Migraines are severe headaches. They are usually on one side of your head and can also make you sensitive to light and noise. You can also have nausea (feeling sick) and vomiting (being sick) with a migraine.
Key points about migraine
- About one in 10 people get migraines, with more women affected than men.
- Migraines usually first occur between 10 and 30 years of age, and may get better in middle age.
- If you are over 50 and a severe headache occurs for the first time, see your doctor.
- Some people have a ‘migraine aura’ before the headache begins. This could be problems with your eyes (eg, seeing zig-zag lines), dizziness or pins and needles.
- Treatment includes lifestyle changes and using medications for relief or, in some cases, to stop a migraine from happening.
- See your doctor if treatments are not helping or if your migraines are happening more often or getting more severe.
What causes migraine?
The exact cause of migraines is still being studied but it could be partly genetic. People with migraines often find that others in their wider family have also had migraines.
What are the triggers for migraines?
Triggers are the things that can cause migraine. Learning what triggers your migraine and finding ways to avoid or reduce these triggers is an important part of managing your migraine.
There are many different trigger factors that may start a migraine. Keeping a diary about when you get migraines and what may have started them is a useful way to work out your triggers.
Triggers can include one or more of the following:
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- stress, anxiety or depression
- tiredness
- hunger (missing meals)
- not drinking enough water (dehydration)
- exercise (especially heavy exercise when unfit)
- hormonal changes in women (taking the contraceptive pill, having your period, going through menopause)
- excess caffeine from coffee, tea, caffeinated energy drinks
- alcohol (especially red wine)
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- changes in sleep patterns (lack of sleep or oversleeping)
- relaxation following stress such as on weekends or holidays
- long distance travel
- changes in the weather or temperature
- strong smells, loud noise, bright or flickering lights
- some medicines used for other conditions (eg, some angina medicines, the contraceptive pill, hormone therapy)
- overuse of pain-relieving medicines (can cause rebound headaches).
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Some foods such as chocolate, brown vinegar, cheese, citrus fruits, onions and MSG (monosodium glutamate) can be a trigger for some people. Food may be considered a trigger for migraine if an attack occurs within 6 hours of eating and you don't get migraines when you don't eat that food.
Women and migraine
Female hormone fluctuations, the oral contraceptive, menopause and pregnancy may affect migraine.
- Migraine often happens around menstruation or at other regular times of the menstrual cycle (menstrual migraine).
- Many women find migraine disappears during pregnancy.
- Oral contraceptives containing oestrogen may change migraine frequency.
- Some women get migraines during menopause.
Non-migraine headache is also a common feature of pre-menstrual syndrome.
What are the symptoms of migraine?
Some people notice a migraine aura before the headache starts, and this can alert them that a migraine is coming. The symptoms of an aura may be different for everyone. Examples include:
- feeling tired, fatigue
- repetitive yawning
- restless or irritability
- anxiety
- food cravings, feeling hungry or thirsty
- difficulty concentrating
- sensitivity to light or sound
- problems with vision (seeing zig-zag lines)
- dizziness
- tingling or numbing feelings in your body.
When the headache starts, it is a strong pain, usually on one side of your head. You may feel sick or vomit, get tingling around your mouth, have trouble talking or feel dizzy or weak.
How are migraines diagnosed?
The following are common with migraines and don't usually happen during a tension headache:
- aura
- headache on one side
- high sensitivity to light and noise
- nausea or vomiting.
These symptoms are very particular to migraines. Your doctor may do other tests if they are concerned the headaches may have another cause. However, migraines are not a sign of a stroke or a tumour, and your doctor will reassure you of this.
How are migraines treated?
Migraine can't be cured but you can relieve symptoms during an attack and prevent further attacks. Migraines vary between people and so does the treatment. Some things are commonly known to trigger migraines in some people. Avoiding these triggers can reduce how often and how severe your migraines are.
Medicines
Medicines for the treatment of migraines fall into a few categories:
- Pain-relieving medicines, which are taken during the migraine attack to help stop symptoms that have already begun.
- Medicines for nausea (feeling sick) or vomiting (being sick).
- Medicines to prevent migraines, which are taken regularly to reduce how often and how severe migraine are.
The type of medicine you need depends on many things, including how often, severe and disabling your migraines are. Your doctor will advise you on the best treatment based on your symptoms and experience. The usual approach has 3 steps:
- Step 1: Pain relievers such as paracetamol and NSAIDs such as ibuprofen, diclofenac, naproxen.
- Step 2: Triptans.
- Step 3: Combination treatment with a triptan and an NSAID.
Anti-sickness medicines may be used at any step to relieve nausea associated with migraine and can help the absorption of pain-relieving medicines (if taken before or at the same time). Examples of anti-sickness medicines include metoclopramide, domperidone and prochlorperazine. Read more in-depth about medicines for migraine.
Examples of medicines to treat migraine |
Description |
Painkillers
- paracetamol
- ibuprofen
- diclofenac
- naproxen
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- These medicines are most effective when taken early in an attack, before severe pain and nausea have set in.
- Pain relievers may not be effective once severe migraine has set in.
- Read more about medicines for migraine.
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Anti-sickness medicines
- metoclopramide
- domperidone
- prochlorperazine
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- These medicines relieve nausea associated with migraine and can help the absorption of pain relieving medication (if taken before or at the same time).
- Get medical advice before taking anti-sickness medicines as they are not suitable for some people.
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Triptans
- sumatriptan
- rizatriptan
- zomitriptan
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- Triptans are specific pain relieving medicines for migraine.
- They are available as tablets, injections and nasal sprays.
- They work by releasing a chemical in the brain called serotonin, and this causes the blood vessels around your brain to contract (narrow). This reverses the dilating (widening) of blood vessels that are believed to be part of the migraine process.
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Ergotamine
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- Ergotamine is only for people who have recurring migraines that cannot be managed by other medications.
- They have many side effects including nausea, vomiting, abdominal pain and muscle cramps.
- They should not be used more than twice per month.
- In New Zealand it is combined with caffeine and is available as Cafergot.
- Cafergot can cause serious effects on your heart and arteries, especially in older people.
- If you suspect you have had an adverse reaction to Cafergot or any other medicine, report it to the Centre for Adverse Reactions Monitoring (CARM).
Note: Cafergot is no longer available in New Zealand (from 1 May 2020).
- Talk to your doctor about alternative treatment options if you are currently taking Cafergot.
- Don't stop taking your medicine before talking to your doctor.
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Caution – medication overuse headache
Medication overuse (or rebound) headache can happen from using too many pain relievers to treat headaches and migraines. It may feel like a tension-type headache or migraine-like attack.
Headaches often improve within 2 to 4 weeks of withdrawal of the overused medicine but can feel worse before improvement is seen. To avoid this:
- triptans should not be used for more than 10 days per month
- paracetamol and NSAIDs should not be taken for headache on more than 15 days per month.
What self-care can I do when I have a migraine?
Here are some simple measures that you can try to ease your symptoms.
- Lie in a quiet, cool, dark room.
- Avoid moving around too much.
- Put a cold flannel on your neck or forehead.
- Avoid drinking tea, coffee or orange juice.
- Try to relax by listening to music or through meditation.
- Don't read, watch TV or drive.
- Sleep through the attack.
How can I prevent migraines?
Not all migraines have an obvious trigger, but sudden changes in daily routine can be a trigger. This includes a missed meal, a late night or doing more strenuous exercise than you normally do.
To reduce your chance of getting a migraine you may find it helpful to make the following lifestyle changes:
- have regular meals
- make sure you drink enough water/fluid to stay hydrated
- do relaxation and exercises for stress (eg, meditation and yoga)
- aim for a regular sleep pattern and ensure you have enough sleep (but avoid long sleep-ins)
- avoid sudden strenuous exercise
- limit caffeine intake, such as no more than 2 cups of coffee a day.
Addressing other conditions that may be causing your migraines is also important. These include stress, anxiety, depression, hormonal changes and head or neck trauma. If these are problems, talk to your doctor. They may be able to help you work out how to manage these things.
Cognitive behavioural therapy (CBT), coping strategies and relaxation training are helpful for many people with migraine especially if they are associated with anxiety or stress.
Preventive medicines
Preventive medicines are taken daily to prevent migraines from happening. They are not used to treat a migraine attack. Medicines to prevent migraines are an option if you:
- have at least 2 migraine attacks a month
- have significant disability despite suitable treatment for migraine attacks
- cannot take suitable treatment for migraine attacks.
Preventative medicines aim to reduce how long and severe your migraines are and how often you get them. They can help to reduce disruption to your daily activities that happens with migraine, and reduce overuse of pain relief medications. They must be taken every day to work well. They may take a few weeks to start working. Read more about preventive medicines for migraine.
What happens if a migraine is not treated?
You will keep having headaches but will not come to any harm. Migraines are likely to happen again and again.
Support
Migraine Down Under Blog with New Zealand-specific support and resources.
Learn more
The following links provide further information about migraine. Be aware that websites from other countries may have information that differs from New Zealand recommendations.
Migraine Neurological Foundation, NZ
A patient's guide to Migraine Dr Jon Simcock, Medical Adviser, Neurological Foundation, NZ
Living with migraine The Migraine Trust, UK
Range of topics American Migraine Foundation
References
- Cafergot tablets to be prohibited 1 May 2020 Medsafe, NZ, 2019
- The role of triptans in the treatment of migraine in adults BPAC, Z, 2014
- Medication-overuse headache BPAC, NZ, 2008
Reviewed by
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Angela is a pharmacist in the Quality Use of Medicines Team at Waitematā District Health Board. She has experience in hospital pharmacy in New Zealand and in the UK, and was previously a medical writer for Elsevier in The Netherlands. Angela is interested in promoting the safe use of medicines, particularly high-risk medicines.
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What are the different medicines for migraine?
Medicines for migraines fall into a few categories.
Pain-relieving medicines
These are taken during migraine attacks, for immediate relief, to stop symptoms that have already begun. Pain relievers are most effective if taken at the first signs of a migraine attack, as this gives it time to absorb into your bloodstream and ease your symptoms. The choice of pain relief depends on the severity of your migraine and your response to the treatment. A usual approach is:
- Step 1: paracetamol and/or NSAIDs
- Step 2: triptans
- Step 3: combination treatment with a triptan and an NSAID.
Paracetamol
Paracetamol can be an effective pain reliever, especially for mild symptoms, either when used alone or in combination with other medicines, such as:
- paracetamol + ibuprofen (Maxigesic®, Nuromol®)
- paracetamol + caffeine (Panadol Extra®, Panadol Extra with Optizorb®)
- paracetamol + codeine (Panadeine ®, Panadeine Extra ®, Panadeine Plus ®).
Paracetamol is mostly a safe option if you don't take more than 4 grams per day. Too much paracetamol can harm your liver and may cause severe liver damage. Accidental overdose can happen because many different products include paracetamol, so if you are taking more than one medication, make sure you check the label for ingredients. Read more about paracetamol.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Examples of NSAIDs include ibuprofen, diclofenac and naproxen. Some people find one form of NSAID more effective than another, so it's worth trying different ones to find the one that is best for you. NSAIDs usually need a prescription from your doctor, although you can buy some in small quantities over the counter in smaller doses. There are risks associated with taking NSAIDs.
- The main risk is stomach problems such as indigestion, stomach upset and stomach ulcers.
- Extra care is needed if you have high blood pressure, high cholesterol, or diabetes or if your kidneys do not work very well, you smoke, have cardiovascular disease (heart disease) or vomiting and diarrhoea. NSAIDs increase the chance of a heart attack or stroke, which can lead to death.
- Some medicines interact with NSAIDs, and they should not be taken together.
Check with your doctor or pharmacist if NSAIDs are a safe option for you.
Triptans
If paracetamol or NSAIDs don't help to relieve your migraine symptoms, you may be prescribed triptan medications such as rizatriptan, sumatriptan or zolmitriptan. These are available as tablets, injections and nasal sprays.
Triptans are a specific pain reliever for migraine headaches. They work by releasing a chemical in the brain called serotonin, and this causes the blood vessels around the brain to contract (narrow). This reverses the dilating (widening) of blood vessels that's believed to be part of the migraine process.
Common side effects of triptans include warm sensations, tightness, tingling, flushing and feelings of heaviness in the face, limbs or chest. Some people also experience nausea, dry mouth and drowsiness. These side effects are usually mild and improve on their own.
Read more about triptans, including sumatriptan tablets, sumatriptan injection and rizatriptan.
Avoid opioids - choose wisely
Many people with migraine are given strong painkillers, called opioids, to treat migraines. Examples of opioid painkillers available in New Zealand include codeine, tramadol, morphine, oxycodone, fentanyl and pethidine. Opioids are not preferred to relieve migraines because:
- They can make headaches worse: using opioids for migraine can cause more headaches and chronic migraines than you had to begin with. This is called “medication overuse headache”. It is possible with all pain medications, but is more likely with opioids.
- They are not as effective as other migraine medicines: there are other medicines that can reduce the number of migraines you have and how severe they are—better than opioids. This includes medicines called triptans, which work directly on the blood vessels in your head to relieve the pain from migraine.
- They can be harmful: opioids are strong medications which may cause you harm, including dependence and addiction. Opioids can cause serious withdrawal symptoms if you stop taking them suddenly. People who use high doses for a long time may need to be in the hospital in order to stop using them. Opioids, even at low doses, can make you feel sleepy or dizzy. Other side effects include constipation and nausea. Using them for a long time can lower your sex drive and cause depression and sleep problems.
Opioids may be needed in some instances
- In some people, the migraine-specific medicines don’t work. Opioid painkillers may be a short-term “rescue” option for these people. In this situation, you should not take opioids more than 9 days per month. At the same time, you and your doctor should continue to focus on other strategies to help you prevent and manage your migraines. Long-term follow-up is needed to make sure you do not develop complications from taking opioids.
- If you have certain medical conditions, such as some heart diseases or you are pregnant, you may not be able to take the migraine-specific medicine. Talk to your doctor if this applies to you.
Read more about Treating migraine headaches: some drugs should rarely be used Choose Wisely, NZ 
Caution – medication overuse headache
Medication overuse (rebound) headache can happen from using too many pain relief medicines to treat headaches and migraines. It may feel like tension-type headache or migraine-like attack. Headaches often improve within 2 months of withdrawal of the overused medicine, but can feel worse before improvement is seen. To avoid this:
- triptans should not be used for more than 10 days per month
- paracetamol and NSAIDs should not be taken for headache on more than 15 days per month.
Medicines for nausea (feeling sick) or vomiting (being sick)
Examples include metoclopramide, domeperidone and prochlorperazine. These medicines are called anti-sickness medicines or antiemetics. They can be helpful to treat migraine even if you don't experience nausea or vomiting. These are prescribed by your doctor and can be used together with other pain relievers and triptans. Seek medical advice before taking anti-sickness medicines as they are not suitable for some people.
As with pain relievers, anti-sickness medicines work better if taken as soon as your migraine symptoms begin. They usually come in the form as tablets, but are also available as a suppository.
Preventive medicines
Preventive medicines are taken daily to prevent migraine attacks from happening. They are not used to treat an acute attack. Medicines to prevent migraines are an option if you:
- have at least 2 attacks a month
- have significant disability even with suitable treatment for migraine
- cannot take suitable treatment for migraine attacks.
Preventative medicines help to reduce the severity and duration of attacks and how often you get them, reduce disruption to your daily activities, and reduce overuse of acute medications. They must be taken every day to be effective. They may take a few weeks to start working.
Many different preventive medications are available, and the choice depends on many things such as:
- other medical conditions that you have, including high blood pressure, asthma, diabetes or pregnancy (among others)
- potential side effects of the medicine
- your response to preventive medicines, if you've used them before.
Examples of medicines to prevent migraine |
Description |
Beta-blockers
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- These medicines are mostly used to treat high blood pressure but they do have other uses.
- Common side effects include tiredness and depression.
- Read more about beta-blockers.
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Antidepressants
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- These medicines are also used to treat depression and other conditions.
- Common side effects include weight gain, dry mouth, feeling sleepy, tiredness and decreased libido (sex drive).
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Anti-epileptics
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- These medicines are mostly used to treat epilepsy but they have many other uses.
- Common side effects include weight gain or loss, drowsiness and skin rash.
- Sodium valproate must not be taken during pregnancy.
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References
- Treatment of acute migraine New Zealand Medicines Formulary
- Prophylaxis of migraine New Zealand Medicines Formulary
- The role of triptans in the treatment of migraine in adults BPAC July 2014, NZ