An estimated 39 million Americans have migraine, with symptoms that can range from mild to severe, according to the Migraine Research Foundation. Migraine attacks previously were thought to be a result of abnormal dilation of blood vessels in the brain, but scientists now believe that the cause may be more complex and involve inherited differences in brain chemistry.
Women are much more likely than men to have migraine, as are people with a family history of migraine, according to the Migraine Research Foundation.
But not all migraine attacks are alike, and not everyone has the same migraine symptoms, says neurologist Alexander Mauskop, MD, a founder and director of the New York Headache Center in Manhattan and White Plains, New York.
The length of time a migraine attack lasts can vary, too. The National Headache Foundation says most migraine attacks last 4 to 72 hours. “But some people have migraines for a shorter time and some people have them for longer — it’s very individual,” Dr. Mauskop says.
Phases of a Migraine Attack
Often a migraine attack involves distinct phases, though people can experience them differently, says Roderick Spears, MD, a neurologist and headache specialist at Penn Medicine in Philadelphia.
Prodrome Phase This first phase of migraine can occur hours to days prior to the attack, says Dr. Spears. “It typically involves a change in mood and energy; certain cravings or excessive yawning can be a sign of prodrome,” he says.
People sometimes confuse these prodrome, or “premonitory,” symptoms, with migraine triggers. That’s to say, a person who craves chocolate as a prodrome symptom may mistakenly believe that consuming chocolate triggered the migraine attack, according to MigraineAgain.
Aura About 25 to 35 percent of people with migraine have aura, says Spears. “The most common aura is a visual change with a kaleidoscope-like phenomenon that can last anywhere from five minutes to an hour but usually much less than an hour,” he says. Other aura symptoms may include tingling sensations, numbness, garbled speech, and clumsiness or weakness.
Headache Phase “This stage can last 4 to 72 hours, and in most patients, it’s marked by a headache on one side of the head that’s throbbing and pulsating in quality. Typically, the pain is described as moderate to severe,” says Spears.
The headache phase is also associated with becoming sensitive to the environment, he adds. “Light, sound, and odor sensitivity are common, as are nausea and vomiting,” he says.
A survey of 1,100 U.S. adults with migraine published online in May 2020 in Headache found that 44 percent of people reported that the headache or attack phase of migraine lasts for up to 24 hours, while one-third said it can persist for more than 24 hours.
Postdrome or Recovery Phase This phase — where there’s no pain or very mild pain, but people don’t feel normal — can last 24 to 48 hours, says Spears. “They’re not as sharp cognitively, and they can feel ‘hungover,’” he says.
“There are also some people who feel elated — almost euphoric — because they don’t have the pain anymore, and they’re full of energy, even verging on hyper,” he says.
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How to Shorten Your Migraine Attack
If you recognize the signs that a migraine attack may be coming on, you may be able to reduce the amount of time it lasts, says Spears. “Often the person with migraine doesn’t always recognize the prodrome phase, but someone close to them — a spouse or family member — may pick up on it,” he says.
Spears offers a few tips to potentially reduce the length of your migraine attack:
- Aggressively hydrate. Drinking a lot of water is usually helpful.
- Limit your physical activity. If possible, sit or lie down somewhere.
- Avoid stimulating environments. Go to a dark, quiet place.
Some people find that relaxation techniques, such as meditation or massage, will help release the tension they feel in their face, jaw, or neck. If you can release tension with these techniques, your migraine attack may not be as severe or last as long. Others find that putting a cold compress on their temples will help relieve their migraine symptoms and keep their migraine from lasting as long, Mauskop says.
Acute Drug Treatment to Stop a Migraine Attack
There are several different medication options for treating a migraine attack once it’s begun. The type of migraine you have as well as the frequency and severity of your attacks is something you should discuss with your doctor when developing a treatment plan.
For people with mild to moderate symptoms, over-the-counter medications are often sufficient to relieve them, according to the American Migraine Foundation. These include:
Your doctor may also prescribe any of a number of drugs for acute treatment of migraine. Generally speaking, acute migraine treatments work better the earlier in the attack you take them, before the pain has gotten severe. Triptans are the most commonly used acute migraine medications, and gepants and ditans are two new classes of migraine drugs that may be helpful if you can’t take triptans or are not helped by them.
Triptans
There are seven different triptan drugs, of which sumatriptan (sold as Alsuma, Imitrex, Onzetra, Zembrace, and Treximet, which is a combination of sumatriptan and naproxen) is probably the best known. All of the triptans are available as pills, two as nasal sprays or powders, and one as a self-administered injection.
Most triptans start relieving pain in 30 to 60 minutes, although two longer-acting triptans, Amerge (naratriptan) and Frova (frovatriptan), take one to three hours and about two hours, respectively, to start working. Many people report being pain-free within two hours of taking a faster-acting triptan, according to MigraineAgain.
If migraine pain recurs within 24 hours of taking a triptan, a second dose may be needed. But migraine recurrence may be an indication that a different triptan or different dose of the one you’re taking may work better for you, according to Eric Baron, DO, writing for Virtual Headache Specialist.
Because one of the effects of triptans is to narrow blood vessels in the brain, these medications should not be used by people with coronary artery disease, a history of stroke, peripheral vascular disease, or uncontrolled high blood pressure. Women who are pregnant or planning to become pregnant should discuss the relative risks and benefits of using triptans during pregnancy, according to John Rothrock, MD, and Deborah Friedman, MD, writing for the American Headache Society (PDF).
Gepants
A new class of migraine drugs called calcitonin gene-related peptide (CGRP) receptor antagonists may be an alternative for people who can’t use triptans because of vascular disease, because they do not narrow the blood vessels. CGRP receptor antagonists are also sometimes called “gepants” because of how the drugs in this class are named: Nurtec ODT (rimegepant) and Ubrelvy (ubrogepant).
According to Spears, “These medications target a different neurotransmitter pathway than triptans.”
Both Nurtec and Ubrelvy begin reducing migraine pain within 60 minutes. In studies, 20 percent of participants who took either drug reported being pain-free after two hours, and 35 percent of those who took Nurtec ODT and 34 percent of those who took Ubrelvy reported being free of their “most bothersome symptoms,” such as nausea, sensitivity to light, and sensitivity to sound, in that time.
However, the drugs can also cause nausea, as well as sleepiness, as a side effect.
Data on Nurtec ODT was published online on July 13, 2019, in The Lancet, while data on Ubrelvy was published online on November 19, 2019, in The Journal of the American Medical Association.
Ditans
Reyvow (lasmiditan) belongs to a new class of headache medication called selective 5-HT(1F) receptor agonists, or ditans, for short. The drug binds to a particular type of serotonin receptor found on the trigeminal nerves, according to the American Headache Society. It does not constrict blood vessels and may therefore be another alternative for people who can’t use triptans because of vascular disease.
Reyvow is available as a tablet in three dose sizes. In research published on July 24, 2019, in The Journal of Headache and Pain, about 30 percent of people who took Reyvow reported that their pain and their most bothersome migraine symptom had resolved two hours after treatment.
No more than one dose of Reyvow should be taken in 24 hours, and people should not drive or operate machinery for eight hours after taking Reyvow. Common side effects include dizziness, fatigue, abnormal skin sensations (such as tingling or numbness), and sleepiness, according to RxList.
Other Acute Migraine Treatment Options
In addition to the drugs mentioned above, other options for acute migraine relief include the prescription NSAID Voltaren (diclofenac); a class of drugs called ergots, which are sometimes used in people who don’t respond to triptans; and a variety of neurostimulation devices that deliver magnetic or electric pulses to specific nerves involved in migraine.
If the combination of drugs and home remedies you’re using to stop migraine attacks isn’t working, speak to your doctor about other treatment possibilities.
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The Danger of Using Acute Migraine Medication Too Often
When people with migraine use acute medication too often, they can develop medication-overuse headache, according to the American Migraine Foundation. These headaches are also known as rebound headaches.
The risk of medication-overuse headaches can put people with migraine in a difficult position, says Spears. “Migraine is a condition where the sooner you treat it with medication, the more likely it is that you’ll be successful in stopping it. At the same time, if you take your rescue medication too frequently, it will lead to rebound,” he says.
Most of the medications commonly used to treat migraine attacks, such as aspirin, NSAIDs, acetaminophen, triptans, and others, have all been associated with rebound headaches, according to the American Migraine Foundation. It’s recommended that people don’t take these medications for acute treatment of migraine for more than two days a week.
The one class that hasn’t been shown to cause medication-overuse headache is gepants, says Spears. But “we still try to limit patients to using them two days a week,” he says.
What If a Migraine Attack Lasts 3 Days or More?
A debilitating migraine attack that lasts longer than 72 hours and doesn’t respond to normal treatment is called status migrainosus, or intractable migraine.
It can be more medically serious than a normal migraine attack, especially if symptoms such as vomiting are prolonged, due to the risk for severe dehydration, according to the National Headache Foundation.
Status migrainosus is what brings many people to the hospital emergency department, where a variety of IV drugs may be administered to break the pain cycle.
Could My Migraine Attack Be a Symptom of COVID-19?
“We are still learning about migraine and COVID-19,” says Spears. “We do know that the COVID-19 headache usually presents differently than a typical headache. It’s been described as intense pressure in the head that is made significantly worse with coughing and sneezing,” he says.
Is it true that people with migraine are more likely to experience headache as a symptom of COVID-19? There isn’t enough data to know if that’s the case with COVID-19, but it is true in many other conditions, says Spears.
“If someone has migraine and they develop a sinus infection, they’re more likely to develop a migraine-like headache. When people with migraine have anything going on that’s head- or neck-related, they’re more likely to experience a migraine-like headache,” he says.
This also applies in people with migraine who also have diabetes or high blood pressure, says Spears. “If something is going on in the entire body or systemically, they’re more likely to manifest that in migraine-like headache if they have a history of migraine,” he says.
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Preventing Future Migraine Attacks
In addition to there being medication that can stop a migraine attack in progress, there are also drugs that can be taken for migraine prophylaxis, or preventive therapy, as a way to reduce the frequency and severity of migraine attacks.
Preventive migraine treatments include prescription medications that were originally developed for epilepsy, depression, or high blood pressure — these can often prevent future attacks, Mauskop says. They also include a newer class of drugs called CGRP antibodies that were developed specifically to treat migraine.
Women whose migraines are associated with their menstrual cycles may find relief through taking certain types of hormonal birth control or hormone replacement therapy, although in some cases, these options can make migraine worse, according to the American Migraine Foundation.
Many people do get migraine relief from various treatments. “However, if your headaches persist or they last a long time, you should seek medical help from a neurologist or headache specialist,” says Mauskop. “You shouldn’t self-treat migraines if they are unusually long or you’re having them for the first time.”
Additional reporting by Beth Orenstein.