D., Earon, G., and Carasso, R. Feverfew (Tanacetum parthenium) as a prophylactic treatment for migraine: A double-blind placebo-controlled study. Phytotherapy Res. 1997; 11:508-511

11. Ernst E, Pittler MH. The efficacy and safety of feverfew (Tanacetum parthenium L.): an update of a systematic review. Public Health Nutr. 2000;3:509-514.

By The National Library of Medicine

Brain
Headache
Headache
Tension-type headache

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Muscle contraction headache; Benign headache; Headache - tension

A tension headache is a condition involving pain or discomfort in the head, scalp, or neck, usually associated with muscle tightness in these areas.

Causes, incidence, and risk factors   

Tension headaches are one of the most common forms of headache. They can occur at any age, but are most common in adults and adolescents. If a headache occurs two or more times weekly for several months or longer, the condition is considered chronic.

Tension headaches result from the contraction of neck and scalp muscles. One cause of this muscle contraction is a response to stress, depression or anxiety. Any activity that causes the head to be held in one position for a long time without moving can cause a headache. Such activities include typing or use of computers, fine work with the hands, and use of a microscope. Sleeping in a cold room or sleeping with the neck in an abnormal position can also trigger this type of headache.

Other causes include eye strain, fatigue, alcohol use, excessive smoking, excessive caffeine use, sinus infection, nasal congestion, overexertion, colds, and influenza. Tension headaches are not associated with structural lesions in the brain.

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• Headache
• Dull, pressure-like
• Generalized, worse in the scalp, temples or back of the neck
• Not one sided
• Feels like a tight band or vise on the head
• Occurs as an isolated incident (or occurs constantly or daily)
• Worsened or triggered by stress, fatigue, noise, glare, etc.
• Difficulty sleeping

A headache that is mild to moderate, not accompanied by other symptoms, and which responds to home treatment within a few hours may not need further examination or testing. If a neurological examination is performed, a tension headache causes no abnormal findings but musculoskeletal tenderness is often present.

The health care provider should be consulted (to rule out other disorders that can cause head pain) if a headache is severe, persistent or if other symptoms accompany the headache.

Headaches that disturb sleep, occur whenever the person is active, or that are recurrent or chronic may also require examination and treatment by a health care provider.

The goal is to relieve symptoms and prevent future headaches. Prevention is the best treatment. If possible, remove or control precipitating factors.

Learn and practice stress management strategies. Some people find relaxation exercises or meditation helpful. Biofeedback (a means of providing information about certain body functions) may enhance relaxation exercises and may be helpful for chronic tension headache.

Other preventive measures may include keeping warm if the headache is associated with cold, using a different pillow, or sleeping position or similar changes. Use good posture when reading, working, or doing other activities that may cause headache. Exercise the neck and shoulders frequently when typing, working on computers, or doing close work.

Adequate sleep and rest or massage of sore muscles can help reduce the chance that a headache will occur. Hot or cold showers or baths may relieve a headache for some people.

Over-the-counter analgesics such as aspirin, ibruprofen, or acetominophen (NSAID's) may relieve pain if the above measures are ineffective. An antidepressant or other medication may be advised for chronic headache. A non sedating muscle relaxant like Skelaxin helps some patients.

A headache diary can help you identify the source of chronic headaches. When a headache occurs, write down the date and time the headache began. Note what you ate for the preceding 24 hours, sleep pattern and amount of sleep, what was being experienced immediately before the headache, unusual stress or other circumstances, how long the headache lasted, and what made it stop.

Lifestyle changes may be required for chronic tension headaches. This may include adequate rest and exercise, change in job or recreational habits, or other changes.

Tension headaches usually respond well to treatment without residual effects. They are annoying, but not dangerous.

Complications   

• The headache may not be a tension headache, but it may be a symptom of another more serious disorder.
• Rebound headaches may occur from overuse of analgesic medications.

See your health care provider if headaches are severe, persistent, recurrent, or accompanied by other symptoms (such as drowsiness, vision changes, changes in movement or sensation, seizures, changes in alertness, nausea/vomiting or other symptoms).

Also call if headaches disturb sleep, occur whenever your are active, are recurrent or chronic, or if a headache does not respond to treatment.

Avoid situations that may cause a tension headache. This can include keeping warm if the headache is associated with cold, using a different pillow or sleeping position, or similar changes.