How Do Migraines Start?Where Migraine Live?

Despite their prevalence, migraines are still one of the most poorly understood medical disorders. Most people assume that a migraine involves a headache, but we now know that is not necessarily the case. A definitive cause of migraines has not yet been discovered, largely because most people vary dramatically in their reported causes and symptoms. For a long time, they were believed to be caused by problems with the blood vessels in the head; however, it is now understood that migraines are a disorder of the central nervous system.

Although the exact chain of physical and chemical events that occurs in the brain in advance of a migraine is unclear, it appears that migraines are sometimes caused by changes in the brain stem and its interactions with the body’s largest cranial nerve and its major pathway to pain, the trigeminal nerve. Sometimes, they may be caused by imbalances in brain chemicals—predominantly serotonin, which helps regulate pain in the body as well as control mood, sleep, and appetite. Serotonin levels drop during migraine attacks, which may cause the trigeminal nerve to release neuropeptides—the molecules through which neutrons communicate with one another. These neuropeptides then travel to the meninges—the protective membrane covering the brain—resulting in headache pain.

“I have had a long history with migraines. Early on, I identified triggers such as secondhand cigarette smoke; then, later, alcohol, caffeine, stress, sudden changes in barometric pressure, and hormonal fluctuations. In the last two years, I’ve seen remarkable results by avoiding sugar, dairy, and gluten, and eating primarily organic foods. It’s been a long road, but I’m grateful to be on this side of understanding and controlling my condition.”

—Lori, nurse, age 54

Within about 10 minutes, the pain-sensing nerves in this network become hypersensitive to pressure. They are so sensitive, they become affected by the natural rise and fall of blood pressure occurring during each heartbeat, which produces the feeling of throbbing pain within the head. Alongside these changes, an unknown factor seems to contribute to the dilation of blood vessels, which in turn produces abnormal activity at the surface of the brain.

On the Migraine Spectrum

As a migraine is more than just the headache most people think of, and symptoms vary greatly from person to person, it is difficult to pin down exactly what a migraine is not. That said, many people mistakenly believe that a migraine is simply a recurring bad headache that can be fixed by popping a few painkillers; in fact, the majority of headaches are not migraines. As explained earlier, a migraine is a severe, debilitating condition with a clear set of symptoms that do not occur alongside regular headaches. Finally, many migraines do not even involve the presence of severe head pain.

Regular headaches can successfully be treated with standard medicine or rest, and they do not typically last for longer than a day. There are different types of headaches, but they are not as serious as migraines as they generally do not interfere with productivity and quality of life. Other headaches may present like migraines but in actuality be either a tension headache or a cluster headache. Increasingly, however, physicians believe the following are extremes on the migraine spectrum—what separates these from what we think of as “true” migraines is that they are typically unaffected by dietary changes.

Tension Headaches

Tension headaches are the most common type of headache, with an estimated 80 to 90 percent of the population suffering from at least one in their lifetime (American Headache Society). Characterized by a dull ache, tension headaches are typically caused by muscle tension, caffeine withdrawal, lack of sleep, or dehydration. The pain typically occurs throughout the head, across the forehead, or at the base of the neck and is generally rated as mild to moderate in severity. These recurrent headaches can last anywhere from minutes to days.

Cluster Headaches

Cluster headaches are commonly distinguished by a sudden and severe pain behind or around the eye, which typically peaks within 10 minutes but can last up to three hours. They can be accompanied by other symptoms such as watering eyes, nasal congestion, and swelling around the side of the eye where pain is being experienced.

The main difference between these types of headaches and a migraine is that the former usually respond to over-the-counter pain relievers. None of the symptoms associated with migraines such as aura, nausea, and sensory sensitivity are present with these other types of headaches.

Triggers and Thresholds

There are two important factors to consider regarding the onset of migraines: triggers and thresholds. A trigger is an external stimulus or physical act that increases the sensitivity of the sensory system and can result in a migraine. Some of these sensors are “external” and affect the olfactory, auditory, and ocular nerves which, in turn, explains a migraineur’s potential sensitivity to smell, noise, and lights, respectively. The “internal” sensors are thought to be located within the brainstem, and are those that react to fatigue, stress, hormonal, and barometric pressure.

“Starting at age eight, my migraines were episodic until my mid to late twenties, when the condition became chronic. I still live with the disorder. Four years ago I stopped using prescription medications due to their side effects and ineffectiveness. I manage my pain through the use of a neurostimulator, Botox injections, and natural pain relief methods. I avoid my individual food triggers (alcohol, peanuts, and popcorn, among others) and exclude dairy, soy, gluten, and processed foods from my diet.”

—Valerie, age 37, Virginia

The brains of migraineurs have been shown to have a poor ability to adapt to strong sensory stimulation, which is why these triggers do not cause negative reactions in all people. Because of the accompanying chemical changes that occur inside the body during a migraine, being exposed to triggers does not always result in migraines. This is where the idea of a migraine threshold comes into play.

Everyone has a threshold, which is determined by genetic makeup. This threshold is raised or lowered by both internal and external factors. When a sufficient number of different internal and external triggers build up, a migraineur’s threshold may be crossed, resulting in a migraine.

Triggers

The following are common contributing factors to migraines. Remember that exposure to just one of the following may not always be sufficient to cause an attack.

Alcohol. Alcohol can cause two different types of migraine. The first occurs when you experience a more immediate attack, occurring within a few hours of drinking. The second is a delayed hangover-type headache; many people develop a headache after a night of heavy drinking, but the pain is intensified in migraineurs. Those who report alcohol to be a trigger only need the smallest amount to be affected, so it is best to abstain.

Bright Lights. Many people are negatively affected by bright light such as fluorescent and strobe lighting and sun glare as well as flickering sunlight.

Caffeine. Highly caffeinated beverages are closely tied to migraine episodes. Most people have heard about the horrible headaches that can occur when a regular person suffers caffeine withdrawals, due to its addictive properties. As you might imagine, these headaches can be significantly worse for migraineurs.

In some cases, caffeine can be strategically used to prevent an oncoming migraine during the prodrome or aura stage. Many pain-relieving medications contain caffeine, and even a shot of espresso can help. This is because caffeine constricts cranial blood vessels, which counteracts the dilation effect that usually causes a migraine. Furthermore, it enhances the absorption of other medications.

Personally, when I suffered from more regular attacks, I could prevent an episode by drinking coffee if I recognized the oncoming signs of a migraine early enough. It worked well as I never consumed caffeine outside of these times.

Computer Screens. Using a computer for long periods of time can be problematic for migraineurs, both due to the strain on the eyes and the buildup of muscular tension in the neck and shoulders.

Dehydration. Even mild dehydration can cause migraines, so it is important to ensure you drink at least eight glasses of water per day. Caffeine and alcohol also have a dehydrating effect, so you should be all the more careful about consuming them.

Environmental Extremes. Severe heat and other extremes in weather, including changes in barometric pressure, are thought to cause migraines. There is not much that can be done to avoid these triggers; however, certain preventive treatments can help reduce your sensitivity to these factors.

Foods. While this will be discussed in significantly more detail in part 2 of this book, it is widely accepted that salty and processed foods, aged cheeses and other dairy products, fermented and pickled foods, and foods containing the additive tyramine (such as soy products, fava beans, sausages, and smoked fish) often cause migraines. The sweetener aspartame and the preservative monosodium glutamate (MSG) are also widely thought to trigger migraines. Even certain types of fruits and vegetables are recognized as triggers.

High Stress Levels. A sudden increase in stress at home or at work will alter the chemicals in your body and increase muscle tension, both of which frequently lead to migraines. Interestingly enough, the converse is also true as a sudden reduction in stress can cause an attack. For example, it is not unusual to be struck down by a migraine on the weekend or when you go on vacation.

Hormonal Fluctuations. Estrogen fluctuations during a normal menstrual cycle are often strongly linked to migraine patterns among females. Women with histories of migraines typically report attacks occurring before or during their periods, when they experience a major drop in estrogen. Many women also report that their suffering began at puberty, with the onset of their first period (The Migraine Trust, 2015).

Those women who already experience migraines often report an increase in their intensity of attacks during both pregnancy and menopause. In addition, women who have never previously had a history of migraines can be suddenly stricken during these two moments of significant hormonal change.

Skipping Meals. Missing meals or fasting will cause blood sugar levels to drop, which can in turn trigger migraines. Similarly, frequently eating sugary snacks instead of proper meals will create peaks and valleys in your blood sugar levels.

Sleep. There is a strong correlation between sleep and migraines. Although it may seem obvious that sleeping too little can bring about migraines, sleeping too much can also be problematic. New sleep schedules and jet lag can also trigger migraines. Those who suffer from migraines often report having difficulty falling asleep and frequently waking up feeling tired.

Unusual Smells. The most common smells thought to spark migraines include perfume, secondhand smoke, air freshener, and paint thinner.

Threshold

As mentioned previously, a combination of the aforementioned triggers can accumulate past your threshold and result in a migraine. This explains why certain triggers do not always cause migraines on their own or in various combinations. For example, your three worst triggers may be red wine, bright sunshine, and lack of sleep, but one of those triggers on its own may not be enough to provoke a migraine. If all three occur simultaneously, however, you may be more likely to cross your threshold.

By identifying your most problematic triggers, you can better avoid reaching your own personal threshold and thereby reduce the frequency of your migraine attacks. It is important to keep in mind that individual thresholds will vary from day to day and from environment to environment, and some days you will be more vulnerable to certain triggers.