Migraines can cause severe pain and leave a person unable to function for hours or even days.
Sufferers commonly have throbbing or pulsating moderate to severe headaches — usually on one side of the head, though it can be two-sided. “The headaches tend to worsen when people exert themselves — like they go up a flight of stairs,” says Dr. Vincent Martin, a professor in the University of Cincinnati College of Medicine and co-director of the Headache and Facial Pain Center at the UC Gardner Neuroscience Institute. “And they have characteristic symptoms that are associated with the headaches: They get nausea or vomiting or both, sensitivity to light or noise, and the headaches last a characteristic duration — namely, four to 72 hours.”
But there are various types of migraines, and some don’t even seem like migraines at first blush. So experts say it’s important not only to diagnose migraines — which plague about 38 million people in the U.S. alone — but to determine what type a person has, since that can affect treatment and prevention.
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Generally speaking, people experience migraine with or without what’s called aura — visual, sensory or motor symptoms that typically start about an hour before head pain begins. “About 10 to 35 percent of migraine patients have this preceding aura prior to their headache,” Martin says. For those individuals who do have aura, these symptoms occur on average with about 20 percent of episodes, adds Dr. Noah Rosen, director of Northwell Health’s Headache Center in Great Neck, New York.
An example of a visual aura — the most common type of aura people with migraine experience — is scintillating scotoma. “So scintillating is like a twinkling, and a scotoma is a dark area that you can’t see through. That tends to slowly develop over the vision. It’s been described as a rose unfurling across the vision,” Rosen explains. “Another common visual aura is what’s called a fortification spectra — so it looks like the old-fashioned forts — that is, these jagged diagonal lines that occur across the vision.”
Sensory aura is the second most common type of aura, Martin says — which could include numbness of the face, which could continue down a person’s arm into their hand.
Some people also experience motor symptoms associated with migraine, as with a rare and serious type of migraine that’s often confused with stroke called hemiplegic migraine, “which is where people develop paralysis and/or weakness on one side of their body,” Martin says. “The way you differentiate that from a stroke is the symptoms tend to gradually move from one location to another,” he notes. “So you might have weakness of the hand, then it might march up the arm, and then you might get weakness of the face.”
Making this distinction is critical, since some people with hemiplegic migraine are actually mistakenly treated for stroke with clot-busting medication — which carries a serious risk of bleeding. “So if you’re given that unnecessarily, you could actually cause somebody to [be put in] significant danger,” Rosen says.
That also speaks to the critical importance of recognizing that migraines involve far more than head pain. “Migraine’s become synonymous with just a bad headache — and that’s unfortunate, because it’s so much more complicated than that.” says Dr. David Dodick, chair of the American Migraine Foundation, immediate past president of the International Headache Society and a professor of neurology at the Mayo Clinic in Arizona.
The problem is that while treatment has been studied for patients who have typical migraine — and study participants have included those with aura — there’s little data to go on regarding how to treat people with less common types, like hemiplegic migraine.
Medications called triptans are the standard of care for the treatment of migraine pain, but they’re contraindicated — the Food and Drug Administration explicitly states they shouldn’t be used — for patients with hemiplegic migraine, Dodick points out. That leaves doctors to look elsewhere to more novel treatments for some less well-known types of migraine — like a nasal spray in this case. “We normally would never use ketamine nasal spray for any other migraine subtype; but that’s been shown to sort of shorten the duration of those hemiplegic episodes,” Dodick says. “So that might be something we would use in hemiplegic migraine.”
However, experts emphasize that improvised treatment approaches for less common migraine subtypes are just that — and not proven by large clinical trials.
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From a preventive standpoint, verapamil is a medication that’s often used for those who have hemiplegic migraine or an anti-seizure medication might be used, “because the electrical event that occurs in the brain during a hemiplegic episode can be suppressed by anti-seizure medications like Topiramate, Dodick says, adding that heart medicines called calcium channel blockers are sometimes used for prevention as well.
“While the majority of symptoms are experienced from the neck and above — many patients with migraine will describe feelings throughout their body,” Dodick points out.
Another uncommon type of migraine that’s primarily seen in children is called an abdominal migraine. When kids or adults (who can have abdominal migraines, too) develop the pain, it’s typically unexplained. “The pain generally tends to be more in what’s call the epigastric region, which is just right below the breast bone in the upper part of the abdomen,” Martin says. “Sometimes they can have pretty intense nausea as well.”
That can lead to the gastrointestinal equivalent of a wild goose chase, as doctors try to determine the source of the problem.
One revealing tidbit experts advise paying close attention to is a family history of migraine. Share that with your doctor along with any features or symptoms known to be associated with family members’ migraines — as well as unexplained problems, like abdominal pain. “You certainly wouldn’t want to have an exploratory surgery to find out what might be causing your abdominal pain, and you avoid being exposed to medicine for a GI issue that you don’t have,” Dodick says. “It’s all about making an accurate diagnosis and making sure that the treatment that’s delivered is specific for that diagnosis.”
Abdominal migraine is usually treated in the same way that typical migraine is treated, Dodick says. But he adds that there haven’t been any placebo-controlled trials to evaluate the effectiveness of any medication to treat this type of migraine. Experts hope future research will provide a clearer idea of how to treat and prevent this and other uncommon kinds of migraines — like retinal migraine and migraine with brainstem aura.
Unlike a typical visual aura, retinal migraine typically only affects one eye; those with retinal migraine usually experience short-lived diminished vision or even blindness in one eye. Partially or not, “it’s quite frightening, and quite obviously debilitating for patients to lose their vision,” Dodick says — “even though it’s only temporary.”
As for treatment, there’s nothing that’s ever been shown to restore vision during an episode. “What we would do is in patients who also experience head pain during an episode of retinal migraine, we would use nonsteroidal anti-inflammatory drugs, we might use aspirin,” Dodick says. The focus is primarily on prevention, like using a calcium channel blocker to try to prevent attacks of retinal migraines, he says.
As for migraine with brainstem aura, he notes that its name is derived from the fact that many of the symptoms and the signs reflect dysfunction that likely originated in the area of the brainstem — although that’s not known for sure. “So people whose speech becomes slurred, where they’re unsteady on their feet, they may develop vertigo or dizziness; they may experience double vision; their hearing may be affected; they may experience numbness or tingling on both sides of the body,” Dodick says.
As with other types of migraines — the symptoms go way beyond headache pain. “Drugs that we typically would use in patients with hemiplegic migraine, [including] verapamil, acetazolamide, anti-seizure medications … are the same medications that are used in migraine with brainstem aura, by and large,” he says.
[See: Which Practitioner Do I See, and When?]
With any type of migraine, experts reiterate, targeted treatment and prevention starts with getting an accurate diagnosis. “I would probably say that in most cases you’ll start off with seeing your primary physician, getting the appropriate workup,” Martin says. A small group of doctors — perhaps 450 to 500 — are board-certified headache doctors, like Martin. “Many states don’t have any headache doctors whatsoever that are board certified,” he says. So for most people with migraine (if they even know that’s what it is), if the issue is more complicated, it will be referred on to a local neurologist. “Then if they can’t figure it out, it would be probably on to a headache doctor,” Martin says.
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