Migraine: What Causes It, What Stops It, and How to Prevent the Next One

Migraine is one of the most common and most undertreated neurological conditions in the world. It affects approximately one billion people globally, is the second leading cause of disability worldwide, and is ranked among the top ten most disabling diseases by the World Health Organization. Despite this burden, the majority of people with migraine have never received a diagnosis and are managing attacks with over-the-counter painkillers that are either inadequate for their migraine severity or, used too frequently, contributing to medication overuse headache. As a neurologist, the patients I see with migraine who have been most transformed by treatment are those who previously thought they "just get bad headaches" and did not know that migraine was a treatable neurological disorder with specific, effective therapies.

What Migraine Is

Migraine is a neurological disease characterized by recurrent episodes of typically moderate to severe head pain, usually unilateral and pulsating, accompanied by nausea, vomiting, or sensitivity to light and sound. An attack lasts between four and 72 hours without treatment. The condition is driven by abnormal excitability of the trigeminal pain pathways and the release of neuropeptides including calcitonin gene-related peptide (CGRP), which produces the painful vasodilation and neurogenic inflammation of the meningeal blood vessels that characterizes a migraine attack.

Migraine with aura, present in approximately 25 to 30 percent of migraine sufferers, includes neurological symptoms preceding the headache by 20 to 60 minutes. Aura symptoms are fully reversible and include visual disturbances (the most common type: zigzag lines, blind spots, flashing lights), sensory changes (tingling spreading from one hand up the arm and to the face), and speech difficulties. The aura reflects a slowly spreading wave of cortical depolarization called cortical spreading depression. Migraine with aura is associated with a slightly elevated risk of ischemic stroke, particularly in women who smoke and use estrogen-containing contraception; this combination should be avoided.

Phases of a Migraine Attack

Understanding that migraine is a four-phase process helps both with recognition and with treatment timing. The prodrome, beginning one to two days before the headache, involves subtle changes including mood shifts (depression or euphoria), food cravings, yawning, neck stiffness, and increased sensitivity. Recognizing the prodrome allows early treatment, which significantly improves outcomes. The aura phase, in those who experience it, produces the neurological symptoms described above. The headache phase is the most disabling period. The postdrome, lasting up to 48 hours after the pain resolves, involves fatigue, cognitive difficulties, and a washed-out feeling that patients sometimes describe as a headache "hangover."

Common Triggers

Migraine triggers lower the threshold for an attack in susceptible individuals rather than causing attacks directly. The most commonly reported triggers include hormonal changes (menstruation is the most consistent trigger in women; the fall in estrogen before the period is the specific driver), sleep changes (both too little and too much sleep), stress and stress relief (the "let-down" migraine at the start of a weekend is classic), dehydration, skipped meals, alcohol (particularly red wine), strong odors, bright or flickering lights, and weather changes.

Trigger avoidance is helpful but should not be obsessive: excessive trigger-avoidance can become debilitating and paradoxically increase migraine susceptibility by heightening anxiety around potential exposures. The goal is to identify and address modifiable high-yield triggers while building pharmacological prevention that reduces the underlying sensitivity.

Acute Treatment

NSAIDs and Combination Analgesics

For mild to moderate attacks, NSAIDs (ibuprofen 400 to 600 mg, naproxen sodium 550 mg, aspirin 900 mg) taken early in the attack before the pain fully establishes are effective for many patients. Fixed-dose combinations containing aspirin, acetaminophen, and caffeine also have good evidence. Gastric stasis during migraine slows oral drug absorption; taking an antiemetic such as domperidone or metoclopramide alongside oral analgesics improves absorption and addresses nausea.

Triptans

Triptans are selective serotonin 1B/1D receptor agonists that abort migraine attacks by constricting meningeal blood vessels and blocking CGRP release. They are the standard acute treatment for moderate to severe migraine and are highly effective when taken early in the attack before central sensitization establishes. Multiple triptans are available (sumatriptan, rizatriptan, eletriptan, naratriptan, among others) and they differ in onset of action, duration, and route of administration. When an oral triptan is insufficient, subcutaneous sumatriptan (fastest onset) or nasal spray formulations are alternatives. Triptans should not be used more than 10 days per month to avoid medication overuse headache.

CGRP Receptor Antagonists (Gepants)

Rimegepant and ubrogepant are newer acute treatments targeting the CGRP pathway directly. They have the advantage over triptans of not causing vasoconstriction, making them appropriate for patients with cardiovascular disease where triptans are contraindicated. They also do not appear to cause medication overuse headache when used frequently, which has made them useful as both acute and preventive treatment (rimegepant has evidence for alternate-day dosing as prevention).

Anti-emetics

Prochlorperazine, metoclopramide, and domperidone address nausea and also have independent analgesic effects in migraine. In the emergency department, IV or IM metoclopramide or prochlorperazine are frequently effective even without a triptan.

Prevention

Preventive treatment is indicated when attacks occur four or more days per month with significant disability, when acute treatments are overused, or when attacks are severely disabling regardless of frequency. The goal is to reduce attack frequency, duration, and severity. Only approximately 13 percent of patients who meet criteria for preventive treatment are currently receiving it, representing a major treatment gap.

CGRP Monoclonal Antibodies

Erenumab, fremanezumab, galcanezumab, and eptinezumab are monthly or quarterly injections or infusions targeting the CGRP pathway. They have transformed preventive migraine treatment with efficacy rates of 40 to 60 percent reduction in monthly migraine days in clinical trials, rapid onset (within weeks), minimal side effects, and convenient dosing. They are now considered first-line preventive treatment for episodic migraine and are the standard of care for chronic migraine (15 or more headache days per month).

Traditional Preventive Medications

Beta-blockers (propranolol, metoprolol), amitriptyline (a tricyclic antidepressant), topiramate (an anticonvulsant), and valproate are the older first-line oral preventive options with established evidence. They are less well-tolerated and have more side effects than CGRP antibodies but remain widely used due to cost and access considerations. Candesartan and lisinopril (antihypertensives) have evidence particularly for patients with comorbid hypertension. Magnesium supplementation has modest evidence and an excellent safety profile.

Lifestyle as Prevention

Regular sleep schedule (consistent wake time seven days per week), regular meals and adequate hydration, aerobic exercise three to five times per week, and stress management all reduce migraine frequency as part of a comprehensive approach. These are not alternatives to medication in moderate to severe migraine; they are adjuncts that enhance medication effectiveness.

Menstrual Migraine

Migraine occurring specifically around menstruation, driven by the drop in estrogen before the period, is particularly treatment-resistant to standard acute therapy. Strategies include taking an NSAID or triptan for three to five days starting two days before the expected period (short-term prevention), using a CGRP antibody prophylactically, or in women using hormonal contraception, adjusting the regimen to minimize estrogen fluctuation.

When to Seek Emergency Evaluation

Most migraines, while severely painful, are not medically emergencies. However, certain headache features warrant immediate evaluation: a thunderclap headache (the worst headache of your life, reaching peak intensity within seconds), headache with fever and stiff neck, headache with neurological symptoms that do not follow the typical gradual aura pattern, headache in someone over 50 with a new pattern, or headache following head trauma. These features may signal subarachnoid hemorrhage, meningitis, or other serious conditions requiring emergency evaluation.

When to See a Doctor

If headaches are occurring more than four days per month and significantly affecting your functioning, or if you have never been formally diagnosed and evaluated, speaking with a neurologist or a physician experienced in headache management is appropriate. Effective treatment can dramatically change quality of life for migraine sufferers. JourneyDoctors neurologists and GPs can evaluate your headache pattern and discuss appropriate treatment options. Consultations start at $19.

Disclaimer: This article is for educational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment of any medical condition.

Frequently Asked Questions

Is migraine genetic?

Yes. Migraine has a strong hereditary component. Approximately 60 percent of migraine sufferers have a first-degree relative with migraine. Several genetic variants associated with neuronal excitability and pain processing have been identified, though migraine is polygenic rather than caused by a single gene. Familial hemiplegic migraine, a rare subtype with motor aura, follows a more direct Mendelian inheritance pattern.

Can migraine cause permanent brain damage?

Recurrent migraine, particularly migraine with aura, has been associated in imaging studies with small white matter lesions, but the clinical significance of these findings is uncertain and they are not associated with cognitive decline or functional neurological deficits in the vast majority of cases. Migraine itself does not cause strokes in otherwise healthy individuals, though migraine with aura is an independent (modest) risk factor, particularly in women who smoke or use estrogen-containing contraceptives.

What is medication overuse headache?

Medication overuse headache (MOH) develops when acute pain medications are used too frequently, typically more than 10 to 15 days per month depending on the medication type. The brain becomes sensitized to pain signals, and headache becomes more frequent and difficult to treat. Triptans and opioids carry the highest risk. MOH is one of the most common causes of chronic daily headache and requires a supervised withdrawal from the overused medication, which initially worsens headache before improving it.

Can children have migraines?

Yes. Migraine is common in children, though it often presents differently than in adults. Pediatric migraine may be bilateral rather than unilateral, shorter in duration, and more strongly associated with nausea and vomiting. Many adults with migraine report their first episodes in childhood or adolescence. Diagnosis in children is based on the same criteria adjusted for pediatric presentation, and several preventive and acute treatments are available and evidence-based for pediatric use.

Does caffeine help or worsen migraines?

Caffeine has a complex relationship with migraine. In small amounts, caffeine can enhance the effectiveness of analgesics in acute migraine (this is why acetaminophen-aspirin-caffeine combinations are effective). However, regular high caffeine intake can increase migraine frequency, and caffeine withdrawal is itself a migraine trigger. People with frequent migraine should moderate their caffeine intake to minimize withdrawal effects and avoid using caffeine as a regular acute treatment.