Dec. 5, 2024 – It can often start with fatigue. Then come the spots of color in your vision. Next thing you know, an unrelenting, throbbing head pain takes effect, which can last hours, or even days. The only thing you need right now is a dark, quiet room. Even after the pain fades, you may have a “migraine hangover,” or lingering fatigue and trouble concentrating. You’ve just had a migraine episode, a hallmark sign of a migraine disability.
"I think of [a migraine] as a ‘headache plus,’ ” said Elizabeth Loder, MD, a neurology professor at Harvard Medical School. And while the headache can be the most noticeable part of migraine, patients may also have other symptoms, with nausea, vomiting, and sensitivity to light and noise being the most common.
Despite the severe pain and discomfort, many who have migraine episodes are used to others doubting their symptoms.
“There's a lot of stigma around people who live with disabilities, and when those disabilities are invisible and cannot be seen externally, that stigma can be highlighted and augmented,” said Rashmi B. Halker Singh, MD, an associate professor of neurology at the Mayo Clinic in Scottsdale, Arizona. “As a clinician, I think one of my important jobs is really to validate that patient's experience and to let them know that what they are experiencing is a real neurologic condition.”
Migraine is a major public health concern that affects about 1 in 5 women and 1 in 15 men, according to Andrew Charles, MD, a neurology professor and director of the UCLA Goldberg Migraine Program. While about 10% of adolescents also have migraine, the illness usually peaks around middle age.
“People share with me the impact migraines have on their quality of life and their ability to work in the workplace, to the impact it has on school, relationships that are meaningful to them, parenting, and all kinds of other aspects,” said Singh, who is on the executive board of directors of the American Headache Society.
Migraine is a largely genetic disorder that can be made worse by things in the environment, the experts said.
“It often runs in families, and we know that certain genes increase the likelihood of developing migraine or having frequent migraines,” said Loder. “Most of the genes that have been found cause changes in brain functions that make it easier for a migraine to happen.”
If you have one of these genes, things like not getting enough sleep or skipping meals can trigger headaches.
“We know that hormonal changes that occur with menstrual cycles can play a role,” Loder said. “Many women with migraines notice that headaches are more common right around their menstrual period.”
Know What to Do
It’s important to have effective strategies in place before a migraine attack hits.
“For many people, if migraine develops when they are tired or haven't eaten, simple approaches like resting or eating can help,” said Loder. “For many patients, however, attacks are best treated by using effective medications early, before the headache has time to build up, when it can be more difficult to treat.”
Migraine treatments are often divided into two categories: acute therapies (those taken after a migraine attack to help shorten or relieve pain) and preventive therapies (treatment taken regularly to try to prevent future attacks), Charles said.
Acute therapies are recommended for all people with migraines.
“The first-line therapies for acute treatment of migraine are those in the class of medications called the ‘triptans,’ ” said Charles. “All of them are effective, migraine-specific treatments, but each may work differently in different individuals.”
Most people tolerate the medications well, although some say the drugs make them lightheaded.
Other types of first-line treatments are called nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen.
Preventive treatments are often recommended if a migraine happens more than four days per month.
Newer medications to prevent migraine include onabotulinumtoxinA (Botox), which is only recommended for people who have 15 or more headache days per month, Charles said.
There are other new prevention drugs that can be very effective, he said, but they are difficult to find.
The Pain Is Real
People who write off migraine pain as an “exaggeration” are often either misinformed or uneducated about how severe this illness is, said Vladimir N. Kramskiy, MD, a neurologist and director of the Ambulatory Recuperative Pain Medicine Program at the Hospital for Special Surgery in New York City.
“I can only imagine if somebody even had a moderate headache at any one point in time would they realize how disabling migraines can be,” Kramskiy said. “I think this requires significant education on the part of the general public about migraines in terms of loss of productivity, and the kind of social ostracization that can happen regarding not being able to spend time with family and friends.”
Another tip for when people downplay your migraine pain is comparing the experience to other “invisible illnesses,” such as high cholesterol or diabetes. These diseases may not have an outward appearance, but this doesn’t make them any less severe, noted the experts.
But also keep in mind: It’s not your job to educate everyone who questions your experience with migraines, especially to protect your own mental and emotional health, said Singh.
“Not everyone is able to understand what a person is experiencing, and it's OK to just set boundaries,” she said. “It's really important to make sure that we each have a community that understands us and supports us.”
