Migraine: Why It Happens and What Helps
Migraine is a disorder of how the brain processes signals, not a headache caused by tension or weak eyesight. A typical attack is a throbbing pain, usually on one side, lasting from four hours to three days, made worse by movement and accompanied by nausea and a strong dislike of light and noise; about one person in four also gets an aura, most often flickering zigzag lines in the vision, for twenty to sixty minutes before the pain. Treatment has two halves: stopping an attack early with paracetamol or an anti-inflammatory taken at the first sign, or with a prescribed triptan when those are not enough; and, for people having attacks on more than four days a month, a daily preventive medicine that reduces how often they come. The most important thing most people can change is trigger management — regular meals, regular sleep, enough water in the heat, and limiting painkillers to fewer than ten days a month, because taking them more often than that causes a daily headache of its own.
Health writers · Aslam Clinic
What a migraine is
A migraine is not a severe version of an ordinary headache. It is an inherited tendency for the brain to become temporarily over-excitable, during which a wave of altered electrical activity spreads across the surface of the brain, the trigeminal nerve system is activated, and inflammatory chemicals are released around the blood vessels of the head. That process produces the pain — but it also produces everything else about an attack: the nausea, the intolerance of light, the difficulty finding words, the exhaustion the day after.
Attacks often move through phases. A day or two before, many people notice a warning stage — yawning, food cravings, mood change, neck stiffness, unusual energy or unusual fatigue. Some then get an aura. Then comes the headache itself, from four hours to three days if untreated. Afterwards there is a recovery stage, often described as feeling wrung out or hungover, that can last another day. Recognising the warning stage is useful, because treatment taken then works better than treatment taken at the peak.
What it feels like, compared with other headaches
| Migraine | Tension-type headache | Needs urgent assessment | |
|---|---|---|---|
| Where | Usually one side, may swap sides between attacks | Both sides, like a band around the head | Anywhere, but new and unfamiliar |
| What it feels like | Throbbing, pulsating | Pressing, tightening, dull | Sudden, explosive, worst-ever |
| How long | 4 to 72 hours | 30 minutes to several days | Reaches peak within a minute |
| Effect of movement | Worse — climbing stairs makes it worse | No real change | Often worse on coughing or lying flat |
| What comes with it | Nausea, dislike of light and noise, aura | Usually nothing else | Fever, stiff neck, weakness, confusion, fit, visual loss |
| What to do | Treat early; keep a diary; consider prevention if frequent | Simple painkillers sparingly; address posture, stress and sleep | Emergency department, today |
Aura
About one person in four with migraine gets an aura. It is a neurological event that comes on gradually over about five minutes and lasts less than an hour, usually just before the pain. The commonest form is visual: a small flickering spot that expands into a shimmering zigzag arc across the field of vision, sometimes leaving a blind area behind it. Others get tingling that creeps up one hand and into the face over several minutes, or temporary difficulty finding words.
Two things about aura matter clinically. First, its speed distinguishes it from a : aura spreads over minutes and clears; stroke symptoms appear all at once and stay. Second, migraine with aura carries a small increase in stroke risk, which becomes clinically important in women who also smoke or use combined oral contraceptives — combined pills are generally avoided in women who have migraine with aura, and that is worth raising with the doctor prescribing them.
What sets an attack off
Triggers rarely act alone. Most people have a threshold, and an attack happens when several things stack up on the same day — a short night, a missed lunch, and a long drive in the heat, rather than any one of them. A diary kept for a month is far more useful than a list of things to avoid.
- Missed or delayed meals, and the drop in blood sugar that follows. One of the most consistent triggers, and one of the easiest to fix.
- Irregular sleep — too little, too much, or a shifted schedule. Weekend migraines are often a lie-in.
- and heat. In a Punjabi summer this is a leading trigger in its own right, and the fix is water and shade rather than a tablet.
- Hormonal changes. Many women have attacks in the two days before and the first three days of a period, and these are often longer and harder to treat.
- Stress — and the relief afterwards. Attacks commonly arrive on the first day of a holiday rather than during the crisis.
- Bright or flickering light, loud noise, and strong smells — perfume, paint, incense, petrol fumes.
- Caffeine, in both directions. Regular strong chai keeps some people stable and gives others attacks; abruptly stopping causes a withdrawal headache within a day.
- Certain foods in some people: aged cheese, chocolate, processed meats, monosodium glutamate. Far less universal than the internet suggests — test with a diary rather than eliminating everything.
- Fasting, including during Ramadan, through the combination of missed meals, dehydration and caffeine withdrawal.
- Overuse of painkillers, which is dealt with in its own section below.
How it is diagnosed
Migraine is diagnosed from the history and a normal neurological examination. There is no blood test and no scan that confirms it — a normal does not rule migraine in or out, because migraine does not show on one. A doctor will ask how long attacks last, what the pain is like, what comes with it, what makes it worse, how many days a month you have headache, and how many days a month you take something for it.
Imaging is reserved for people with the red-flag features listed above, for a headache pattern that has changed, for a first headache after 50, or for an abnormal finding on examination. Ordering an or for typical migraine is not reassurance — it finds harmless incidental spots in a substantial minority of people, and those then need explaining, following up and worrying about. Blood pressure is checked, and thyroid function or may be tested where the picture suggests them.
Stopping an attack
The single most important principle is speed. Treatment taken within the first twenty minutes of pain starting works far better than the same treatment taken two hours later, because once the attack is fully established the stomach slows and tablets are poorly absorbed. Waiting to see whether it will be a bad one is the commonest self-inflicted reason a migraine becomes unmanageable.
- Paracetamol, 500 mg to 1 g for an adult, up to a maximum of 4 g in twenty-four hours from all sources combined. Effective for mild to moderate attacks, particularly taken early.
- An such as ibuprofen or naproxen, taken with food. These work well for many people. Avoid them if you have , a stomach ulcer, kidney disease, uncontrolled high , or are in the later part of pregnancy, and do not combine two of them.
- A triptan, which is a prescription medicine designed specifically for migraine and works on the mechanism rather than on pain alone. Several are available in Pakistan. Which one, at what dose, and whether it is safe for you depends on your heart and blood-pressure history, so it is a prescriber's decision.
- An anti-sickness medicine, prescribed both for the nausea and because it helps the stomach absorb whatever else you have taken.
- A dark, quiet room and sleep, which for many people ends an attack more reliably than anything in a packet.
- Cold on the forehead or the back of the neck, and a cool drink. Simple, and it helps some people considerably.
Preventing attacks
A daily preventive medicine is worth discussing if you have migraine on four or more days a month, if attacks are severe enough to stop you working or studying, or if attack treatments are not working or cannot be used. The goal is realistic: a good result is roughly halving the number of attack days, not eliminating headache. Every preventive takes six to twelve weeks at an adequate dose before its effect can be judged, and the commonest reason one is declared useless is that it was abandoned in week three.
| Class | Often chosen when | Points to raise with your doctor |
|---|---|---|
| Beta blockers (propranolol) | There is also high or performance anxiety | Avoided in ; can cause tiredness and cold hands |
| Tricyclics (amitriptyline) | There is also poor sleep, tension-type headache or neuropathic pain | Taken at night; dry mouth and morning grogginess are common early on |
| Anti-epileptics (topiramate, sodium valproate) | Attacks are frequent and other classes have failed | Topiramate can cause tingling, word-finding difficulty and weight loss. Sodium valproate must not be used by women who could become pregnant — it causes serious birth defects |
| Candesartan | There is also high | Not used in pregnancy; kidney function is checked |
| CGRP monoclonal antibodies | Several other preventives have failed | Given by monthly or quarterly injection; expensive and not widely available here |
| Riboflavin (vitamin B2) and magnesium | A person prefers to start with something non-prescription | Modest evidence, few ; still worth telling your doctor about |
What you can do yourself
- Keep a headache diary for at least a month: date, start time, how long, how bad out of ten, what you took, whether it worked, and what happened in the twenty-four hours before. This is the single most useful thing you can bring to an appointment.
- Eat at regular times, including breakfast. Do not skip lunch and expect to be fine.
- Keep sleep and waking times within about an hour of each other every day, weekends included.
- Drink enough, particularly between April and September. Two to three litres a day in the heat, more if you work outdoors.
- Count the days a month you take any painkiller. If it is more than ten, that is a finding in itself.
- Treat early, at the first hint, and take a full dose rather than half.
- Address the things that lower the threshold: untreated anxiety, poor sleep, and neck and shoulder strain from long hours at a screen or a sewing machine.
Migraine in women
Migraine is two to three times commoner in women, and much of that difference is hormonal. Attacks around a period tend to be longer, more severe and less responsive to treatment, and there are specific approaches for them worth asking about. Migraine usually improves during pregnancy, particularly after the first trimester — paracetamol is the preferred treatment then, and most other migraine medicines need review before conception rather than after a positive test. Attacks often worsen temporarily around the menopause before settling. And, as above, combined hormonal contraception is generally avoided in women who have migraine with aura.
When to see a doctor
Book an appointment if headaches are stopping you working, studying or looking after your family; if you are taking a painkiller on more than ten days a month; if attacks are becoming more frequent; if over-the-counter treatment is not working; or if you have never had the diagnosis confirmed. Ask specifically about prevention if you are having four or more headache days a month. And use the emergency guidance near the top of this page for a sudden worst-ever headache, a headache with weakness or confusion, or a headache with fever and a stiff neck — those are not migraine appointments.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
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