Why Migraines Happen and How to Manage Them

A migraine is more than just a bad headache. It is a complex neurological condition that can leave a person bedridden for hours, even days at a time suffering from pounding head pain, nausea, and an extreme sensitivity to light and sound. Yet despite how debilitating it can be, migraine is frequently undertreated, often because it is not fully understood, either by patients or by those around them.

Understanding migraine causes and management is the first step toward feeling better.

What happens in the brain during a migraine

Migraines are a neurological event, not simply a vascular one. A key process involved is cortical spreading depression, a wave of electrical and chemical changes that moves across the brain's cortex and is thought to be responsible for the aura phase that some migraine sufferers experience before the headache begins.

At the same time, a neuropeptide known as calcitonin gene-related peptide, or CGRP, plays a central role. CGRP is one of the principal mediators in migraine and causes the vasodilation and neurogenic inflammation that leads to the pain phase. When released in high doses, it activates pain pathways in the trigeminal nerve system, the network of nerves that carry feeling across the face and head, resulting in the acute, typically one-sided pain that is characteristic of a migraine attack. 

This is why migraines feel so different from a tension headache, and why standard painkillers often fail to provide adequate relief.

What triggers a migraine

Most migraine patients have identifiable triggers, specific factors that, when they cross a threshold, set off an attack. Common migraine triggers include:

• Stress and anxiety

This is one of the most frequently reported triggers, both during periods of high stress and in the "let-down" phase after stress subsides

• Disrupted sleep

If you are sleeping too little or too much it can both provoke an attack

• Hormonal changes

If you are experiencing fluctuations around menstruation it can be a significant trigger for women, which is one reason migraines are more prevalent in women than in men

• Dietary factors

If you are skipping meals, are dehydrated, and experiencing caffeine withdrawal. Certain foods such as aged cheese, processed meats, and alcohol have all been linked to attacks in susceptible individuals

• Sensory overload

If there are bright lights, loud noise, and strong smells around you, they are common environmental triggers

• Dehydration

This is particularly relevant during the current summer, where sustained heat accelerates fluid loss through sweating. Even mild dehydration is enough to lower the migraine threshold and precipitate an attack. Patients who are already prone to migraines need to be especially vigilant about fluid intake during peak heat months. 

To confirm whether a specific food or factor is a trigger, a patient should eliminate it for a minimum of four weeks and then reintroduce it gradually to observe whether it provokes an attack.

The four phases of a migraine

Migraines often unfold in stages, though not every patient experiences all four:

• Prodrome

It occurs hours or a day before the headache; may involve mood changes, food cravings, neck stiffness or increased yawning

• Aura

It is experienced by about one in three migraine patients; can involve visual disturbances such as flashing lights or blind spots, tingling sensations, or temporary difficulty with speech

• Headache

Moderate to severe throbbing pain, typically on one side of the head, worsened by physical activity and accompanied by nausea, vomiting, or sensitivity to light and sound

• Postdrome

This is the recovery phase; patients often feel drained, cognitively foggy, and physically weak even after the pain has fully resolved

Recognising these phases can help patients act early, taking medication during the prodrome or early headache phase tends to be more effective than waiting until the pain peaks.

How migraines are managed

Migraine management falls into two categories: acute treatment for an ongoing attack and preventive migraine treatment to reduce frequency over time.

For acute attacks:

• Triptans are the most effective class of medications for moderate to severe migraine, targeting serotonin receptors to interrupt the attack
• Non-steroidal anti-inflammatory drugs are also used, often alongside triptans for better relief
• Medication overuse is an important caution, taking pain relief more than ten days per month can itself trigger a condition called medication overuse headache

For prevention:

• Newer CGRP inhibitors have shown effectiveness in chronic migraine prevention, offering longer-lasting relief with fewer side effects than older preventive medications.
• Gepants- a newer class of oral medicines that block CGRP receptors and can be used for both acute migraine treatment and as a preventive strategy, providing an alternative for people who do not respond satisfactorily to triptans.
• Botulinum toxin injections (Botox) – indicated for chronic migraine, defined as 15 or more headache days per month. Given every 12 weeks by a neurologist, it has strong evidence for lowering attack frequency in resistant cases
• Neuromodulation is a non-pharmacological treatment option for patients with refractory migraine who have not responded to medicines. Devices that deliver transcranial magnetic stimulation or external trigeminal nerve stimulation can reduce both the frequency and severity of attacks
• Staying well hydrated, maintaining regular meals, securing consistent sleep, and engaging in regular aerobic exercise are all evidence-based lifestyle measures that can significantly reduce migraine frequency
• Stress management through mindfulness or relaxation therapy has also shown measurable benefit

Keeping a headache diary, recording the date, duration, severity, and possible triggers of each attack, is a practical first step that helps both patients and neurologists identify patterns and refine treatment.

Takeaways

Migraines aren't simply a bad headache, but a neurological condition that results from alterations at the brain level. They are affected by specific recognised triggers, including stress, hormone changes, sleep disruption and certain foods. The treatment includes consumption of triptans or anti-inflammatory drugs and medical and lifestyle preventative measures. If you experience frequent migraines, it is important to visit a neurologist for the right treatment plan. It is not advisable to depend on entirely on over-the-counter pain management.