electrical nerve stimulator and a transcranial magnetic stimulator are approved in the united states for the prevention of migraines. there is also tentative evidence for transcutaneous electrical nerve stimulation decreases the frequency of migraines. migraine surgery, which involves decompression of certain nerves around the head and neck, may be an option in certain people who do not improve with medications. management there are three main aspects of treatment: trigger avoidance, acute symptomatic control, and medication for prevention. medications are more effective if used earlier in an attack. the frequent use of medications may result in medication overuse headache, in which the headaches become more severe and more frequent. this may occur with triptans, ergotamines, and analgesics, especially opioid analgesics. due to these concerns simple analgesics are recommended to be used less than three days per week at most. analgesics recommended initial treatment for those with mild to moderate symptoms are simple analgesics such as nonsteroidal anti-inflammatory drugs (nsaids) or the combination of paracetamol (also known as acetaminophen), aspirin, and caffeine. several nsaids, including diclofenac and ibuprofen have evidence to support their use. aspirin (900 to 1000 mg) can relieve moderate to severe migraine pain, with an effectiveness similar to sumatriptan. ketorolac is available in intravenous and intramuscular formulations. paracetamol, either alone or in combination with metoclopramide, is another effective treatment with a low risk of adverse effects. intravenous metoclopramide is also effective by itself. in pregnancy, paracetamol and metoclopramide are deemed safe as are nsaids until the third trimester. naproxen by itself may not be effective as a stand-alone medicine to stop a migraine headache as it is only weakly better than a placebo medication in clinical trials. triptans triptans such as sumatriptan are medications used to stop an active migraine headache (an abortive medication). triptans are the initially recommended treatments for those with moderate to severe pain from an acute migraine headache or those with milder symptoms who do not respond to simple analgesics. triptans have been shown to be effective for both pain and nausea in up to 75% of people. there are different methods or routes of administration to take sumatriptan including oral (by mouth), injectable (subcutaneous), rectal, nasal spray, and oral dissolving tablets. for people with migraine symptoms such as nausea or vomiting, taking the abortive medicine by mouth or through the nose may be difficult. all route of administration have been shown to be effective at reducing migraine symptoms, however, nasal and injectable subcutaneous administration may result in more side effects. the adverse effects associated with rectal administration have not been well studied. some people may find that they respond to one type of sumatriptan better than another. most side effects are mild, including flushing; however, rare cases of myocardial ischemia have occurred. they are thus not recommended for people with cardiovascular disease, who have had a stroke, or have migraines that are accompanied by neurological problems. in addition, triptans should be prescribed with caution for those with risk factors for vascular disease. while historically not recommended in those with basilar migraines there is no specific evidence of harm from their use in this population to support this caution. triptans are not addictive, but may cause medication-overuse headaches if used more than 10 days per month. sumatriptan does not prevent other migraine headaches from starting in the future. for increased effectiveness at stopping migraine symptoms, a combined therapy that includes sumatriptan and naproxen may be suggested. cgrp receptor antagonists calcitonin gene-related peptide receptor antagonists (cgrp) target calcitonin gene-related peptide or its receptor to prevent migraine headaches or reduce their severity. cgrp is a signaling molecule as well as a potent vasodilator that is involved in the development of a migraine headache. there are four injectable monoclonal antibodies that target cgrp or its receptor (eptinezumab, erenumab, fremanezumab, and galcanezumab) and the medications have demonstrated efficacy in the preventative treatment of episodic and chronic migraine headaches in phase iii randomized clinical trials. zavegepant was approved for medical use in the united states in march 2023. ergotamines ergotamine and dihydroergotamine are older medications still prescribed for migraines, the latter in nasal spray and injectable forms. they appear equally effective to the triptans and experience adverse effects that typically are benign. in the most severe cases, such as those with status migrainosus, they appear to be the most effective treatment option. they can cause vasospasm including coronary vasospasm and are contraindicated in people with coronary artery disease. magnesium magnesium is recognized as an inexpensive, over-the-counter supplement which can be part of a multimodal approach to migraine reduction. some studies have shown to be effective in both preventing and treating migraine in intravenous form. the intravenous form reduces attacks as measured in approximately 15-45 minutes, 120 minutes, and 24 hour time periods, magnesium taken orally alleviates the frequency and intensity of migraines. other intravenous metoclopramide, intravenous prochlorperazine, or intranasal lidocaine are other potential options. metoclopramide or prochlorperazine are the recommended treatment for those who present to the emergency department. haloperidol may also be useful in this group. a single dose of intravenous dexamethasone, when added to standard treatment of a migraine attack, is associated with a 26% decrease in headache recurrence in the following 72 hours. spinal manipulation for treating an ongoing migraine headache is not supported by evidence. it is recommended that opioids and barbiturates not be used due to questionable efficacy, addictive potential, and the risk of rebound headache. there is tentative evidence that propofol may be useful if other measures are not effective. occipital nerve stimulation, may be effective but has the downsides of being cost-expensive and has a significant amount of complications. there is modest evidence for the effectiveness of non-invasive neuromodulatory devices, behavioral therapies and acupuncture in the treatment of migraine headaches. there is little to no evidence for the effectiveness of physical therapy, chiropractic manipulation and dietary approaches to the treatment of migraine headaches. behavioral treatment of migraine headaches may be helpful for those who may not be able to take medications (for example pregnant women). feverfew is registered as a traditional herbal medicine in the nordic countries under the brand name glitinum, only powdered feverfew is approved in the herbal community monograph issued by european medicines agency (ema). sexual activity, particularly orgasm, may provide relief for some migraineurs. children ibuprofen helps decrease pain in children with migraines and is the initially recommended treatment. paracetamol does not appear to be effective in providing pain relief. triptans are effective, though there is a risk of causing minor side effects like taste disturbance, nasal symptoms, dizziness, fatigue, low energy, nausea, or vomiting. ibuprofen should be used less than half the days in a month and triptans less than a third of the days in a month to decrease the risk of medication overuse headache. chronic migraine topiramate and botulinum toxin (botox) have evidence in treating chronic migraine. botulinum toxin has been found to be useful in those with chronic migraine but not those with episodic ones. the anti-cgrp monoclonal antibody erenumab was found in one study to decrease chronic migraines by 2.4 days more than placebo. prognosis "migraine exists on a continuum of different attack frequencies and associated levels of disability." for those with occasional, episodic migraine, a "proper combination of drugs for prevention and treatment of migraine attacks" can limit the disease's impact on patients' personal and professional lives. but fewer than half of people with migraine seek medical care and more than half go undiagnosed and undertreated. "responsive prevention and treatment of migraine is incredibly important" because evidence shows "an increased sensitivity after each successive attack, eventually leading to chronic daily migraine in some individuals." repeated migraine results in "reorganization of brain circuitry," causing "profound functional as well as structural changes in the brain." "one of the most important problems in clinical migraine is the progression from an intermittent, self-limited inconvenience to a life-changing disorder of chronic pain, sensory amplification, and autonomic and affective disruption. this progression, sometimes termed chronification in the migraine literature, is common, affecting 3% of migraineurs in a given year, such that 8% of migraineurs have chronic migraine in any given year." brain imagery reveals that the electrophysiological changes seen during an attack become permanent in people with chronic migraine; "thus, from an electrophysiological point of view, chronic migraine indeed resembles a never-ending migraine attack." severe migraine ranks in the highest category of disability, according to the world health organization, which uses objective metrics to determine disability burden for the authoritative annual global burden of disease report. the report classifies severe migraine alongside severe depression, active psychosis, quadriplegia, and terminal-stage cancer. migraine with aura appears to be a risk factor for ischemic stroke doubling the risk. being a young adult, being female, using hormonal birth control, and smoking further increases this risk. there also appears to be an association with cervical artery dissection. migraine without aura does not appear to be a factor. the relationship with heart problems is inconclusive with a single study supporting an association. migraine does not appear to increase the risk of death from stroke or heart disease. preventative therapy of migraines in those with migraine with aura may prevent associated strokes. people with migraine, particularly women, may develop higher than average numbers of white matter brain lesions of unclear significance. epidemiology disability-adjusted life year for migraines per 100,000 inhabitants in 2004 no data <45 45–65 65–85 85–105 105–125 125–145 145–165 165–185 185–205 205–225 225–245 >245 worldwide, migraine affects nearly 15% or approximately one billion people. it is more common in women at 19% than men at 11%. in the united states, about 6% of men and 18% of women experience a migraine attack in a given year, with a lifetime risk of about 18% and 43% respectively. in europe, migraines affect 12–28% of people at some point in their lives with about 6–15% of adult men and 14–35% of adult women getting at least one yearly. rates of migraine are slightly lower in asia and africa than in western countries. chronic migraine occurs in approximately 1.4 to 2.2% of the population. these figures vary substantially with age: onset of migraine is most commonly between 15 and 24 years of age, and occur most frequently in those 35 to 45 years of age. in children, about 1.7% of 7 year olds and 3.9% of those between 7 and 15 experience migraine, with the condition being slightly more common in boys before puberty. children as young as two years may be affected. during adolescence, migraine becomes more common among women and this persists for the rest of the lifespan, being twice as common among elderly females than males. in women migraine without aura are more common than migraine with aura; however in men the two types occur with similar frequency. during perimenopause symptoms often get worse before decreasing in severity. while symptoms resolve in about two thirds of the elderly, in 3 to 10% they persist. history the head ache, george cruikshank (1819) an early description consistent with migraine is contained in the ebers papyrus, written around 1500 bce in ancient egypt. in 200 bce, writings from the hippocratic school of medicine described the visual aura that can precede the headache and a partial relief occurring through vomiting. a second-century description by aretaeus of cappadocia divided headaches into three types: cephalalgia, cephalea, and heterocrania. galen of pergamon used the term hemicrania (half-head), from which the word migraine was eventually derived. he also proposed that the pain arose from the meninges and blood vessels of the head. migraine was first divided into the two now used types – migraine with aura (migraine ophthalmique) and migraine without aura (migraine vulgaire) in 1887 by louis hyacinthe thomas, a french librarian. the mystical visions of hildegard von bingen, which she described as “reflections of the living light", are consistent with the visual aura experienced during migraines. a trepanated skull, from the neolithic. the perimeter of the hole in the skull is rounded off by ingrowth of new bony tissue, indicating that the person survived the operation. trepanation, the deliberate drilling of holes into a skull, was practiced as early as 7,000 bce. while sometimes people survived, many would have died from the procedure due to infection. it was believed to work via "letting evil spirits escape". william harvey recommended