Nearly 40 million people in the U.S. suffer from migraines, making the painful disorder one of the most common that neurologists treat. It’s also among the most confusing. Because of the many ways it can show up, it can take more than a decade to receive an accurate diagnosis.
“The general concept about migraine in the common population is that it’s a headache syndrome,” says Dr. Hamid S. Hamdi, a neurologist who leads the Headache Clinic at UTHealth Houston Neurosciences in Sugar Land, Texas. And certainly, many migraine sufferers—though not all—experience a throbbing headache. Beyond that, however, “people don’t know about all the other symptoms that migraine can cause, so they’re very surprised in the beginning,” he says. “Even as neurologists, we don’t always write off all the symptoms to migraine until we’ve ruled out things like a stroke.”
We asked Hamdi and other neurologists which non-headache migraine symptoms they see most often.
Food cravings
About two to three days before developing a headache, people typically enter the prodrome (early) phase of a migraine. Symptoms include irritability and other mood changes, fatigue and trouble sleeping, difficulty concentrating, neck pain, and hyperactivity. More surprisingly, many report food cravings—especially for salty foods, sweets, and chocolate.
The way that scientists think about this kind of craving has evolved. While some once believed that foods like chocolate caused migraines, research suggests that’s not the case, and there’s no reason for people to avoid it. “Generally, it was believed that chocolate could trigger migraine,” Hamdi says. “But what we believe now is that it’s not chocolate that triggered it—it’s that people were having a craving for chocolate as a prodrome of migraine.” The urge to wolf down something sweet may be caused by a sudden spike or drop in glucose and other metabolic changes in the body, researchers have found.
Vision changes
About 20% of people with migraines experience a visual aura, or temporary changes in vision. These can show up as shimmering spots, zig-zag lines, blind spots, tunnel vision, or even temporary blindness. Visual aura is likely caused by a wave of electrical and chemical activity that spreads across the brain.
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“People have described it all different ways,” says Dr. Thomas Bravo, a neurologist and director of the Headache Center at Loma Linda University Health in California. “It can be disturbing to a patient if it’s the first time,” but once they know it’s linked to their migraine and will pass within 20 minutes to an hour, it’s not quite so scary. Some people experience vision changes with every headache, he adds, while others report these symptoms only accompany a portion of their headaches.
Speech difficulties
You might recall the clip of a TV reporter that went viral more than a decade ago, when the journalist suddenly became incoherent—leaving many watching at home worried she was having a stroke. It turned out she had aphasia, or temporary language impairment, caused by a migraine.
Someone with aphasia might have difficulty forming full sentences, instead repeating jumbled words, or will start slurring. “We see this all the time in the emergency department, and we’ll go through an evaluation, making sure it’s not something like a stroke,” Bravo says. Doctors generally do imaging tests such as CT scans or MRIs before concluding—often through process of elimination—that a patient is experiencing a migraine.
Sensory sensitivity
Migraines are often accompanied by increased sensitivity to light, sound, and smells. The scents you’re exposed to every day may strike you as much stronger and more putrid than usual, for example, and you may need to wear sunglasses outside because the sun’s bright glow irritates your eyes. “The light and sound can be anywhere from unpleasant to actually painful, depending on the person,” Bravo says.
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You also might find that you can’t stand even the gentlest touch. Some people experience tactile allodynia, which happens when the central nervous system becomes extra sensitive to things that touch your skin. “You have a heightened sense of pain to stimuli that wouldn’t normally cause pain, like a light touch across your skin,” says Dr. Brian Gerhardstein, a neurologist and director of headache medicine at JFK Neuroscience Institute in New Jersey. That also includes light touch on your scalp from brushing your hair, the sensation of rubbing a blanket over your body, or feeling a breeze brush against your skin.
Motor changes
Hemiplegic migraines—which are rare but serious—are associated with motor changes, like one-sided body weakness or paralysis. This type of migraine has a strong genetic component and is often passed down from a parent, Gerhardstein says. “Basically, your face, arm, and leg get weak during the migraine attack, and then it goes away afterward,” he says. “It can look exactly like a stroke, so a lot of these patients end up in the emergency room.” Seeking urgent care is a good idea, Gerhardstein adds, since it’s important for doctors to rule out potentially life-threatening conditions.
Abdominal pain
An “abdominal migraine” can cause a terrible stomachache, nausea, vomiting, and a lack of appetite. “People vomit over and over and over, and they don’t even necessarily have headaches,” Gerhardstein says. While there are different theories why this happens, research suggests it’s likely related to changes in the gut-brain axis.
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These gastrointestinal symptoms are common among kids and can be hard to diagnose, especially if young patients don’t have a headache or are unable to articulate that they do. “I see pediatric doctors a lot of times scratching their heads trying to figure out what exactly is going on,” Gerhardstein says. “When they’ve ruled out all the more organic causes, they come to migraine as the final diagnosis.”
How to treat migraines
There are a number of theories why some people get migraines and others don’t. Women are three to four times more likely than men to experience them, “which makes us think the estrogen hormone has something to do with it,” Hamdi says. Genetic factors also play a role, as do neurochemical imbalances involving serotonin, dopamine, and glutamate. Migraines can be progressive, Hamdi adds, striking more and more frequently, especially when people don’t learn how to manage them or have poor lifestyle habits, like inconsistent sleep or high stress levels.
Fortunately, experts say, there are more options than ever to treat migraines, including targeted therapies and nerve-stimulation devices. People who only have these attacks occasionally might rely on rescue medications they take when symptoms start, while those with more regular migraines often take daily preventive treatment. “We usually say, ‘OK, if it’s more than a day a week, then we might think about prevention,’” Bravo says. “It goes back to how disabling the attack is, and how impactful it is on a person’s life.”
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