Migraine questions, answered honestly

A migraine is a neurological event, not a strong headache. The usual picture: throbbing pain, often on one side, worse when you move, nausea, and light, sound or smells that suddenly feel unbearable. Untreated it runs 4 to 72 hours and it usually forces you to stop. A tension-type headache is a band of pressure on both sides, milder, without nausea, and you can generally keep going. Women tend to get longer attacks, more recurrence and longer recovery. Only a doctor can diagnose it. A cold cap cannot.

That is the prodrome (doctors also call it the premonitory phase), and around 80% of people with migraine have one. Yawning, food cravings, mood changes, neck pain, peeing more often, light sensitivity, up to 48 hours before any pain. Brain imaging shows the hypothalamus switching on during this phase, so the attack has genuinely started even though your head does not hurt yet. It is the most useful part of an attack, because it is your earliest signal to act.

About 1 in 3 people with migraine get an aura: zigzag lights, shimmering, blind spots, tingling in a hand or the face, trouble finding words, usually 5 to 60 minutes before the pain. A known, usual aura is not a stroke. A new aura, a very different one, one lasting more than an hour, or one with weakness, confusion or lasting vision loss must be checked the same day.

That is the postdrome. More than 80% of people report symptoms for 24 to 48 hours after the pain ends: 88% feel drained, more than half cannot concentrate, 42% have a stiff neck. It is part of the attack. Count it when you add up what migraine actually costs you in days.

Largely. Inheritance accounts for 40 to 50% of a person's susceptibility, and relatives of someone with migraine carry about three times the risk. Dozens of genetic regions have been linked to it. In children it often travels with motion sickness, sleepwalking, night terrors and teeth grinding. It is a real, inherited condition, not a weakness.

Roughly three times more. About 1 woman in 5 will have migraine at some point, with the heaviest burden between 15 and 49. The main driver is the fluctuation of estrogen, and above all the drop that happens just before a period. It is a real biological terrain, not something in your head.

About 60% of women with migraine have menstrually-related migraine, meaning attacks that cluster around the period but also happen at other times. The window is usually the two days before bleeding through the first three days of it, and attacks in that window tend to be longer, harder, and slower to respond to treatment. Pure menstrual migraine, attacks only in that window, is rare: fewer than 1% of women, which is why almost everyone who prepares for the window also uses the same tools the rest of the month.

Often, not always. In the second and third trimesters, 50 to 80% of women improve or stop having attacks, thanks to high and stable estrogen, and the improvement is more reliable in migraine without aura. The first trimester and the months of trying can be worse, because hormones are unstable and some medicines are stopped. A migraine that starts during pregnancy more often comes with aura and needs a doctor. Any new or different headache in pregnancy is a same-day call.

Estrogen falls fast after delivery. Attacks come back in more than 30% of women within the first week and in about 65% within the first month. Breastfeeding tends to delay the return, because it suppresses ovulation. With medication limited while you nurse, this is the moment where drug-free tools matter more than anywhere else. A severe or unusual headache in the weeks after birth is urgent, not something to sleep on.

Ask your doctor, and mention your migraine type. With migraine with aura, combined hormonal contraception (the estrogen-containing kind) raises stroke risk; the risk stays small, but contraception is usually adapted. With migraine without aura, a combined pill taken continuously, without the 7-day break, is often preferred over schemes with a break, because the break recreates exactly the estrogen drop that triggers attacks. Do not change anything on your own.

Perimenopause often makes it worse first, because hormones become erratic rather than cyclical. After menopause, most women improve, unless hormone therapy reintroduces the ups and downs. The type and delivery of hormone therapy matters here, and it is a specific question worth asking your doctor.

A published review graded the evidence. Probable triggers: stress and the letdown after stress, menstruation, bright or flickering light, weather changes, nitrates (cured meats), skipping meals or fasting, and wine. Unproven, despite their reputation: chocolate, smoking, strong smells, and tyramine in aged cheese. Sleep disruption and aspartame are possible. Triggers stack: a short night, a stressful day and your period on the same day is the classic recipe. A six-week diary tells you more than memory ever will.

Act early. Every treatment works better when the pain is still mild, ideally within the first hour, and waiting to see is the most common mistake. Dark room, quiet, screens off. Drink if you can. Deal with the nausea rather than ignoring it. Take whatever your doctor has agreed with you. Cold on the head and neck is a recognised complement to all of that, not a replacement for any of it. The best treatment is very often simply the one taken early.

No. Triptans or combination painkillers on 10 or more days a month, or simple painkillers and anti-inflammatories on 15 or more days a month, for three months, can cause medication overuse headache, where the medicine starts feeding the headache. Most specialists put the practical ceiling at about two days a week. If you are above it, that is not a discipline problem, it is the signal to ask about prevention. Cold has no daily limit and no rebound, which is the honest reason it earns a place.

When attacks are frequent, cost you days at work or school, cancel plans repeatedly, or when you are using acute medication too often. Options range from regular sleep and meals, magnesium and riboflavin, to prescription preventives (beta-blockers, amitriptyline, topiramate), the newer CGRP-targeting treatments (the migraine-specific preventives), and botulinum toxin for chronic migraine. Neck physiotherapy and dry needling help some people when cervical tension is part of the picture. The benchmark for a preventive that works is half as many migraine days. Even the best ones reach that in only 50 to 60% of people, so one that fails is information about the drug, not a verdict on you.

No, and the old idea that migraine is a blood-vessel problem is not supported anymore: the throbbing is not in sync with your heartbeat, imaging shows no meaningful widening of the vessels during attacks, and narrowing them is not needed to stop the pain. Migraine is a nervous-system disorder. Cold works locally: slower nerve conduction, a strong competing sensation, and cooling of the tissue. What it gives is short-term pain relief during the attack. Nothing more, and we will not claim more.

A headache that is sudden and explosive. One that is new or very different from your usual pattern. Weakness, trouble speaking, confusion, or vision loss that does not pass. Fever, a stiff neck, or a recent head injury. A strong or unusual headache during pregnancy or in the weeks after birth. An attack past 72 hours, or an aura that lasts far longer than yours ever does. The rule specialists give: when it is the same migraine as usual, you know the terrain. When it is different, you check.