migraine migraine migraine (uk: /ˈmiːɡreɪn/, us: /ˈmaɪ-/) is a common neurological disorder characterized by recurrent headaches. typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hours to three days. non-headache symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell. the pain is generally made worse by physical activity during an attack, although regular physical exercise may prevent future attacks. up to one-third of people affected have aura: typically, it is a short period of visual disturbance that signals that the headache will soon occur. occasionally, aura can occur with little or no headache following, but not everyone has this symptom. migrainewoman with migraine headachespecialtyneurologysymptomsheadaches, nausea, sensitivity to light, sound, and smellusual onsetaround pubertydurationrecurrent, long termcausesenvironmental and geneticrisk factorsfamily history, femaledifferential diagnosissubarachnoid hemorrhage, venous thrombosis, idiopathic intracranial hypertension, brain tumor, tension headache, sinusitis, cluster headachepreventionmetoprolol, valproate, topiramatemedicationibuprofen, paracetamol (acetaminophen), triptans, ergotaminesprevalence~15% migraine is believed to be due to a mixture of environmental and genetic factors. about two-thirds of cases run in families. changing hormone levels may also play a role, as migraine affects slightly more boys than girls before puberty and two to three times more women than men. the risk of migraine usually decreases during pregnancy and after menopause. the underlying mechanisms are not fully known. they are, however, believed to involve the nerves and blood vessels of the brain. initial recommended treatment is with simple pain medication such as ibuprofen and paracetamol (acetaminophen) for the headache, medication for the nausea, and the avoidance of triggers. specific medications such as triptans or ergotamines may be used in those for whom simple pain medications are not effective. caffeine in combination with other analgesics is safe and effective in treatment of acute migraine. systematic reviews show a range of pharmacological treatments and medical devices reduce migraine frequency and intensity. non-pharmacological interventions have also been shown to be effective, including oral magnesium, aerobic exercise, progressive strength training, and mindfulness-based therapy (including meditation, yoga, and acceptance-based approaches). there is suggestive evidence for the efficacy of acupuncture, coq10, and vitamin b2. globally, approximately 15% of people are affected by migraine. in the global burden of disease study, conducted in 2010, migraines ranked as the third-most prevalent disorder in the world. it most often starts at puberty and is worst during middle age. as of 2016, it is one of the most common causes of disability. an early description consistent with migraines is contained in the ebers papyrus, written around 1500 bc in ancient egypt. the word migraine is from the greek ἡμικρᾱνίᾱ (hēmikrāníā), 'pain in half of the head', from ἡμι- (hēmi-), 'half' and κρᾱνίον (krāníon), 'skull'. signs and symptoms migraine typically presents with self-limited, recurrent severe headache associated with autonomic symptoms. about 15–30% of people living with migraine experience episodes with aura, and they also frequently experience episodes without aura. the severity of the pain, duration of the headache, and frequency of attacks are variable. a migraine attack lasting longer than 72 hours is termed status migrainosus. there are four possible phases to a migraine attack, although not all the phases are necessarily experienced: the prodrome, which occurs hours or days before the headache the aura, which immediately precedes the headache the pain phase, also known as headache phase the postdrome, the effects experienced following the end of a migraine attack migraine is associated with major depression, bipolar disorder, anxiety disorders, and obsessive–compulsive disorder. these psychiatric disorders are approximately 2–5 times more common in people without aura, and 3–10 times more common in people with aura. prodrome phase prodromal or premonitory symptoms occur in about 60% of those with migraines, with an onset that can range from two hours to two days before the start of pain or the aura. these symptoms may include a wide variety of phenomena, including altered mood, irritability, depression or euphoria, fatigue, craving for certain food(s), stiff muscles (especially in the neck), constipation or diarrhea, and sensitivity to smells or noise. this may occur in those with either migraine with aura or migraine without aura. neuroimaging indicates the limbic system and hypothalamus as the origin of prodromal symptoms in migraine. aura phase aura is a transient focal neurological phenomenon that occurs before or during the headache. aura appears gradually over a number of minutes (usually occurring over 5–60 minutes) and generally lasts less than 60 minutes. symptoms can be visual, sensory or motoric in nature, and many people experience more than one. visual effects occur most frequently: they occur in up to 99% of cases and in more than 50% of cases are not accompanied by sensory or motor effects. if any symptom remains after 60 minutes, the state is known as prolonged aura. visual disturbances often consist of a scintillating scotoma (an area of partial alteration in the field of vision which flickers and may interfere with a person's ability to read or drive). these typically start near the center of vision and then spread out to the sides with zigzagging lines which have been described as looking like fortifications or walls of a castle. usually the lines are in black and white but some people also see colored lines. some people lose part of their field of vision known as hemianopsia while others experience blurring. sensory aura are the second most common type; they occur in 30–40% of people with auras. often a feeling of pins-and-needles begins on one side in the hand and arm and spreads to the nose–mouth area on the same side. numbness usually occurs after the tingling has passed with a loss of position sense. other symptoms of the aura phase can include speech or language disturbances, world spinning, and less commonly motor problems. motor symptoms indicate that this is a hemiplegic migraine, and weakness often lasts longer than one hour unlike other auras. auditory hallucinations or delusions have also been described. pain phase classically the headache is unilateral, throbbing, and moderate to severe in intensity. it usually comes on gradually and is aggravated by physical activity during a migraine attack. however, the effects of physical activity on migraine are complex, and some researchers have concluded that, while exercise can trigger migraine attacks, regular exercise may have a prophylactic effect and decrease frequency of attacks. the feeling of pulsating pain is not in phase with the pulse. in more than 40% of cases, however, the pain may be bilateral (both sides of the head), and neck pain is commonly associated with it. bilateral pain is particularly common in those who have migraine without aura. less commonly pain may occur primarily in the back or top of the head. the pain usually lasts 4 to 72 hours in adults; however, in young children frequently lasts less than 1 hour. the frequency of attacks is variable, from a few in a lifetime to several a week, with the average being about one a month. the pain is frequently accompanied by nausea, vomiting, sensitivity to light, sensitivity to sound, sensitivity to smells, fatigue and irritability. many thus seek a dark and quiet room. in a basilar migraine, a migraine with neurological symptoms related to the brain stem or with neurological symptoms on both sides of the body, common effects include a sense of the world spinning, light-headedness, and confusion. nausea occurs in almost 90% of people, and vomiting occurs in about one-third. other symptoms may include blurred vision, nasal stuffiness, diarrhea, frequent urination, pallor, or sweating. swelling or tenderness of the scalp may occur as can neck stiffness. associated symptoms are less common in the elderly. silent migraine sometimes, aura occurs without a subsequent headache. this is known in modern classification as a typical aura without headache, or acephalgic migraine in previous classification, or commonly as a silent migraine. however, silent migraine can still produce debilitating symptoms, with visual disturbance, vision loss in half of both eyes, alterations in color perception, and other sensory problems, like sensitivity to light, sound, and odors, and aura sudden outbreak without headache can be scary. it can last from 15 to 30 minutes, usually no longer than 60 minutes, and it can recur or appear as an isolated event. postdrome the migraine postdrome could be defined as that constellation of symptoms occurring once the acute headache has settled. many report a sore feeling in the area where the migraine was, and some report impaired thinking for a few days after the headache has passed. the person may feel tired or "hung over" and have head pain, cognitive difficulties, gastrointestinal symptoms, mood changes, and weakness. according to one summary, "some people feel unusually refreshed or euphoric after an attack, whereas others note depression and malaise." for some individuals this can vary each time. cause the underlying causes of migraines are unknown. however, they are believed to be related to a mix of environmental and genetic factors. they run in families in about two-thirds of cases and rarely occur due to a single gene defect. while migraines were once believed to be more common in those of high intelligence, this does not appear to be true. a number of psychological conditions are associated, including depression, anxiety, and bipolar disorder, as are many biological events or triggers. genetics main article: genetics of migraine headaches studies of twins indicate a 34% to 51% genetic influence of likelihood to develop migraine. this genetic relationship is stronger for migraine with aura than for migraines without aura. a number of specific variants of genes increase the risk by a small to moderate amount. single gene disorders that result in migraines are rare. one of these is known as familial hemiplegic migraine, a type of migraine with aura, which is inherited in an autosomal dominant fashion. four genes have been shown to be involved in familial hemiplegic migraine. three of these genes are involved in ion transport. the fourth is an axonal protein associated with the exocytosis complex. another genetic disorder associated with migraine is cadasil syndrome or cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. one meta-analysis found a protective effect from angiotensin converting enzyme polymorphisms on migraine. the trpm8 gene, which codes for a cation channel, has been linked to migraines. triggers migraine may be induced by triggers, with some reporting it as an influence in a minority of cases and others the majority. many things such as fatigue, certain foods, alcohol, and weather have been labeled as triggers; however, the strength and significance of these relationships are uncertain. most people with migraines report experiencing triggers. symptoms may start up to 24 hours after a trigger. physiological aspects common triggers quoted are stress, hunger, and fatigue (these equally contribute to tension headaches). psychological stress has been reported as a factor by 50 to 80% of people. migraine has also been associated with post-traumatic stress disorder and abuse. migraine episodes are more likely to occur around menstruation. other hormonal influences, such as menarche, oral contraceptive use, pregnancy, perimenopause, and menopause, also play a role. these hormonal influences seem to play a greater role in migraine without aura. migraine episodes typically do not occur during the second and third trimesters of pregnancy, or following menopause. dietary aspects between 12 and 60% of people report foods as triggers. there are many reports that tyramine – which is naturally present in chocolate, alcoholic beverages, most cheeses, processed meats, and other foods – can trigger migraine symptoms in some individuals. likewise, monosodium glutamate (msg) is frequently reported as a trigger for migraine symptoms. environmental aspects a 2009 review on potential triggers in the indoor and outdoor environment concluded that while there were insufficient studies to confirm environmental factors as causing migraine, "migraineurs worldwide consistently report similar environmental triggers". the article suggests that people living with migraine take some preventive measures related to indoor air quality and lighting. pathophysiology animation of cortical spreading depression migraine is believed to be primarily a neurological disorder, while others believe it to be a neurovascular disorder with blood vessels playing the key role, although current evidence does not support this completely. others believe both are likely important. one theory is related to increased excitability of the cerebral cortex and abnormal control of pain neurons in the trigeminal nucleus of the brainstem. aura