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Migraine attacks are said to be episodic if they occur less than 15 days in a month. Learn the causes, symptoms, and treatment of episodic migraines below.

Migraine is a neurological condition characterized by a severe throbbing headache. A migraine may be associated with symptoms such as nausea, vomiting, sensitivity to light (photophobia), or sounds (phonophobia). Sometimes, a migraine attack may make the patient physically weak and hinder their ability to perform any activity.

Migraine attacks are said to be episodic if they occur less than 15 days in a month. However, some episodic migraines may not show repetitive episodes in a month. If migraines occur more than 15 days a month for at least three months, they are called chronic migraine.

What are the causes of an episodic migraine?

The exact underlying cause of migraine is unclear, and research is going on in that particular area; however, it has been believed that the two main causes of migraine include:

1. External triggers
2. Abnormal changes in the activity within the brain itself

Possible causes of migraine include:

• Stimulation of perivascular nerves (nerves around the blood vessels) influences major brain arteries.
• Neuronal alterations in subcortical regions (regions within the brain) occur and cause symptoms such as tiredness and decreased focus hours before the migraine begins.
• Changes occur in the activity of certain areas in the brain such as the brain stem and hypothalamus. 
• The hypothalamic function is important and may be involved in modifying the sensitivity of brainstem locations that influence incoming trigeminal signals.

Risk factors for migraine include:

• Age: An episodic migraine is more common among young people and is mostly seen in people who are 20 to 50 years.
• Gender: Women are more prone to migraines than men
• Genetics: Migraines run in the family; if an immediate relative has a migraine, there are high chances for the patient to have a migraine.
• Lifestyle factors:
  • Smoking
  • Excessive alcohol intake
  • Stress
  • Tiredness
  • Obesity
  • Improper sleeping habits or change in sleep pattern
  • Heavy exercise
• Medical conditions:
  • Depression
  • Anxiety
  • Sleep apnea
  • Epilepsy
  • Hormonal imbalance (due to hormonal medications such as hormone replacement therapy or birth control pills)
  • Abuse of medications, especially painkillers
• Other triggers:
  • Caffeine
  • Bright light
  • Loud noises
  • Skipping meals
  • Strong smell
  • Sudden change in altitudes or weather
  • Certain processed foods

The onset of episodic migraine is uncertain and can occur anywhere at any time.

Triggers for a migraine attack differ from person to person, and they are not always constant in the same person. Different triggers may cause migraine attacks in the same person at different intervals.

What are the common symptoms of an episodic migraine?

The most common symptoms associated with migraine include:

• Nausea and vomiting
• Intense throbbing or dull ache on one or both sides of the head
• Changes in eyesight, such as fuzzy vision or blind spots
• Worsening of pain with exertion or physical activity
• Unable to tolerate sounds, light, or smells
• Lightheadedness
• Confusion
• Exercise
• Increased sweating
• Chills
• Tenderness and stiffness in the neck

What are the four phases of a migraine attack?

A typical migraine attack is categorized into four phases, each lasting for a certain period and exhibiting different symptoms. However, it is not necessary to go through all phases of migraine with every attack.

The four phases of a migraine attack include:

1. Prodrome: This phase begins up to 24 hours before the migraine. Food cravings, inexplicable mood swings, uncontrolled yawning, fluid retention, and increased urination are early signs and symptoms.
2. Aura: If a patient experiences this phase, they may notice flashing or bright lights and zig-zag lines. They may have muscle weakness or the sensation of being touched or grasped. A migraine aura can occur before or during the migraine.
3. Headache: A migraine normally begins gently and progresses to become more severe. It often causes throbbing or pulsing discomfort on one side of the head. However, a migraine can occur without causing a headache.
   • Other migraine symptoms could include:
     • Vomiting and nausea
     • Increased sensitivity to light, noise, and scents
     • Worsening of pain with exertion, coughing, or even sneezing
4. Postdrome: This is the last phase that is a pain-free period, but the patient feels uneasy, tired, weak, and confused. This phase can last for about one day.

A migraine attack can occur at any time of the day, but migraines in the morning are more common.

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How is an episodic migraine diagnosed?

The doctor takes the patient’s medical history and asks questions about the frequency of headaches and symptoms. They may perform a physical examination.

Headaches can be caused by many medical conditions. To rule out the possible causes, the doctor may advise radiological brain scans such as magnetic resonance imaging and computer tomography scans.

What are the treatment options for an episodic migraine?

Migraine has no definitive cure, and there is no definitive treatment for a migraine attack. Various studies and research toward the causes and treatment of migraine have provided us with the best possible drugs that can be used to treat a migraine episode and can even prevent possible migraine attacks in the future.

The best way to manage migraine attacks is to avoid the triggers for migraine and make lifestyle modifications to eliminate possible risk factors.

First-line treatments of mild to moderate migraine attacks include:

• Acetaminophen
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as:
  • Aspirin
  • Naproxen
  • Ibuprofen
  • Ketoprofen
• Antiemetics that are given in the presence of nausea and vomiting

Severe migraine attacks can be treated with the following:

• Triptans
• Antiemetic drug
• Calcitonin gene-related peptide antagonists
• Lasmiditan
• Nonoral migraine-specific medications such as:
  • Subcutaneous sumatriptan
  • Nasal sumatriptan and zolmitriptan
  • Parenteral dihydroergotamine

Non-pharmacological treatment options include:

• Transcranial magnetic stimulation: Magnetic fields are used to stimulate neurons in the brain.
• Electrical neuromodulation: Alteration of neuronal activity with external electric stimulus delivered directly to the target area.
• External trigeminal nerve stimulation: Stimulation of trigeminal nerve with external electric stimulus through electrodes placed on the skin.
• Noninvasive vagus nerve stimulation: External stimulation of the vagus nerve using an electric device.

The choice of treatment depends on the associated symptoms, intensity, and frequency of the pain. Treatment options differ from patient to patient. If the pain doesn’t go away with initial treatment with acetaminophen, NSAIDs, or painkillers, the patient may be given combination drugs or other medications such as triptans.

There is a possibility that pain and other symptoms caused by migraine may go away by:

• Moving to a darker and noise-less room as soon as a migraine episode commences.
• Having a proper sound sleep.
• Scalp massage.

Lifestyle modifications, stress management, adequate physical activity, proper hydration, and avoiding migraine triggers are the best possible ways to manage migraine and prevent further episodes.