Causes and Risk Factors of Migraine

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Migraine is more than just a bad headache that occurs from time to time. It’s a neurological disease that typically causes severe, throbbing headaches that are often accompanied by visual disturbances, nausea, vomiting, and extreme sensitivity to light, sound, touch, and smell.

Episodes of migraine symptoms are referred to as migraine attacks, and they can last from a few hours to a few days. However, some people with chronic migraine have symptoms on most days of the month.

Chances are, you or someone you care about has migraine: It’s the third most common illness in the world, and nearly 1 in 4 households in the United States includes someone with migraine, according to the Migraine Research Foundation.

Experts are still learning about the complexities of migraine and what causes it. There are things that make certain people more likely to have migraine disease, and there are factors that can increase the chances of a migraine attack.

Genetics and Migraine

Genetics play a fairly significant role with migraine, according to Roderick Spears, MD, medical director of neurology at Penn Medicine in Pennsylvania.

“If you have migraine, you have about a 75 percent chance of having a first-degree relative with migraine. It can be passed equally from both the mother’s and the father’s side,” Dr. Spears says, adding that family history is particularly important in migraine with aura.

In migraine with aura, a person experiences visual, sensory, or speech-language symptoms for several minutes up to an hour, usually followed by a headache. Visual symptoms may include flashes of light or temporary vision loss. Sensory symptoms can include numbness and tingling. And speech-language symptoms include difficulty speaking.

Even though the strength of the genetic component is highest for migraine with aura, the specific genes related to that connection aren’t known.

“We have the genetic map of specific types of migraine that are very rare, such as hemiplegic migraine, but for common migraine that most people experience, we don’t have a specific gene that’s been identified,” says Spears.

Many other factors may affect whether a person will have migraine, as demonstrated by a study of twins published in the Journal of Psychosomatic Research. The study found that even monozygotic (identical) twins don’t have the same risk for migraine; if one has it, the other has a 26 percent chance of having it, not 100 percent. The same study found that in nonidentical twins, the likelihood of both having migraine was 13 percent.

The Role of Hormones in Migraine

“If you look at children, boys and girls have about the same rate of migraine, but that changes at puberty, with women jumping to a 3 to 1 ratio. The estrogen hormones, specifically, play a pretty significant role in the expression of migraine,” says Spears.

Girls are more likely to have the onset of migraine around the time of their first menstrual cycle, with migraine prevalence in women peaking during childbearing years, according to the American Migraine Foundation.

It’s very common for women to get migraine around their menstrual period, according to Nada Hindiyeh, MD, a headache specialist and researcher at Stanford Health Care in Palo Alto, California. “There are several different types of migraine, and there is a subset of migraine that is related to the menstrual cycle.”

“We believe the reason many women get migraine around their menstrual cycle is because of the drop in estrogen that happens right as the cycle starts. That’s a big trigger for migraine,” says Dr. Hindiyeh.

Increasing levels of estrogen, which happen during pregnancy, and stable ovarian estrogen production, as occurs after menopause, appear to reduce the risk of migraine attacks, according to a review published in Current Opinion in Neurology.

Neurotransmitters and Migraine

Both depression and anxiety are common in people with migraine. About 1 out of 4 people with migraine have depression and about 1 in 2 have anxiety, according to the American Migraine Foundation.

Neurotransmitters are chemicals that carry signals from one neuron, or nerve cell, to another and from neurons to muscle cells. The messages communicated by neurotransmitters control a variety of functions in the body, some of which play a role in anxiety and depression.

There’s evidence to suggest that the neurotransmitters serotonin, which affects functions such as mood, sleep, and hunger, and dopamine, which affects things like motivation and learning, play a role in migraine as well.

Some experts believe that migraine pain occurs because of waves of activity by groups of excitable brain cells, which could cue chemicals such as serotonin to narrow blood vessels, according to Johns Hopkins Medicine.
PET scans of the brain have revealed that dopamine levels fall and fluctuate at different times during a migraine attack, according to research published in April 2017 in Neurology.

According to the authors, physicians and emergency department personnel often give people with migraine dopamine antagonists, which are drugs that block overactive dopamine receptors, to level off big dopamine fluctuations, which can ease migraine attacks.

The investigators found that when people with migraine are between attacks, their dopamine levels were stable and normal, but during the attack, the levels fell significantly.


The Difference Between Causes and Triggers of Migraine

While the underlying cause of most types of migraine — or why one person has migraine and another doesn’t — remains unknown, the various triggers for a migraine attack are better understood. Those include the following:

  • Changes in hormone levels, particularly in women
  • Allergies
  • Environmental conditions, which include changes in weather, stress levels, and food intake, as well as odors and lack of sleep
  • Certain medications, including nitroglycerin and phosphodiesterase inhibitors, which are used for sexual dysfunction and include Viagra (sildenafil) and Cialis (tadalafil)
  • Dehydration, even mild dehydration
  • Excessive caffeine consumption or reduced caffeine consumption
Identifying one’s personal triggers can be difficult, according to the Migraine Trust, since it can take numerous triggers to result in a migraine attack and a particular trigger may not lead to an attack every time it occurs.

Environmental Triggers of Migraine

“The migraine brain is a brain that likes what we call homeostasis; it does not like a lot of change. When there is change in weather, light, noise, even nutrition — those types of situations will tend to trigger migraine attacks,” says Spears.

According to the National Headache Foundation, the types of environmental factors that can trigger a migraine attack include the following:
  • Weather changes, including changes in humidity, temperature, or barometric pressure
  • Extreme cold, extreme humidity, or a very dry, dusty atmosphere
  • Bright lights, flickering lights, and glare
  • Fumes and vapors, including tobacco smoke and carbon monoxide
  • Intense odors
  • Motion sickness from travel in a car, train, or boat
  • Changes in routine that affect stress level, eating, or sleeping
  • Physical overexertion
Can Head Trauma Cause Migraine?

“We know that it’s fairly common to have headache after head trauma,” says Spears. If you have a genetic predisposition for migraine, you have a greater chance of that post-traumatic headache presenting as a migraine-type headache, he adds.

“But there are cases of people who never had headaches, have no family history of headaches, and after head trauma they end up with persistent, severe, migrainelike headaches going forward. They usually don’t have them every day, but they are more prone to them after head trauma,” says Spears.

A study published in 2018 in The Journal of Headache and Pain found that people hospitalized due to a mild head injury were more likely to develop new headache onset or report exacerbation of existing headache compared with the general population.

Does Child Abuse, Maltreatment, or Other Psychological Trauma Cause Migraine?

There is evidence that abuse in childhood is associated with a higher risk of developing migraine later in life, says Spears. Research published in January 2017 in the journal Headache found that children who experienced emotional abuse may be more likely to experience migraine as young adults. Emotional abuse was assessed by asking study participants how often a parent or other adult caregiver said things that really hurt their feelings or made them feel like they were not wanted or loved. Emotional abuse was more strongly linked to the likelihood of future migraine than physical or sexual abuse, according to the study.
An earlier study compared the effects of emotional abuse, emotional neglect, and sexual abuse in childhood. It found that while all of these types of abuse were associated with a higher risk of migraine, the association was strongest for emotional abuse. Emotional abuse was evaluated by asking people how frequently such statements as “People in my family said hurtful, insulting things to me” were true, whereas emotional neglect was evaluated by asking people how frequently such statements as “Someone in my family helped me feel that I was important, special” were true. Sexual abuse was determined by asking people how frequently such statements as “Someone tried to pressure or force me to have unwanted sexual contact” were true.

What Is the Risk of Episodic Migraine Becoming Chronic Migraine?

Episodic migraine is defined as less than 15 headache days per month, while chronic migraine is 15 or more days per month of headache with migrainous features, says Spears. “There is a risk of progressing from episodic migraine to chronic migraine that’s in a range of 1.5 percent to 3 percent per year,” he says.

A review published in March 2019 in the journal Headache analyzed 17 studies that looked at risk factors for developing chronic migraine, says Spears.
 These factors had the strongest evidence for progressing from episodic migraine to chronic migraine:
  • Acute medication overuse, meaning three or more days per week of using acute medications to treat headache
  • Depression
  • Increasing headache day frequency

Increasing headache and acute medication overuse can go together, says Spears. “For example, if you have someone who has two headaches a month, and they notice that increases to more like one headache a week, then two headaches a week, and then they start to treat those headaches with acute medication, which leads to more headache,” he says.

This can turn into a vicious cycle of increased headache days leading to increased treatment days, says Spears. “As you treat more, your risk to progressing to chronic migraine goes up.”

Nonmodifiable Risk Factors for Migraine and Migraine Attacks

Risk factors that a person doesn’t really have control over are known as nonmodifiable risk factors. For migraine, those would include the following factors:
  • Age and Gender Migraine is more prevalent in women between age 20 and 45.
  • Low Socioeconomic Status Research published in Cephalalgia found that women with lower socioeconomic status had increased risk of migraine and increased risk of more frequent migraine attack.
  • Head Injury The majority of people who have a concussion have a headache with migraine features afterward, according the American Migraine Foundation.

Modifiable Risk Factors for Migraine Attacks

Spears suggests these ways to reduce the risk of migraine attack:

  • Lose excess weight or prevent the development of obesity. According to the American Migraine Foundation, obesity is associated with episodic migraine progressing to chronic migraine.
  • Limit caffeine intake.
  • Monitor headache frequency and use of acute medication.

“The thinking is that if you go past two [migraine] days a week, you really need to seek medical care for your headache to get it investigated and potentially get onto a treatment plan to keep the frequency down,” says Spears.

Improving your sleep habits has also been found be effective in reducing migraine attack frequency. A study published in Headache found that women who followed simple instructions for improving sleep (including scheduling enough time for sleep; avoiding watching television, listening to music, or reading in bed; practicing visualization to go to sleep faster; avoiding naps; and limiting food and drink in the hours prior to bedtime) had fewer headaches, and when they did have one, it was less intense.
Keeping track of your daily habits — such as when and what you eat or drink, when you sleep, and how much physical activity you get — can also sometimes help identify triggers for migraine so that you can avoid them in the future, according to MedlinePlus.

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Photo by: Daniel Szwalkiewicz

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