Related Terms

• Abortive, anticonvulsant, antiviral, arrhythmia, arteriovenous malformations, artery, aura, basilar, artery, beta-blocker, caffeine, calcium channel blocker, carotid, carotidynia, cerebrovascular, cluster headache, computer tomography, constriction, cranial, CT, dilation, EEG, electroencephalography, epidural hematoma, ergot, estrogen, headache, heredity, herpes simplex encephalitis, hormone, intracerebral, magnetic resonance imaging, menopause, MRI, neuropeptides, nociceptors, norepinephrine, ophthalmoplegic migraine, opiate, pallor, parasthesia, photophobia, PMS, postdrone, premenstrual syndrome, preventative, primary headache, prodrome, progesterone, prophylactic, ptosis, rebound headache, scintillating scotomas, secondary headache, serotonin, stroke, subarachnoid hemorrhages, subdural hematoma, tension headache, TIA, transient ischemic attack, trauma, tricyclic antidepressant, triptan, vertigo.

Background

• A migraine is not just headache pain. Migraine is thought to be a genetic neurological disease characterized by flare-ups often called "migraine attacks" or "migraine episodes." A headache can be one symptom of a migraine attack. Some individuals with migraine disease often have migraine attacks without having a headache.

• Migraine attacks, or episodes, occur in phases or parts. A typical migraine attack consists of four phases. Not every individual experiencing a migraine has all four phases. The four phases of a migraine attack are prodrome, aura, headache, and postdrome (see Signs and Symptoms).

• Individuals suffering from migraines tend to have recurring attacks triggered by a lack of food or sleep, certain food allergies, exposure to light, or hormonal changes in women, including puberty, menopause, and premenstrual syndrome (PMS). Anxiety, stress, or relaxation after stress can also be triggers. Exposure to a trigger does not always lead to a headache. Conversely, avoidance of triggers cannot completely prevent headaches. Different migraine sufferers respond to different triggers, and any one trigger will not induce a headache in every person who has migraine headaches.

• Attacks tend to become less severe as the migraine sufferer ages. The uncertainty of when attacks may occur leads to additional patient anxiety. Symptoms, incidence, and severity of migraine headaches vary by individual.

• Migraine headaches are the second most common type of primary headache. An estimated 28 million people in the United States (about 12% of the population) will experience migraine headaches at one time in their lives.

• In the United States, migraine headaches often go undiagnosed or are misdiagnosed as tension or sinus headaches. As a result, many migraine sufferers do not receive effective treatment.

• Treatments for migraine attacks involve prevention of the attack and treatment of acute (immediate) symptoms such as the headache.

Types of Headaches

• A headache is pain in occurring in the head. There are two types of headaches: primary headaches and secondary headaches. Primary headaches are not associated with (caused by) other diseases. Examples of primary headaches are migraine headaches, tension headaches, and cluster headaches. Secondary headaches are caused by associated disease, such as brain tumors. The associated disease may be minor or serious and life threatening. Seven in ten people have at least one type of headache a year.

• Migraine headaches:

• Migraine with aura: Migraine with aura is a migraine headache characterized by a neurological (nervous system) experience originating in the brain called an aura. Most auras appear as bright shimmering lights around objects (halos) or at the edges of the field of vision (called scintillating scotomas), zigzag lines, wavy images, or other visual hallucinations. Other individuals may experience temporary vision loss. An aura is usually experienced 10-30 minutes before the headache.

• Non-visual auras include muscle weakness, speech or language abnormalities, dizziness, and paresthesia (tingling or numbness) of the face, tongue, or extremities.

• Migraine without aura: Migraine without aura, or "silent" migraine, is the most prevalent type of migraine headache and may occur on one or both sides of the head. Tiredness or mood changes may be experienced the day before the headache. Nausea, vomiting, and sensitivity to light (also called photophobia) often accompany migraine without aura.

• Basilar migraine: Basilar migraine or basilar artery migraine, involves a disturbance of the basilar artery (blood vessel) in the brainstem. Symptoms include severe headache, vertigo (dizziness), double vision, slurred speech, and poor muscle coordination. Basilar migraines pain is usually bilateral, or on both sides of the head. This type occurs in any age, but mostly occurs in females.

• Carotidynia: Carotidynia is also called lower-half headache or facial migraine. It produces deep, dull, aching, and sometimes piercing pain in the jaw or neck. There is usually tenderness and swelling over the carotid artery (blood vessel) in the neck. Episodes can occur several times weekly and last a few minutes to hours. This type occurs more commonly in older people.

• Headache-free migraine: A headache-free migraine is characterized by the presence of aura without a headache. This occurs in patients with a history of migraine with aura.

• Ophthalmoplegic migraine: Ophthalmoplegic migraine begins with a headache felt in the eye and is accompanied by vomiting. As the headache progresses, the eyelid droops (ptosis), and the nerves responsible for eye movement become paralyzed. Eyelid dropping may persist for days or weeks.

• Status migraine: Status migraine is a rare type involving intense pain that usually lasts longer than 72 hours. The patient may require hospitalization.

• Other primary headaches:

• Tension headaches: Tension headaches are the most common type of primary headache. As many as 90% of adults have had or will have tension headaches. Tension headaches are more common among women than men, possibly due to hormonal changes. Tension headaches often begin in the back of the head and upper neck as a band-like tightness or pressure. Tension headaches also are described as a band of pressure surrounding the head with the most intense pain over the eyebrows. The pain of tension headaches usually is mild (not disabling) and bilateral (affecting both sides of the head). Tension headaches are not associated with an aura or visual disturbances, and the patient normally has proper vision. Tension headaches are seldom associated with nausea, vomiting, or sensitivity to light and sound. Tension headaches usually occur sporadically (infrequently and without a pattern) but can occur frequently and even daily in some people. Most people are able to function despite their tension headaches. Tension headaches do not have a clear cause. Many healthcare professionals attribute tension headaches to excess stress during daily activities and anxiety.

• Cluster headaches: Cluster headaches are headaches that come in groups lasting weeks or months, separated by pain-free periods of months or years. During the period in which the cluster headaches occur, pain typically occurs once or twice daily, but some patients may experience pain more than twice daily. Each episode of pain lasts from 30 minutes to one and one-half hours. Attacks tend to occur at about the same time every day and often awaken the patient at night from a sound sleep. The pain typically is excruciating and located unilaterally around or behind one eye. Some patients describe the pain as feeling like a hot poker in the eye. The affected eye may become red, inflamed, and watery. The nose on the affected side may become congested and runny. Unlike patients with migraine headaches, patients with cluster headaches tend to be restless. They often pace the floor, bang their heads against a wall, and can be driven to desperate measures. Cluster headaches are much more common in males than females. Cluster headaches do not have a clear cause, although alcohol and cigarettes can precipitate attacks. Many healthcare professionals believe that cluster and migraine headaches share a common cause that begins in the nerve that carries sensation from the head to the brain (trigeminal nerve) and ends with the blood vessels that surround the brain dilating (widening) and contracting (narrowing), which causes pain. Others believe that the pain arises in the deep vascular channels in the head and does not involve the trigeminal nerve. Cluster headaches are a rare type primary headache, affecting 0.1% of the population. An estimated 85% of cluster headache sufferers are men. The average age of cluster headache sufferers is 28-30 years, although headaches may begin in childhood.

• Secondary headaches:

• Secondary headaches are headaches caused by conditions other than those related to primary headaches, such as migraine. Secondary headaches have diverse causes, ranging from serious and life threatening conditions such as intracranial hemorrhage (bleeding within the skull), cerebral venous sinus thrombosis (blood clot within the membrane that covers the brain), cerebral stroke or infarct (lack of oxygen to the brain causing neurological damage), cerebral aneurysm (bulging blood vessel in the brain), Lyme disease (a bacteria from ticks), excess cerebrospinal fluid in the brain (hydrocephalus), meningitis (inflammation of the membranes of the brain or spinal cord), low level of cerebral spinal fluid (CSF), nasal sinus blockage, postictal headache (occurs after a stroke or seizure), temporomandibular joint dysfunction(TMJ), and brain tumor. Secondary headache pain can vary in severity.

• Less serious but common conditions may also cause headaches, such as withdrawal from caffeine and the discontinuation of pain medications. Overuse of pain relievers causes the pain relievers to become less effective. As the effect of the pain reliever wears off, headaches recur (rebound headache). These drugs include Over-The-Counter (OTC) or prescription pain relievers, such as acetaminophen (Tylenol®), ibuprofen (Advil®, Motrin®), or opiates such as oxycodone (Percocet®, Oxycontin®) and hydrocodone (Lortab®, Vicodin®). Medications such as estrogen, progestins, calcium channel blockers (commonly used for treating high blood pressure), and selective serotonin reuptake inhibitors (SSRIs, commonly used to treat depression) can cause secondary headaches.

• Individuals with a subarachnoid hemorrhage typically report having a sudden onset of severe headache. The pain of recurrent migraine headaches tends to build up gradually. Sometimes the headache of subarachnoid hemorrhage is triggered by exertion, such as exercise or sex.

• Musculoskeletal problems, such as injuries or poor posture, can cause or contribute to headaches such as tension and migraine headaches.

• Headaches soon after trauma (injury) to the head may be caused by subdural (inner layer of the brain) or epidural (outer layer of the brain) hematomas (blood clots).

• Headaches that persistently occur on the same side are often secondary headaches associated with conditions such as brain tumors or arteriovenous malformations (abnormal clusters of blood vessels in the brain).

• Bacterial meningitis is a rapidly progressive and life-threatening disease with fever, headaches, stiff neck, and deterioration in mental function. Herpes simplex encephalitis (brain swelling caused by a herpes virus) is an infection of the brain that causes death of brain tissue. Symptoms include fever, headache, and deterioration in mental function. Early treatment with antibiotics and anti-viral agents can decrease the extent of brain damage and improve survival.

• Associated temporary weakness of the extremities or facial muscles can be symptoms of transient ischemic attacks (TIAs, or temporary lack of oxygen to the brain). TIAs are warning signals for future strokes that can cause permanent brain damage. Headache also can accompany strokes and intracerebral bleeding (bleeding into the brain).

Risk Factors and Causes

• Central nervous system disorder: The precise cause of a migraine attack is not completely understood. There appears to be general agreement, however, that a key element is changes in the blood flow within the brain due to a variety of triggers. The most widely accepted theory suggests that a migraine attack is precipitated when pain-sensing nerve cells in the brain (called nociceptors) release chemicals called neuropeptides (nerve proteins) in response to stimulation of the trigeminal nerve system. At least one of the neurotransmitters (chemicals that transmit impulses to the brain), substance P, increases the pain sensitivity of other nearby nociceptors. Other neuropeptides act on the smooth muscle surrounding cranial (skull) blood vessels, causing inflammation. This smooth muscle regulates blood flow in the brain by causing vasodilation (relaxation of blood vessels) or vasoconstriction (contracting the blood vessel). At the onset of a migraine headache, neuropeptides are thought to cause muscle relaxation, allowing vessel dilation and increased blood flow. Other neuropeptides increase the permeability of cranial (skull) blood vessels, allowing fluid containing inflammatory chemicals to leak and promote inflammation and tissue swelling. The pain of migraine is though to result from this combination of increased pain sensitivity, tissue, and vessel swelling, and inflammation.

• Heredity: Susceptibility to migraine may be inherited. A child of a migraine sufferer has as much as a 50% chance of developing a migraine attack in their lifetime. If both parents are affected, the chance rises to 70%. However, the gene or genes responsible have not been identified. Genetics also increase the chances of having migraine attacks that are chronic (or long-term).

• Neurotransmitters: Neurotransmitters are chemical messengers in the brain. Two important ones, serotonin and dopamine, appear to be critical in the processes leading to a migraine attack. Serotonin (also called 5-hydroxytryptamine or 5-HT) is involved in regulation of pain perception and mood, among other important functions. A number of studies have suggested that serotonin can stop the migraine process. To support this observation, higher-than-normal levels of a serotonin compound are excreted in urine and levels of serotonin in the blood drop during a migraine attack. Also, drugs that target receptors in the brain for serotonin are generally effective in stopping a migraine. The receptors for serotonin implicated in a migraine attack are found on the trigeminal nerve endings. Serotonin appears to block the peptides (including substance P) involved in over-stimulating nerves and producing inflammation.

• Dopamine, another important neurotransmitter, may act as a stimulant or accelerator of the migraine process. Some evidence suggests that certain genetic factors make people over-sensitive to the effects of dopamine, which include nerve cell excitation. Such nerve-cell over-activity could trigger the events in the brain leading to migraine. The prodromal symptoms (including mood changes, yawning, or drowsiness), for example, have been associated with increased dopamine activity. Dopamine receptors are also involved in regulation of blood flow in the brain, which may be of importance when dealing with vasoconstriction and vasodilation.

• Calcium-channels: Some migraines may be due to abnormalities in the channels within cells that transport the electrical ions calcium, magnesium, sodium, and potassium. Calcium-channels regulate the release of serotonin, an important neurotransmitter in the migraine process. Magnesium interacts with calcium-channels and magnesium deficiencies have been detected in the brains of migraine patients. Calcium-channels also play a major role in cortical spreading depression (CSD), a brain event that includes a "wave" of nerve impulses (firing) that spreads across the surface of the brain, moving from the back (occipital region) of the cerebral cortex toward the front at about one-eighth to three-sixteenth inches (three to five millimeters) per minute. After the nerve excitation, a depression in nerve cell function occurs that can last for minutes. CSD is thought to be one of the causes of a migraine attack. Some individuals with migraine may inherit one or more factors that impair calcium-channels, making them susceptible to headaches. For example, mutations in a gene that encodes calcium channels appears to be responsible for familial hemiplegic migraine.

• Gender and Age: A migraine attack is three times more common in women than in men. Although the exact relationship between hormones and headaches is not clear, fluctuations in estrogen and progesterone seem to trigger headaches in many women with migraine headaches, including those with premenstrual syndrome (PMS) and menopause. It seems to be hormonal fluctuations, or changes, that trigger migraine attacks, not the presence of the hormone. Prepubescent females, or females prior to reproductive maturity, can also suffer from migraines. Women with a history of migraines often have reported headaches immediately before or during their periods. Others report more migraines during pregnancy or menopause. Hormonal medications, such as oral contraceptives (birth control pills) and hormone replacement therapy (HRT, including estrogen and progesterone therapy), may also worsen migraines. In children younger than 10 years, boys appear to have migraines more often than girls. After puberty starts, migraine headaches are much more common in females (female-to-male ratio, 3:1), most likely due to hormonal changes.

• In general, the rate of migraine occurrence in males drops to a low by age 28-29 years, with one case per 1,000 people in this age group.

• Migraine occurrence among females increases sharply up to age 40 years and then declines gradually.

• The age when migraine headache with aura begins appears to peak at or before age 4-5 years (6.6 cases per 1000 people in that age group), while the highest rate for migraine without aura occurs at age 10-11 years (10.1 cases per 1000 people in that age group).

• The severity and frequency of attacks tend to lessen with age. Data suggests that migraine attacks are a chronic (long-term) condition, although long remissions (illness-free periods) are common. One study showed that 62% of young adults were free of migraine headaches for more than two years, but only 40% continued to be free of them after 30 years.

• Diet: Certain foods and beverages appear to trigger headaches in sensitive individuals. Common dietary triggers include alcohol (especially beer and red wine), aged cheeses, chocolate, fermented, pickled, or marinated foods (tofu, kim chee, miso), aspartame (an artificial sweetener), caffeine, monosodium glutamate (MSG, a key flavor enhancer in some Asian foods), and many canned and processed foods. Skipping meals or fasting also can trigger migraines. Eating proper food is very important in migraine prevention because a continuous supply of proper nutrients is essential to keeping chemical balance in the brain. Brain chemistry can be changed significantly by a single meal and, in turn, some changes in food composition can rapidly affect brain function. While all foods eaten modify brain function, some specifically alter mood or energy, such as caffeine or refined sugars. Eating unhealthy foods that do not supply adequate nutrients for proper brain function, or foods that alter brain function can cause migraine attacks in susceptible individuals

• Magnesium deficiency: Because levels of magnesium (a mineral involved in nerve cell function) also drop right before or during a migraine headache, it is possible that low amounts of magnesium may cause nerve cells in the brain to misfire. About 20% of the population consumes less than two-thirds of the RDA (recommended dietary allowance) for magnesium.

• Stress: A period of hard work followed by relaxation may lead to a "weekend migraine" headache. Acute (immediate) or chronic (long-term) stress at work or home also can set off a migraine.

• Sensory stimulus: Bright lights, sun glare, and unusual smells, including pleasant scents (such as perfume or flowers), and unpleasant odors (such as paint thinner and secondhand smoke) can trigger a migraine attack.

• Physical factors: Intense physical exertion, including sexual activity, may provoke migraines. Changes in sleep patterns, including too much or too little sleep, also can initiate a migraine headache. Sleep changes are usually seen in both adults and children with migraines. Healthcare professionals recommend eight hours of uninterrupted sleep nightly for adults. Sleep helps regulate certain neurochemicals (brain chemicals), including serotonin. Decreases in serotonin may cause a migraine attack.

• Environmental changes: A change of weather, season, altitude level, barometric pressure, or time zone can prompt a migraine headache. Environmental changes such as moving to a new area where the plants and pollens are different may also trigger a migraine attack.

• Medications: Taking certain medications can aggravate migraines, including oral contraceptives (birth control pills), estrogen replacement therapy, nitrates (nitroglycerin), theophylline (Slobid®), reserpine (Serpasil®), nifedipine (Procardia® or Adalat®), indomethicin (Indocin®), cimetidine (Tagamet®), decongestant overuse (such as pseudoephedrine or Sudafed®), and anti-anxiety drug withdrawal, including alprazolam (Xanax®) and diazepam (Valium®). Caffeine withdrawal and the discontinuation of pain medications can trigger a migraine.

Signs and Symptoms

• The prodrome: The prodrome (sometimes called pre-headache) may be experienced hours or even days before a migraine attack. The prodrome is considered a warning sign for individuals suffering migraine attacks that an episode is imminent. For the 30-40% of individuals with migraines that experience prodrome, the warning signs can give the individuals opportunity to abort the migraine attack using conventional and integrative therapies. Symptoms typical of the prodrome include food cravings, constipation or diarrhea, mood changes (such as depression or irritability), muscle stiffness (especially in the neck), fatigue (excessive tiredness), and increased frequency of urination.

• The aura: The aura is the most familiar of the phases. Auras are sensory phenomena that can follow the prodrome and usually last less than an hour. The symptoms and effects of the aura vary widely, and include visual hallucinations (such as flashing lights, wavy lines, spots, partial loss of sight, blurry vision), olfactory hallucinations (smelling odors that are not there), tingling or numbness of the face or extremities on the side where the headache develops, difficult finding words and/or speaking, confusion, vertigo (dizziness), partial paralysis (loss of muscle coordination), auditory hallucinations (hearing noises that are not there), decrease in or loss of hearing, and reduced sensation or hypersensitivity to feel and touch.

• Approximately 20% of individuals with migraines experience aura. As with the prodrome, migraine aura can serve as a warning, and sometimes allows the use of conventional or integrative therapies to abort the episode before the headache begins. Some individuals can experience aura without a headache, termed "silent" migraine.

• The headache: The headache phase is generally the most unbearable part of a migraine episode. The effects of a headache are not limited to the head only, but affect the entire body. Migraine headaches usually are described as an intense, throbbing or pounding pain in the temple area, although the pain can be located in the forehead, around the eye, or the back of the head. The pain usually is on one side of the head (unilateral), although about a third of the time the pain is bilateral (both sides). Unilateral headaches typically change sides from one attack to the next. Although migraine headache pain can occur at any time of day, statistics have reported the most common time to be 6 a.m. It is not uncommon for individuals with a migraine headache to be awakened by the pain. The headache phase usually lasts from one to 72 hours. In less common cases where it lasts longer than 72 hours, it is termed status migrainosus, and medical attention should be sought. Symptoms of the headache phase of a migraine include pain worsened by physical activity, phonophobia (sensitivity to sound), photophobia (sensitivity to light), nausea and vomiting, diarrhea or constipation, nasal congestion and/or runny nose, depression or severe anxiety, hot flashes and chills, dizziness, confusion, and either dehydration or fluid retention, depending on the individual. The combination of disabling pain and symptoms such as nausea or vomiting often prevents sufferers from performing daily activities.

• The postdrome: Once the headache is over, the migraine episode is still not over. The postdrome, or post-headache, follows immediately afterward. The majority of individuals with a migraine take hours to fully recover, while others take days. Most individuals in a postdrome phase are fatigued (excessively tired) and have a "hangover" feeling. These feelings may often be attributed to medications taken to treat the migraine, but may well be caused by the migraine itself. Postdromal symptoms have been shown to be accompanied and possibly caused by abnormal cerebral (brain) blood flow and altered electroencephalogram (a measure of brain electrical impulses) readings have been reported for up to 24 hours after the end of the headache stage. In cases where prodrome and/or aura are experienced without the headache phase, the postdrome may still occur. The symptoms of prodrome include decreased mood levels (especially depression) or feelings of well-being and euphoria, fatigue, poor concentration, and comprehension, and lowered intellect levels.

• Migraine headache symptoms in children: Migraines typically begin in childhood, adolescence or early adulthood and, in general, may become less frequent and intense as the individual grows older. About half of all school-aged children in the United States have experienced some type of headache. During childhood, boys and girls suffer from migraine at about the same rate. However, during their adolescent years, more girls are affected most likely due to hormonal changes. Also, both aging men and women may suffer from secondary headaches, such as tension or cluster headaches, more often than children under 18 years of age.

• Children's migraines tend to last for a shorter time, but the pain can be disabling and can be accompanied by nausea, vomiting, lightheadedness, and increased sensitivity to light. A migraine headache tends to occur on both sides of the head in children (bilateral) and visual auras are rare. Children often have premonition signs and symptoms, such as yawning, sleepiness or listlessness, and a craving for foods such as sugary foods and chocolate. Children may have all of the signs and symptoms of a migraine headache (nausea, vomiting, increased sensitivity to light and sound, aura), but no head pain. These migraines can be especially difficult to diagnose.

Diagnosis

• Diagnosis of a migraine headache is based on the history of symptoms, physical examination, and neurological (nerve) tests. The tests are performed to rule out other neurological and cerebrovascular (blood vessels in the brain) conditions, including bleeding within the skull (intracranial hemorrhage), blood clot within the membrane that covers the brain (cerebral venous sinus thrombosis), cerebral stroke or lack of oxygen to the brain (called an infarct), dilated blood vessel in the brain (cerebral aneurysm), excess cerebrospinal fluid in the brain (hydrocephalus), inflammation of the membranes of the brain or spinal cord (meningitis), low level of cerebral spinal fluid (CSF), nasal sinus blockage, postictal headache (occurs after a stroke or seizure), and brain tumor.

• Computed tomography (CT scan): A computerized axial tomography scan, or CT scan, is an x-ray procedure which combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. An intravenous (into the veins) dye is injected into the individual. Then the patient is placed under a large donut-shaped x-ray machine, which takes x-ray images at many different angles around the body. These images are processed by a computer to produce cross-sectional pictures of the body.

• A CAT scan is a very low-risk procedure. The most common problem is an adverse reaction to intravenous contrast material. Intravenous contrast is usually an iodine-based liquid given in the vein, which makes many organs and structures, such as the brain and blood vessels, much more visible on the CAT scan. There may be resulting itching, a rash, hives, or a feeling of warmth throughout the body. These are usually self-limiting reactions and go away rather quickly. If needed, antihistamines (such as diphenhydramine or Benadryl®) can be given by injection or orally to help relieve the symptoms. A more serious reaction to intravenous contrast is called an anaphylactic reaction. When this occurs, the patient may experience severe hives and/or extreme difficulty in breathing. This reaction is quite rare, but is potentially life-threatening if not treated. Medications taken to reverse this adverse reaction may include corticosteroids (steroids, such as prednisone or Deltasone®), antihistamines, and epinephrine.

• In migraine patients, a CT scan is performed to rule out an underlying brain abnormality, such as a tumor, when migraines are new or when there is a change in their character or frequency. CT scans may not be as reliable as newer diagnostic techniques, such as magnetic resonance imaging (MRI), but are less expensive.

• Electroencephalogram (EEG): An electroencephalogram (EEG) records electrical signals originating in the brain (called brain activity). This test is used to detect malfunctions in brain activity, such as seizures or migraines.

• EEGs are generally performed in a hospital or specialized laboratory. Sometimes the individual having the test will be told to stay up late the night before and to avoid caffeine drinks on the morning of the test. Some EEG tests are made with the patient sitting in a chair. Others are performed with the patient lying down on a couch. The EEG technologist applies small metal disks to several places on the scalp. The hair should be washed on the morning of the test with no additional chemicals, hair sprays, cleansers, cosmetics, or setting gels applied. A special glue, which is washed out afterwards, is used to attach the electrode disks to the scalp. A cap with the wires already attached may be used instead of the glue.

• During the test, the technologist may ask the person to breathe deeply through the mouth for a short time. This may make the person feel slightly dizzy or produce a numb feeling in the hands or feet, but this goes away when normal breathing is started again. The technologist may shine a blinking light into the person's eyes, or ask him or her to open and close them rapidly a few times. The average EEG test may last 35-40 minutes.

• Children should be told what to expect during an EEG test, and can be encouraged to "practice" on a doll or stuffed animal beforehand.

• Lumbar puncture: Lumbar puncture, or spinal tap, is performed to detect infection and determine levels of white blood cells (immune system cells), glucose, and protein in the cerebrospinal fluid. This test involves withdrawing a small amount of fluid from the spinal cord area and examining it under a microscope. The individual lies down on their side on an examination table. There are steps to make sure that the individual does not feel pain during the spinal tap. A topical anesthesia cream (such as Emlon®) on the skin of the back where the spinal tap will be performed (about 30 minutes to one hour before). After the skin is numbed, some doctors also inject liquid anesthesia such as lidocaine into the tissues right under the skin to prevent any further pain. Next, the doctor places a small needle through the skin and then forward through the space between the vertebrae (spine) in the lower back until it enters the space that contains the spinal fluid. When the needle goes into the skin, the individual will not feel sharp pain, only perhaps some pressure. The spinal fluid drips out through the needle into tubes, is collected, and sent to a lab for analysis. This procedure can be uncomfortable for the patient. Side effects can be headaches, pain, infection, or bleeding. Each of these complications are uncommon with the exception of headache, which can appear from hours to up to a day after LP. Headaches occur less frequently when the patient remains lying flat for one to three hours after the procedure. Patients may be given pain medications (such as morphine) or sedatives (such as alprazolam or Xanax®) before and after the procedure. These drugs can cause drowsiness, sedation, and can lead to physical dependence.

• Magnetic resonance imaging (MRI): An MRI (magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed that is inserted into the magnet. The patient may be given a sedative, such as alprazolam (Xanax®), to decrease anxiety and stress associated with the procedure. The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body.

• An MRI in patient's with migraines may be performed for a more complete evaluation of the brain, and can visualize blood vessels in the brain to detect aneurysms (tears in blood vessels) and other vascular abnormalities that can be causative agents in migraines.

Treatment

• Many factors may contribute to the occurrence of migraine attacks, including diet, sleep, hormonal changes, changes in brain chemistry, and heredity. They are known as trigger factors. When identified, avoidance of trigger factors reduces the number of headaches a patient may experience. Trigger factors may be targets of drug therapy also.

• Treatment for migraine attacks is divided into two categories, including acute (immediate) or prophylactic (preventative). Acute treatment is used during a migraine to stop or slow the progress of the attack, and preventative (or prophylactic) treatment tries to prevent migraine attacks from occurring.

• Preventive (Prophylactic):

• Preventative medication may be prescribed for patients who have frequent migraine attacks (three or more a month), those who do not respond consistently to acute treatment, and when specific medicines are contraindicated because of other medical conditions (such as stroke or bleeding in the brain). Studies have reported that as many as 40% of these patients may benefit from preventative treatment. The U.S. Food and Drug Administration (FDA) has approved four prescription drugs for migraine prevention. These include the beta-blockers propranolol (Inderal®) and timolol (Blocadren®), and the anticonvulsants topiramate (Topamax®) and divalproex sodium (Depakote®).

• Anticonvulsants: Anticonvulsant medicines, normally used for seizures, have been used to prevent migraine headaches. Examples of anticonvulsants that have been used are valproic acid (Depakote®, Depakote ER®, Depakene®), phenobarbital, gabapentin (Neurontin®), and topiramate (Topamax®). Control of the cortical spreading depression (CSD), is thought to be the reason for anticonvulsant effectiveness in preventing migraine attacks. Side effects include fatigue (tiredness), nausea, vomiting, and trembling.

• Beta-blockers: Beta-blockers are a class of drugs that safely slow the heart beat and decrease blood pressure. Beta-blockers have been used for many years to prevent migraine headaches. In migraine prevention, beta-blockers help dilate (open) blood vessels in the brain, which may prevent the vascular (blood vessel) symptoms associated with a migraine attack, including vasoconstriction (blood vessel narrowing) and vasodilation (blood vessel widening). Beta-blockers can also help reduce physical symptoms associated with migraine attacks, such as anxiety, heart palpitations, and shaking,

• Beta-blockers used in migraine prevention include propranolol (Inderal®), atenolol (Tenormin®), metoprolol (Lopressor®, Toprol XL®), and nadolol (Corgard®). Beta-blockers generally are well tolerated in most individuals. They can aggravate breathing difficulties in patients with asthma, chronic bronchitis (inflammation of the bronchial tubes), or emphysema (loss of lung function). In patients who already have slow heart rates (bradycardia) and heart block (defects in electrical conduction within the heart), beta-blockers can cause dangerously slow heartbeats. Beta-blockers can aggravate symptoms of heart failure. Other side effects include drowsiness, diarrhea, constipation, fatigue (tiredness), insomnia, nausea, depression, dreaming, memory loss, and impotence (loss of sexual performance).

• Calcium channel blockers (CCBs): CCBs are a class of drugs normally used for high blood pressure, angina (chest pain), and arrhythmias (abnormal heart rhythms). CCBs also appear to alter serotonin (a brain chemical). Serotonin imbalances are a causative factor in developing a migraine. CCBs used in preventing migraine headaches are diltiazem (Cardizem®, Dilacor®, Tiazac®), and verapamil (Calan®, Verelan®, Isoptin®).The most common side effects of CCBs are constipation, nausea, headache, rash, edema (swelling of the legs with fluid), low blood pressure, drowsiness, and dizziness. Drinking grapefruit juice or eating grapefruit may cause levels of CCBs to rise, potentially leading to life threatening arrhythmias (irregular heart beats). Healthcare professionals recommend that individuals taking CCBs not consume grapefruit juice.

• Hormone replacement therapy (HRT): For women with hormonal imbalances that may be causing the migraines, hormone replacement therapy (HRT) may be used, including estrogen and progesterone. HRT, however, may cause side effects such as blood clots, an increased risk of developing some types of cancers, and heart disease. Menstruating women at risk for migraines may be placed on oral contraceptives for HRT. Pre-pubescent girls that are at risk for migraine attacks will not be treated with HRT, but with other methods such as beta-blockers and anticonvulsants.

• Lifestyle: Lifestyle changes, including decreasing stress levels, increasing exercise levels, and controlling the diet, have a major impact on migraine prevention and development. Lifestyle factors that are important in the prevention of migraines include regular sleep patterns, regular exercise (level depends upon the individual), limiting stress, limiting caffeine consumption to less than two caffeine-containing beverages a day, avoiding bright or flashing lights, and wearing sunglasses if sunlight is a trigger. Identifying and avoiding foods that trigger headaches is important. Healthcare professionals recommend keeping a food journal, where the individual writes down everything they have for each meal of the day. Then review the diary with a healthcare professional. It is impractical to adopt a diet that avoids all known migraine triggers; however, it is reasonable to avoid foods that consistently trigger migraine headaches. Triggers vary from one individual to another.

• Tricyclic antidepressants (TCAs): TCAs are thought to prevent migraine headaches by altering the balance of serotonin, a neurotransmitter in the brain. Low levels of serotonin are thought to be a causative agent in migraine attacks. Chronic stress and depression can cause elevated levels of the stress hormone cortisol, which is produced in the adrenal glands. Cortisol can in turn cause imbalances in serotonin, leading to a migraine attack. The tricyclic antidepressants that have been used in preventing migraine headaches include amitriptyline (Elavil®), nortriptyline (Pamelor®, Aventyl®), doxepin (Sinequan®), and imipramine (Tofranil®). Side effects include constipation, dry mouth, low blood pressure (hypotension), increased heart rate, (tachycardia), urinary retention, sexual dysfunction, and weight gain. TCAs may cause excessive sedation and fatigue (tiredness).

• Others: Other drugs less commonly used for migraine prevention include anti-serotonin medications, including methysergide (Sansert®), which prevent migraine headaches by constricting (making smaller) blood vessels and reducing inflammation of the blood vessels. Cyproheptadine (Periactin®) is an antihistamine that increases serotonin activity and is used occasionally in migraine prevention. Low levels of serotonin are a cause of migraine attacks.

• Acute (Immediate):

• Over-the-counter (OTC) treatments: The U.S. Food and Drug Administration (FDA) has approved three over-the-counter (OTC) products to treat migraine attacks. Excedrin® Migraine (a combination of aspirin, acetaminophen, and caffeine) is indicated for migraine and its associated symptoms such as head pain. Advil® Migraine and Motrin® Migraine Pain (both are ibuprofen) have anti-inflammatory action and are approved to treat migraine headache and its pain.

• Triptans: The triptans attach to serotonin receptors on the blood vessels and nerves and thereby reduce inflammation and constrict (narrow) the blood vessels. A reduction in inflammation decreases pressure on nerves in the trigeminal nerve system (nerves in the cranium or head), which decreases the pain signals to the brain and stops the headache. Traditionally, triptans, which are prescription medicines, were prescribed for moderate or severe migraines after over-the-counter (OTC) analgesics such as ibuprofen (Advil®) and other simple measures failed. Newer studies suggest that triptans can be used as the first treatment for patients with migraines that are causing disability. Significant disability is defined as more than ten days of at least 50% disability during a three month period.

• Triptans should be used early after the migraine begins, before the onset of pain or when the pain is mild. Using a triptan early in an attack increases its effectiveness, reduces side effects, and decreases the chance of recurrence of another headache during the following 24 hours. Used early, triptans can be expected to abort more than 80% of migraine headaches within two hours. Triptans include sumatriptan (Imitrex®), almotriptan (Axert®), naratriptan (Amerge®), rizatriptan (Maxalt®), zolmitriptan (Zomig®), frovatriptan (Frova®), and eletriptan (Relpax®).

• The most common side effects of triptans are facial flushing, tingling of the skin, and a sense of tightness around the chest and throat. Other less common side effects include drowsiness, fatigue (tiredness), and dizziness. These side effects are short-lived and are not considered serious. Triptans are not used in pregnant women and are not generally used in young children.

• In patients with severe nausea, a combination of a triptan and an anti-nausea medication, such as prochlorperazine (Compazine®), may be used.

• Ergots: Ergots, like triptans, are medications that abort migraine headaches. Examples of ergots include ergotamine preparations (Cafergot®) and dihydroergotamine preparations (Migranal®, DHE-45®). Ergots, like triptans, cause constriction (narrowing) of blood vessels, but ergots tend to cause more constriction of vessels in the heart and other parts of the body than the triptans, and the produce more negative effects on the heart than the triptans. Therefore, the ergots are not as safe as the triptans. Ergots are used to help stop the vasodilation (blood vessel widening) associated with a migraine attack. The ergots also are more prone to cause nausea and vomiting than the triptans. The ergots can cause prolonged contraction of the uterus and miscarriages in pregnant women.

• Midrin: Midrin is used to abort migraine and tension headaches. It is a combination of isometheptene (a blood vessel constrictor), acetaminophen (a pain reliever), and dichloralphenazone (a mild sedative). The combination medication can help take care of three potential factors associated with a migraine attack, including vasodilation, pain, and anxiety. Midrin® is most effective if used early during a headache. However, because of its potent blood vessel constricting effect, it should not be used in patients with high blood pressure, kidney disease, glaucoma (increased pressure in the eyes), atherosclerosis (hardening of the arteries), liver disease, or in patients taking monoamine oxidase inhibitors (MAOIs) including phenelzine (Nardil®), isocarboxazid (Marplan®), and tranylcypromine sulfate (Parnate®).

• Other prescription medications: Some attacks may not be eliminated by acute therapy, and the individual requires pain-relieving measures. Due to the severity of the headaches, some patients may require a narcotic analgesic, including oxycodone (Percocet®), codeine, or meperidine (Demerol®). If the individual is experiencing frequent migraine attacks, the habitual use of opiate analgesics should be avoided. Opiates can cause addiction (both physical and mental) and may also cause rebound headaches, which are headaches that occur when the pain medicine no longer provides relief.

• Butorphanol (Stadol NS®) is an opiate-like drug available for injection and intranasal (in the nose) administration. The normal dosage of Stadol NS® is one spray into the nostril, which usually relieves migraine symptoms in 15-30 minutes. This drug can be used every hour for relief. The use of Stadol NS® may result in dependency if used regularly for pain relief. Side effects include nausea and vomiting, nasal irritation, and sedation.

• Butalbital, a barbiturate medication, is also used for the immediate relief of migraine headache pain. It is used in various prescription combinations with aspirin, acetaminophen, caffeine, or codeine (an opiate pain medication). These medications are potentially addicting and are not used as initial treatment. They are sometimes used for patients whose headaches fail to respond to over-the-counter (OTC) medications but who are not candidates for triptans either due to pregnancy or the risk of heart attack and stroke. Products include butalbital and acetaminophen (Axocet®, Bupap®, Cephadyn®, Phrenilin®, or Sedapap®); butalbital, acetaminophen, and caffeine (Fioricet®, Esgic®); butalbital and aspirin (Axotal®); butalbital, aspirin, and caffeine (Fiorinal®); butalbital, acetaminophen, caffeine, and codeine (Fioricet #3 with Codeine® or Fioricet w/ Codeine®); and butalbital, aspirin, caffeine, and codeine (Fiorinal #3 with Codeine® or Fiorinal w/ Codeine®).

Integrative Therapies

• Strong scientific evidence:

• Feverfew: Feverfew is often taken by mouth for migraine headache prevention. Laboratory studies show that feverfew may reduce inflammation and prevent blood vessel constriction (squeezing) that may lead to headaches. Most of the available human studies are not high quality and report mixed results. However, overall they do suggest that feverfew may reduce the number of headaches that occur in people with frequent migraines.

• Avoid if allergic to feverfew and other plants of the Compositaefamily (chrysanthemums, daisies, marigolds, ragweed). Stop use prior to surgery and dental or diagnostic procedures. Avoid with drugs that increase bleeding risk. Avoid stopping feverfew use all at once. Instead, slowly take less and less over several days. Avoid with history of heart disease, anxiety or bleeding disorders. Caution is advised with history of mental illness, depression and headaches. Avoid if pregnant or breastfeeding.

• Good scientific evidence:

• 5-hydroxytryptophan (5-HTP): Supplemental use of 5-HTP may help balance serotonin in the body. Serotonin is the brain chemical associated with sleep, mood, movement, eating and nervousness. There is evidence from several studies in both children and adults that 5-HTP may be effective in reducing headache severity and frequency, including tension headaches and migraines. Fewer pain-relieving medications may be needed when taken with 5-HTP; however, many of the available studies show that more proven pharmaceutical drugs may work better than 5-HTP for headaches. Further research is needed.

• 5-HTP is generally safe when used in recommended dosages. Use with caution if taking antidepressant medications. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

• Arginine: L-arginine, or arginine, is a semi-essential amino acid needed by the body. Arginine is a precursor of nitric oxide, which causes blood vessel relaxation (vasodilation). Preliminary studies suggest that adding arginine to ibuprofen (Advil®, Motrin®) therapy may decrease migraine headache pain.

• Arginine is generally regarded as safe in recommended dosages. Avoid if allergic to arginine, or with history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

• Butterbur: Butterbur (Petasites hybridus) is a perennial shrub, found throughout Europe as well as parts of Asia and North America. Pain relief and headache prevention are traditional uses of butterbur. Recent pre-clinical studies suggest anti-inflammatory and vasodilitary (blood vessel opening) properties of butterbur, thereby supporting a possible mechanism of action. A small number of human trials report efficacy of butterbur for migraine prevention when taken regularly for up to four months. This evidence is compelling enough to suggest benefits of butterbur for migraine prophylaxis, although additional evidence from larger, well-designed studies is necessary.

• The use of butterbur during pregnancy and lactation should be avoided due to a lack of safety studies. Butterbur should not be used if there is an allergy to plants in the Aster family, including ragweed, marigolds, daisies, and chrysanthemums.

• Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. Manipulation is the skilled, gentle, passive movement of a joint (or spinal segment) either within or beyond its active range of motion. Despite methodologic problems of available research, overall the evidence suggests some benefits in the prevention of episodic tension headache. Better quality research is necessary in this area before a firm conclusion can be drawn.

• Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders or migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.

• Guided imagery: The term "guided imagery" may be used to refer to a number of techniques, including metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Therapeutic guided imagery may be used by therapists to help patients relax and focus on images associated with personal issues they are confronting. Initial research suggests that guided imagery may provide added benefits when used at the same time as standard medical care for migraine or tension headache.

• Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified health care provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety or emotional upset because imagery may trigger these symptoms. If feeling unusually anxious while practicing guided imagery, or if a history of trauma or abuse, speak with a qualified healthcare provider before practicing guided imagery.

• Hypnotherapy: Hypnotherapy involves the power of suggestion while the individual is in a deep, relaxed state. Several studies report improvements in severity and frequency of tension headaches following several weekly hypnosis sessions. Early research suggests that hypnosis may be equivalent to other relaxation techniques, biofeedback, or autogenic training.

• Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.

• Peppermint: Peppermint is a flowering plant most often grown for its fragrant oil. Application of diluted peppermint oil to the forehead and temples has been tested in people with various types of headache. It is not clear if this treatment is effective for tension headaches.

• Avoid if allergic or hypersensitive to peppermint or menthol. Peppermint is generally considered safe in non-allergic adults when taken in small doses. Use cautiously with G6PD deficiency or gallbladder disease. Menthol, which makes up part of peppermint oil, is generally considered safe in non-allergic adults. However, doses of menthol greater than 1 gram per kilogram of body weight may be deadly in humans. Avoid if pregnant or breastfeeding.

• Unclear or conflicting scientific evidence:

• Acupressure, shiatsu: Acupressure, or shiatsu, has been used in China and Japan for thousands of years for health and healing. In early studies, self-administered acupressure (in the temple region or other areas) is reported to offer relief of tension or migraine headache symptoms.

• With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. Serious long-term complications have not been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

• Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. Although traditionally used to help patients with migraine headaches, there is inconclusive evidence in support of acupuncture for chronic migraine or tension headache. Although the majority of available studies have shown a trend in favor of acupuncture over placebo, most have been small and methodologically flawed. Blinding and follow-up have not been adequate in most studies, and approaches to placebo-control are variable. Larger trials with clear blinding and controls are necessary before a recommendation can be made for or against the use of acupuncture for various types of headache.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers because therapy may interfere with the device.

• Belladonna: Belladonna has been used for centuries to treat many medical conditions. The available studies of belladonna in the treatment of headaches are not well designed and do not show a clear benefit. More studies are needed to test the ability of belladonna alone (not in multi-ingredient products) to treat or prevent headache.

• Avoid if allergic to belladonna or plants of the Solanaceae(nightshade) family (e.g. bell peppers, potatoes, or eggplants). Avoid with a history of heart disease, high blood pressure, heart attack, abnormal heartbeat (arrhythmia), congestive heart failure, stomach ulcer, constipation, stomach acid reflux (serious heartburn), hiatal hernia, gastrointestinal disease, ileostomy, colostomy, fever, bowel obstruction, benign prostatic hypertrophy (enlarged prostate), urinary retention, glaucoma (narrow angle), psychotic illness, Sjögren's syndrome, dry mouth (xerostomia or salivary gland disorders), neuromuscular disorders such as myasthenia gravis, or Down's syndrome. Avoid if pregnant or breastfeeding.

• Black cohosh: Black cohosh (Actaea racemosa, formerly known as Cimicifuga racemosa) is popular as an alternative to hormonal therapy in the treatment of menopausal (climacteric) symptoms such as hot flashes, mood disturbances, diaphoresis, palpitations, and vaginal dryness. Approximately 30% of women afflicted with migraines have menstrual-related migraines. Black cohosh may be a potential treatment for menstrual migraine, although additional study of black cohosh alone is needed to make a strong recommendation.

• Use of black cohosh in high-risk populations (such as in women with a history of breast cancer) should be under the supervision of a licensed healthcare professional. Use cautiously if allergic to members of the Ranunculaceaefamily such as buttercup or crowfoot. Avoid if allergic to aspirin products, non-steriodal anti-inflammatories (NSAIDs, Motrin®, ibuprofen, etc.), blood-thinners (like warfarin) or with a history of blood clots, stroke, seizures, or liver disease. Stop use before surgery/dental/diagnostic procedures with bleeding risk and avoid immediately after these procedures. Avoid if pregnant or breastfeeding.

• Chiropractic: There is currently not enough reliable scientific evidence to conclude the effects of chiropractic techniques in the management of migraine headache. Additional research is needed in this area.

• Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders or migraines. Use cautiously with a risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.

• Coenzyme Q10 (CoQ10): Coenzyme Q10 (CoQ10) is produced by the human body and is necessary for the basic functioning of cells. There is promising evidence to support the use of CoQ10 for migraine prevention or treatment. Properly designed, larger trials of longer treatment duration are needed to confirm these findings.

• CoQ10 is generally regarded as safe in recommended dosages. Allergy associated with Coenzyme Q10 supplements has not been reported in the available literature, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix®), or blood pressure, blood sugar, cholesterol or thyroid drugs. Avoid if pregnant or breastfeeding.

• Dong quai: Dong quai (Angelica sinensis), also known as Chinese Angelica, has been used for thousands of years in traditional Chinese, Korean, and Japanese medicine. It remains one of the most popular plants in Chinese medicine, and is used primarily for health conditions in women. The effects of Dong quai alone for menstrual migraine headache are not clear, and further research is necessary before a clear conclusion can be reached.

• Dong quai supplements may increase the risk of bleeding in sensitive individuals, such as those taking medications to reduce blood clotting, including aspirin and warfarin (Coumadin®). Although Dong quai is accepted as being safe as a food additive in the United States and Europe, its safety in medicinal doses is not known. Long-term studies of side effects are lacking. Avoid if allergic/hypersensitive to Dong quai or members of the Apiaceae/Umbelliferae family (like anise, caraway, carrot, celery, dill, parsley). Avoid prolonged exposure to sunlight or ultraviolet light. Use cautiously with diabetes, glucose intolerance or hormone sensitive conditions (like breast cancer, uterine cancer or ovarian cancer). Do not use before dental or surgical procedures. Avoid if pregnant or breastfeeding.

• Eucalyptus oil: Eucalyptus (Eucalyptus globulus) oil contains 70-85% 1,8-cineole (eucalyptol), which is also present in other plant oils. Effectiveness of topical eucalyptus oil for relief of headache has not been supported with reliable human research.

• Case reports describe allergic rash after exposure to eucalyptus oil, either alone or as an ingredient in creams. Avoid if allergic to eucalyptus oil or with a history of seizure, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Use caution if driving or operating machinery. Avoid with a history of acute intermittent porphyria. Avoid if pregnant or breastfeeding. A strain of bacteria found on eucalyptus may cause infection. Toxicity has been reported with oral and inhaled use.

• Gamma linolenic acid (GLA): GLA is a dietary omega-6 fatty acid found in many plant oil extracts. Limited available study has examined the effect of fatty acids, including GLA, on severity, frequency and duration of migraine attacks. Better-designed clinical trials are required before recommendations can be made. Eighty-six percent of patients experienced a reduction in the severity, frequency, and duration of migraine attacks, while 90% of patients had reduced nausea and vomiting.

• GLA may increase the risk of bleeding. Use cautiously with drugs that increase the risk of bleeding like anticoagulants and anti-platelet drugs. Avoid if pregnant or breastfeeding.

• Ginger: There is currently not enough available scientific evidence to support the use of ginger for migraine treatment. Additional research is needed.

• Avoid if allergic to ginger or other members of the Zingiberaceaefamily (like red ginger, Alpinia purpurata, shell ginger, Alpinia zeru, green cardamom, and balsam of Peru). Avoid with anticoagulation therapy. Avoid large quantities of fresh cut ginger with inflammatory bowel disease or a history of intestinal obstruction. Use cautiously prior to surgery and with gastric or duodenal ulcers, gallstones, cardiovascular disease, and diabetes. Use cautiously long-term and in underweight patients. Use cautiously if taking heart medications or sedatives and if driving or operating heavy machinery. Use cautiously if pregnant or breastfeeding.

• Massage: There is currently not enough scientific evidence available on whether massage is an effective therapy for migraine.

• Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

• Melatonin: Melatonin is a natural hormone that is used for the improvement of sleep patterns. Several small studies have examined the possible role of melatonin for headache prevention, for migraine, cluster, and tension-type headache. Limited initial research suggests possible benefits, although well-designed controlled studies are needed before a firm conclusion can be drawn.

• Melatonin should not be used for extended periods of time. Caution is advised when taking melatonin supplements as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise directed by a doctor.

• Niacin: Well designed clinical trials on the use of niacin for headaches are currently lacking. Additional research is needed to make a conclusion.

• Avoid if allergic to niacin or niacinamide. Avoid with a history of liver disease, liver dysfunction, irregular heartbeats (arrhythmia), heart disease, blood clotting, bleeding disorders, asthma, anxiety, panic attacks, thyroid disorders, stomach ulcers, gout, or diabetes. Avoid if pregnant or breastfeeding.

• Physical therapy: The goal of physical therapy, or physiotherapy, is to improve mobility, restore function, reduce pain, and prevent further injury. Physical therapy has been used to treat chronic headache, migraines, tension-type headaches, and cervicogenic headaches. Available studies have used combination treatments of standard physical therapy in addition to psychotherapy, medications, or adjusting dental occlusion. Better-designed trials of PT alone are needed before it can be recommended for these indications.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Based on the available literature, physical therapy appears generally safe when practiced by a qualified physical therapist; however, complications are possible. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature, although causality is unclear. Erectile dysfunction has also been reported. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. Early research suggests that reflexology may relieve pain from migraine or tension headache, and that pain medication requirements may be reduced. However, study in this area has not been well designed or reported, and further evidence is necessary before a firm conclusion can be reached.

• Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.

• Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. Preliminary evidence suggests that relaxation techniques may be helpful for the reduction of migraine headache symptoms in adults. Study of relaxation in children with headaches has yielded unclear results. Additional research is necessary before a firm conclusion can be drawn.

• Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.

• Riboflavin (vitamin B2): Several studies suggest benefits of high-dose riboflavin in migraine headache prevention. Further research is necessary before a firm conclusion can be drawn.

• Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as safe during pregnancy and breastfeeding. The U.S. Recommended Daily Allowance (RDA) for riboflavin in pregnant women is higher than for non-pregnant women, and is 1.4 milligrams daily (1.6 milligrams for breastfeeding women).

• Soy: Soy (Glycine max) is a plant in the pea family (Fabaceae), and is native to southeastern Asia. Soy has been a dietary staple in Asian countries for at least 5,000 years. Soy supplements have been reported to help with symptoms associated with menopause, including headache. Limited available study of a phytoestrogen (plant estrogen) combination showed a reduced number of migraine attacks suffered. Further research is needed regarding the use of soy for menstrual migraine.

• Use of soy supplements may cause drug interactions. Soy should not be used if the patient is pregnant or breastfeeding, unless otherwise directed by a doctor. Until better research is available, it remains unclear if dietary soy or soy isoflavone supplements increase or decrease the risk of developing breast cancer.

• Tai chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility, and strength. Early study suggests that tai chi practice may be effective in reducing the impact of tension headaches and may also be effective in improving perceptions of some aspects of physical and mental health.

• Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

• Transcutaneous electrical nerve stimulation (TENS): TENS is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Acupuncturists can use TENS by sticking Japanese acupuncture needles into two sites and taping the needles down with surgical tape to prevent them from moving. Practitioners then hook the needles up to a TENS device and an electrical current is applied. The current now travels into the needles, which stimulates points on the body to get the "chi" or energy to flow in a healthy manner. Preliminary controlled trials suggest that TENS may have some benefits in patients with migraine or chronic headache. Additional well-designed research is necessary before a firm conclusion can be reached in this area.

• Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

• Therapeutic touch (TT): Therapeutic touch practitioners hold their hands a short distance from the patient without actually making physical contact. The purpose of this technique is to detect the patient's energy field, allowing the TT practitioner to correct any perceived imbalances. Therapeutic touch may reduce pain in patients with tension headache, based on preliminary research.

• Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.

• Trigger point therapy: The goal of trigger point therapy for headache is to eliminate the trigger points, and thus extinguish the headache. There have been few studies that address the therapeutic potential of this therapy. Overall, the evidence is positive and demonstrates that this therapy may be effective for headache treatment.

• Use cautiously with local or systemic infection, anticoagulation or bleeding disorders, or acute muscle trauma. Avoid aspirin ingestion within three days of injection. Avoid with extreme fear of needles, large bruises, phlebitis, varicose veins, undiagnosed lumps, or open wounds. Avoid if allergic to anesthetic agents (mainly caused by aminoester agents). Use cautiously during pregnancy.

• Willow bark: Willow bark (Salix alba) contains salicin and has been used to treat many different kinds of pain and various inflammatory conditions, including headache. Limited available study investigated a salicin topical cream for the treatment and/or prevention of migraine and tension-type headache. Although early study is promising, additional study is needed to make a conclusion.

• Avoid if allergic/hypersensitive to aspirin, willow bark (Salix spp.), or any of its constituents, including salicylates. Use cautiously with gastrointestinal problems (e.g. ulcers), hepatic disorders, diabetes, gout, hypertension, or hyperlipidemia. Use cautiously with a history of allergy, asthma, or leukemia. Use cautiously if taking antihyperlipidemia agents, alcohol, leukemia medications, beta-blockers, diuretics, phenytoin (Dilantin®), probenecid, spironolactone, sulfonylureas, valproic acid, or methotrexate. Use cautiously with other tannin-containing herbs or supplements. Avoid operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood disorders and renal disorders. Avoid if taking other NSAIDs, acetazolamide, or other carbonic anhydrase inhibitors. Avoid with elevated serum cadmium levels. Avoid if pregnant or breastfeeding.

• Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Preliminary evidence suggests that yoga may effectively reduce the intensity and frequency of tension or migraine headaches, and lessen the need for pain-relief medications.

• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

• Traditional or theoretical uses which lack sufficient evidence:

• Progressive muscle relaxation: Progressive muscle relaxation involves isolating one muscle group, creating tension for eight to ten seconds, and then letting the muscle relax and the tension go. Individuals can sit (in a comfortable chair), lie on a bed, or lie on the floor (on a comfortable rug or carpet). Muscle groups (including the head, shoulders, arms, hands, stomach, legs, and feet), one at a time, are tensed, then relaxed. This technique has been reported effective in headache prevention, but more studies are needed.

• Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Avoid with fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding.

Prevention

• Keeping a diary: A diary can help an individual determine what triggers the migraine attack. Writing down when a migraine attack begins, how long each phase lasts, responses to medications, foods eaten in the 24 hours preceding an attack, any unusual stresses before the attack, and how the individual feels and what they were doing when a migraine attack begins is important.

• Dietary factors: Identifying and avoiding foods that consistently trigger headaches may be important in helping to reduce the occurrence of migraine headaches. Eat meals at regular times daily and do not skip meals.

• Stress reduction: Integrative therapies that reduce stress, such as yoga, therapeutic touch, and relaxation techniques, are important in reducing migraine attacks.

• Regular sleep patterns: It is important for migraine sufferers to get adequate consistent sleep every night. Healthcare professionals generally recommend eight hours of uninterrupted sleep nightly.

• Regular exercise: Regular aerobic exercise reduces tension and can help prevent migraines. If a doctor agrees, choosing an aerobic exercise, such as walking, swimming, or cycling, may help decrease migraine attacks. Warm up slowly, however, because sudden, intense exercise can cause headaches.

• Caffeine intake reduction: Limiting caffeine consumption to less than two caffeine-containing beverages a day may be of benefit for reduction of migraine attacks.

• Light modification: Avoiding bright or flashing lights, and wearing sunglasses, if sunlight is a trigger, may help reduce migraine attacks.

• Smoking cessation: Smoking cessation is important in decreasing migraine attacks, as smoke can be a potential allergen that triggers a migraine. Also, nicotine, one of the components of tobacco, stimulates vascular activity in the brain that may trigger a migraine attack.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. American Academy of Family Physicians. http://familydoctor.org.

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3. Estevez M, Gardner KL. Update on the genetics of migraine. Hum Genet. 2004;114(3):225-35. View Abstract.

4. Hershey AD, Tang Y, Powers SW, et al. Genomic abnormalities in patients with migraine and chronic migraine: preliminary blood gene expression suggests platelet abnormalities. Headache. 2004;44(10):994-1004. View Abstract.

5. Lang E, Kastner S, Neundorfer B, et al. Effects of recommendations and patient seminars on effectivity of outpatient treatment for headache. Schmerz. 2001;15(4):229-40. View Abstract.

6. Miller VA, Palermo TM, Powers SW, et al. Migraine headaches and sleep disturbances in children. Headache. 2003;43(4):362-8. View Abstract.

7. National Institutes of Health. www.nlm.nih.gov.

8. National Institute of Neurological Disorders and Stroke. www.ninds.nih.gov.

9. The National Headache Foundation. www.headaches.org.

10. The National Migraine Association. www.migraines.org.

11. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

12. National Women's Health Information Center. www.4women.gov.