Understanding migraine: causes, triggers, hormones and what the guideline recommends

It starts with a flicker at the edge of your field of vision, in the middle of a meeting. A glittering arc that slowly expands until you can no longer read the numbers on the screen.

Or it starts on Saturday morning, finally the weekend. And that is exactly when it starts throbbing behind your right eye, and the day no longer belongs to you. Many people know this pattern: the darkened room, the nausea, the sound of the dishwasher that suddenly becomes unbearable.

I would like to offer you something other than another list of things to avoid: an understanding of what happens in your brain, an honest sorting of triggers, a close look at hormones, and what the guideline and studies show. With everything that is established, and everything that is still open.

What happens in your brain: a sensitive filter, a traveling wave and a messenger called CGRP

“It's just a headache.” People with migraine hear this sentence surprisingly often, sometimes even from themselves.

Research sees it differently. Migraine is considered a disorder of stimulus processing in the nervous system. A large review from 2017 ranked it at that time as the sixth most common cause of disability worldwide.

The mixing desk with overly sensitive faders

Imagine your brain as a mixing desk. Light, sounds, smells, hunger, tiredness and hormonal signals come in as separate tracks, and the desk blends them into a coherent overall picture. In migraine, some faders seem to be set more sensitively. A team around Goadsby describes migraine as a largely accepted, inherited tendency of the brain to lose control of its incoming sensory signals. That could explain why light is so hard to bear during an attack.

How strong the predisposition is can be seen in a genome analysis around Hautakangas with 102,084 people with migraine and 771,257 controls. It identified 123 risk regions, including genes for CGRP and for a serotonin receptor, in other words for targets of today's migraine medications. Genome analysis Migraine does not come down to a single gene, but to many small variants. You did not choose them.

The attack may begin before the pain

Many people sense hours in advance that something is coming. They yawn, feel irritable or tired, have food cravings or a stiff neck. Hunger, sleep, mood and alertness are timed by a small region in the diencephalon, the hypothalamus, which is also closely linked to the daily rhythm and the menstrual cycle.

The aura: a wave in the stadium

In some people with migraine, at least some attacks come with an aura, usually a shimmering zigzag arc or a blind spot, sometimes tingling or difficulty finding words. Think of the wave in a sports stadium: one block stands up and sits down, the next one stands up, and behind the wave it goes quiet for a moment. The aura seems to arise in a similar way, as a slowly traveling wave of excitation across the cerebral cortex followed by suppression. Specialists call this cortical spreading depolarization.

A team around Hadjikhani made this wave visible in three people during a visual aura using functional MRI. It moved across the visual cortex at 3.5 plus or minus 1.1 millimeters per minute, matching the movement of the shimmer. 3 people How the wave relates to the pain is still open. Charles and Baca emphasize that animal models support the aura explanation, but considerable uncertainty remains. A team around Ferrari puts it this way: spreading depolarization probably causes the aura and may also trigger the pain.

The pain: the trigeminal nerve and CGRP

According to current understanding, the headache arises in the trigeminovascular system. The trigeminal nerve supplies the meninges and their blood vessels with pain fibers that, when activated, can release messengers, including CGRP. For a long time, migraine was considered a vascular disease. The review around Ferrari summarizes the current state differently: the widening of blood vessels is only an accompanying phenomenon. So the vessels react along with it, but they are probably not the engine.

One further level particularly interests me as a physician working integratively: the idea that in migraine, the brain's energy reserve and its workload do not match. I will come back to this in the section on nutrients, with all its limitations.

For everyday life, this first means something unspectacular: a headache diary. The guideline places great value on documentation, and the international classification recommends a headache diary. Note your headache days, intensity, medications, premonitory symptoms, sleep and, for women, the day of the cycle.

And now you know why a migraine attack is more than a headache: a process that may begin in the diencephalon hours before the pain.

Recognizing migraine: phases, aura and the difference from tension-type headache

Is what you have actually migraine? Or is the pressing feeling in your head in the evening something else?

First the good news: the diagnosis usually requires neither blood tests nor an MRI. The guideline of the German Society of Neurology and the German Migraine and Headache Society states that the diagnosis is based on the medical history and an unremarkable neurological examination. Additional diagnostics, and imaging in particular, are necessary for headaches with an unusual clinical presentation. [Guideline]

According to the guideline, the 1-year prevalence of migraine is between 10 and 15 percent. It is most common between the ages of 20 and 50, and during this phase women are affected up to three times as often as men. The classification speaks of chronic migraine when headache occurs on at least 15 days per month for more than three months, with migraine features on at least 8 of those days.

The criteria in everyday language

The International Classification of Headache Disorders, ICHD-3, describes migraine without aura as follows: at least five attacks lasting 4 to 72 hours. In addition, at least two of four features: one-sided, pulsating, moderate to severe, aggravated by routine physical activity such as climbing stairs. And at least one of the following: nausea or vomiting, or sensitivity to light and noise.

In migraine with aura, the aura symptoms are fully reversible. They affect vision, sensation or speech, less often other functions. It is typical for a symptom to spread over at least five minutes, to last 5 to 60 minutes and for headache to follow within 60 minutes. Over 90 percent of people with aura have a visual aura in at least some attacks, and aura can also occur entirely without headache. As accompanying symptoms, the guideline lists loss of appetite almost always, nausea in 80 percent, vomiting in 30 percent, sensitivity to light in 60 percent and sensitivity to noise in 50 percent.

Migraine or tension-type headache?

Both are common, and they often occur together. ICHD-3 describes frequent episodic tension-type headache as something that often occurs together with migraine without aura, and recommends a headache diary to tell them apart.

Two differential diagnoses only briefly, because they have their own articles. Iron deficiency can contribute to headaches and dizziness and belongs in the workup when symptoms fit, see Iron deficiency: headaches and dizziness. If you regularly wake up with a headache and snore loudly, think of a nighttime breathing disorder, described in Recognizing sleep apnea. And if the neck is a source of pain in its own right: Back and neck pain from a holistic perspective.

And now you know why the most important examination in migraine is often the one you prepare at home.

Trigger or warning sign? Stress, relief, sleep, meals, alcohol and weather

No red wine, no chocolate, no aged cheese, go to bed on time, never get hungry. And still the attack comes, on a day when you did everything right. That wears you down. And it raises a question: what if some of the suspects are not the culprits at all?

In Kelman's survey of 1,207 people from a headache clinic, stress was the most frequently named trigger, at 79.7 percent. This was followed by hormones in women at 65.1 percent, not eating at 57.3 percent and weather at 53.2 percent. The reference base for these percentages is not entirely clear in the abstract. Survey On top of that, triggers are highly personal. A team around Peris had 326 people keep a diary on 33 possible factors for 90 days. On average, four factors per person were associated with attacks, and in 85 percent of those with at least one association, the profile was unique. So general lists of things to avoid rarely fit you exactly.

Food cravings: cause or first witness?

The international headache classification explicitly lists cravings for certain foods among the premonitory symptoms, alongside repeated yawning and tiredness. If you reach for chocolate before an attack, the craving could already have been the beginning.

And the chocolate? A team around Marcus gave 63 women with chronic headaches either chocolate or carob in a double-blind design. Headaches did not occur more often after chocolate, not even in women who considered it their trigger. The study is old and small, but it fits the picture.

Why migraine comes on the weekend

On the weekend, the rhythm also often shifts: getting up later, eating later, coffee later. Whether the change in rhythm, the drop in caffeine or the premonitory phase itself is decisive cannot be separated from data like these.

Sleep: fragmentation rather than hours

A team around Bertisch followed 98 adults with episodic migraine for six weeks with a diary and a motion sensor. Short sleep of 6.5 hours or less and poor sleep quality were not associated with migraine. Low sleep efficiency according to the diary, meaning a lot of time awake in bed, was associated with 39 percent higher odds of headache, though not on the day directly after the night, but on the day after that. For fragmented sleep, the motion sensor even showed lower odds on the directly following day. Cohort, 98 people So the data are inconsistent. That is why I would rather focus on regularity than on the pressure to reach a certain number of hours. How this can work without creating new stress is described in Putting sleep hygiene into practice, and why morning light can stabilize the internal clock in Chronobiology and the internal clock.

Alcohol: often suspected, rarely reliable

What alcohol can change in the digestive tract even in small amounts is described in Alcohol and the gut.

Weather: yes for some, predictable no

More than half of the people in Kelman's survey named the weather. Measured data are more cautious. A team around Hoffmann compared attacks with air pressure, humidity and temperature in 100 people over twelve months. A subgroup showed clear weather sensitivity, the pooled analysis of all participants showed no significant association, and an attack could not be predicted from weather data. An analysis around Mukamal with 7,054 people from the emergency department found heat to be a small factor for severe headaches, with an odds ratio of 1.075 per 5 degrees. In this analysis, lower air pressure increased the risk in people without a migraine diagnosis.

Caffeine, drinking and skipped meals

Caffeine cuts both ways. In small amounts it is part of some pain reliever combinations, while regular larger amounts can tend to sustain headaches. The guideline mentions a limit of 200 mg per day to avoid effects that promote chronification. This is a quote from the guideline, not a personal recommendation. More on coffee in Coffee, cortisol, adenosine and hormones.

On drinking, the guideline is honest: it recommends at least 1.5 liters per day, but reports a randomized trial in which drinking more did not change headache frequency. And skipped meals remain a special case, because hunger can be both a trigger and a warning sign. A steady meal rhythm is a reasonable starting point. I would only try strict fasting experiments with frequent migraine under medical supervision. Why food cravings arise is described in Food cravings: where they come from.

What does this mean for you? Keep your diary with both, suspected triggers and premonitory symptoms. Pay attention to regular sleep and meals, on the weekend too, and make transitions gentler. The first day of your vacation does not have to start with sleeping in until noon.

And now you know why an ever longer list of things to avoid rarely gets you further, and why rhythm and an honest diary can reveal more.

Hormones: why the cycle, perimenopause and pregnancy change so much

You could set your watch by it. Two days before your period, at the latest on the first day of bleeding, it is there. And often more stubborn than the attacks in between.

In a US survey around Buse with 162,756 people aged twelve and over, 17.3 percent of women and 5.7 percent of men met the criteria for migraine. A review by Vetvik and MacGregor describes migraine as two to three times more common in women and names female sex hormones as an important factor, alongside genetic differences.

Not the height, but the speed of the slide

A team around MacGregor had 40 women with menstrual migraine who were not using hormonal contraception provide daily urine samples over three cycles. Attacks clustered in the late luteal and early follicular phase, when estrogen falls, and were less frequent in phases of rising estrogen. Cohort, 38 evaluable

For clearly menstrual migraine, the guideline describes medical options, from time-limited prevention around the period to hormonal strategies in consultation with the gynecologist. These are decisions for the consultation room, not schemes to copy. How stress can play into female hormones is described in Cortisol, stress and female hormones.

Perimenopause and pregnancy

Many women find that their migraine changes in the years before their last period. A team around Martin analyzed data from 3,664 women with migraine aged 35 to 65. At least ten headache days per month were reported by 8.0 percent of premenopausal, 12.2 percent of perimenopausal and 12.0 percent of postmenopausal women. In the fully adjusted model, only perimenopause remained associated with an increased risk, with an odds ratio of 1.42. Cross-sectional A good reason to discuss prevention again during this phase. More in Perimenopause: recognizing the symptoms and Menopause and sleep disorders.

During pregnancy, on the other hand, many women experience a break. A team around Sances followed 49 pregnant women with migraine. In migraine without aura, it improved in 46.8 percent in the first, 83.0 percent in the second and 87.2 percent in the third trimester. In the first month after birth, it returned in 55.3 percent, and breastfeeding appeared to protect against this. Cohort, 49 women This small study allows no conclusion about aura. New or changed headaches during pregnancy and after giving birth should always be checked by a doctor, and medications here are exclusively a medical decision. The guideline states that mild attacks during pregnancy can be treated without medication, with shielding from stimuli and rest.

Beyond this, migraine is also a reason to take your blood vessels seriously. In the Nurses’ Health Study II with 115,541 women, migraine was associated over around 20 years with a higher risk of major cardiovascular events, with a hazard ratio of 1.50. These are observational data without a separate analysis by aura. I read this as an invitation to preventive care, not as fate.

What does this mean for you? Note the day of your cycle in your headache diary. After two or three months, it is often possible to see whether your attacks are linked to your period, and you have a basis for a conversation about targeted prevention. And if you have aura, mention it every time hormones are prescribed.

And now you know why migraine before your period can be so punctual, and why a single hormone level does not explain it.

The energy-hungry brain: magnesium, riboflavin, Q10, and what remains open about histamine, the gut and weight

At the drugstore there is a shelf full of migraine combination products, and in forums someone swears by avoiding histamine, someone else by a gut cleanse. What holds up?

Mechanistically plausible, human studies thin: A review around Gross describes migraine as a possible adaptive response, conserved over the course of evolution, in people with a corresponding predisposition whose brain has a mismatch between energy reserve and workload. Imagine a high-performance engine with a small tank. The attack could be a kind of emergency brake that helps to restore the energy balance. The authors speak of growing evidence, much of it from clinical data. However, it is largely indirect, comes from small studies and partly from animal models, and two authors of the review, Schoenen and Sándor, are first authors of the riboflavin and the Q10 study in the table, respectively. Hypothesis with animal data

What the guideline says, and why it sounds contradictory. Chapter 4.2.5 states (translated from German): “Dietary supplements with efficacy in migraine prophylaxis include magnesium, butterbur, riboflavin and coenzyme Q10. However, the scientific evidence is low.” On magnesium: “Overall, magnesium is suitable for patients who do not wish to receive drug therapy with a medication approved for this purpose.” Chapter 11, by contrast, states: “Dietary supplements and probiotics are not effective in the prophylaxis of migraine.” Subsection 11.1, however, names riboflavin, magnesium and Q10 separately and states that for other natural substances efficacy is “less clearly established”. I deliberately place both passages side by side, because even the guideline does not sound consistent here. This is not a recommendation in the strict sense. [Guideline]

The patient information from IQWiG, the German Institute for Quality and Efficiency in Health Care, was more cautious in 2022, before the current guideline: due to a lack of meaningful research, it was not possible to judge whether these remedies protect against migraine.

If at all, I see nutrients as an accompanied trial over several months, with a diary and in consultation with a doctor. Which forms of magnesium exist and how well they are tolerated is covered in Which magnesium is best?, and coenzyme Q10 in Coenzyme Q10 and statins.

Histamine and DAO: a question, not a diagnosis

Thin evidence: A research group around Izquierdo-Casas measured the activity of the histamine-degrading enzyme DAO in 137 people with migraine and 61 without. With migraine it averaged 64.5, without migraine 91.9 HDU/ml. 87 percent of the migraine group were below the cut-off, but so were 44 percent of the people without migraine. In a follow-up study, 100 people with low DAO received the enzyme or placebo for one month. Attack duration fell from 6.14 to 4.76 hours with DAO and from 7.53 to 6.68 hours with placebo. There was no significant difference between the groups, even though the title of the study sounds more positive. The guideline makes no recommendation. How histamine intolerance is properly assessed is described in Histamine intolerance and DAO deficiency. small studies

Gut and diet: plausible, but weakly supported

Hypothesis: A review around Arzani describes associations between migraine and gastrointestinal diseases such as Helicobacter infection, irritable bowel syndrome and celiac disease. How the gut and the brain interact here, however, is not entirely clear. Celiac disease is something that can be concretely tested for, and according to this review a gluten-free diet can reduce migraine frequency in people with it. In a meta-analysis of three studies with 179 people, probiotics showed no significant effect on frequency or severity, with very high heterogeneity. The guideline considers low-sugar, low-fat and ketogenic diets possibly effective and calls the evidence for special diets weak overall. More on the axis between belly and head in The gut-brain axis and vagus nerve stimulation.

Weight: an association, not a question of blame

In a meta-analysis around Gelaye with 288,981 participants, the risk of migraine was 27 percent higher with obesity and 13 percent higher with underweight. Both persisted after further adjustment. In a large telephone survey around Bigal, obesity was associated mainly with chronic migraine, not with chronic tension-type headache. A meta-analysis around Di Vincenzo of ten mostly small studies found that weight loss in people with obesity was associated with fewer headache days, regardless of how much weight was lost. To me, this argues against numerical targets and for a look at physical activity, sleep and silent inflammation, described in Understanding weight holistically.

Mental health: taking it seriously without calling migraine psychological

In a cohort around Breslau, depression at baseline predicted new-onset migraine, with an odds ratio of 3.4. Conversely, migraine predicted new-onset depression, with an odds ratio of 5.8. This does not mean that migraine is psychological. It means that both sides deserve attention. Depression is a serious illness that deserves its own medical and psychotherapeutic treatment. The antidepressant amitriptyline is also used for migraine prevention. An antidepressant is never stopped on your own, because stopping abruptly carries its own risks, and any change belongs in the hands of the doctor who prescribed it. How sleep and mood are connected is described in Sleep and depression.

If you have thoughts of suicide, get help immediately. In Germany, the Telefonseelsorge crisis line is available around the clock and free of charge at 0800 111 0 111 and 0800 111 0 222 (these are German numbers). In acute danger, call 112 or go to the nearest emergency department. Outside Germany, please use your local emergency number.

And now you know why, when it comes to supplements, I neither dismiss nor promise, but place both passages of the guideline side by side.

Prevention without pills: endurance exercise, relaxation, biofeedback, behavioral therapy and acupuncture

Many people wish they did not have to take medication permanently. This wish is legitimate and belongs openly in the conversation with your doctor, not in going it alone. And the evidence here is better than many people think.

Established and anchored in the guideline: “Cognitive behavioral therapy is definitely recommended for the prophylaxis of migraine. It can be used instead of or in combination with drug prophylaxis.” Relaxation techniques and biofeedback are also recommended, with an average reduction in migraine frequency of 35 to 45 percent. “Regular aerobic endurance exercise is recommended for the prophylaxis of migraine.” Mindfulness can be recommended to improve quality of life. And: “Drug therapy shall be combined with behavioral therapy methods …” (all quotes translated from German) [Guideline]

A meta-analysis around Lemmens of six studies found on average 0.6 fewer migraine days per month after endurance training, with moderate quality of evidence. A meta-analysis by Nestoriuc and Martin of 55 studies on biofeedback found a mean effect size of 0.58, which remained stable over an average of 17 months. And in a randomized trial around Wells, migraine days decreased by 1.6 per month with mindfulness training and by 2.0 with headache education, with no difference. Mindfulness training did, however, improve disability, quality of life and depression scores.

Why physical activity can set so much in motion at the cellular level is described in Movement as medicine. You can find breathing exercises as an easy entry point into relaxation in Breathing techniques for the nervous system, and if sleep problems play a part, in Treating sleep disorders holistically.

The guideline uses clear words elsewhere: a daith piercing is “not advisable”, and for homeopathy there were “no effects beyond the placebo effect”. [Guideline]

And now you know why the question is not whether to choose pills or lifestyle, but which combination suits you.

What can help quickly, what medications can do and when pain relievers themselves cause headaches

The attack is here. You just want it to stop. So first the honest answer: for no home remedy is there evidence that it reliably stops a severe attack. Acute medications are the best studied, and according to the guideline their effectiveness is greater when they are taken early in the headache phase. This also applies to triptans. [Guideline]

Acute treatment at a glance, without doses

• Mild to moderate attacks should, according to the guideline, first be treated with pain relievers such as acetylsalicylic acid, nonsteroidal anti-inflammatory drugs or the combination of acetylsalicylic acid, paracetamol and caffeine. A Cochrane review around Kirthi found that acetylsalicylic acid did not differ from sumatriptan at the lower study dose in terms of pain freedom and relief after two hours. An additional medication against nausea reduced nausea and vomiting.
• Triptans should, according to the guideline, be used for severe headaches and for attacks that do not respond to pain relievers. A network meta-analysis around Karlsson with 137 studies and 89,445 participants found the best profiles for eletriptan, rizatriptan, sumatriptan and zolmitriptan, more effective than the newer drugs lasmiditan, rimegepant and ubrogepant. Caution is advised in people with high cardiovascular risk.
• Newer acute medications from the gepant and ditan groups are, according to the guideline, mainly an option when pain relievers or triptans are not sufficient, are not tolerated or must not be taken. After lasmiditan, the guideline points out that you should not drive for 8 hours.
• Opioids are, according to the guideline, not to be used in the treatment of acute migraine attacks.
• Without medication, the guideline names shielding from stimuli and rest. Local cooling is experienced as pleasant, and in a randomized trial higher concentration menthol oils on the forehead and temples were superior to a low concentration comparison solution. External neurostimulation devices are also discussed in the guideline.

Clinical tradition without a study basis: coffee with lemon or warm foot baths. Some people find home remedies like these pleasant, but I am not aware of robust migraine studies on them. I would not sit out a severe attack with them when effective remedies are available.

When the pill itself becomes the problem

The pill that used to seem so reliable is something you now need almost every other day. And the headaches tend to become more frequent. This pattern has a name: headache due to overuse of pain or migraine medication.

According to the guideline, the threshold for triptans and combination pain relievers is at least 10 days of use per month, and for simple pain relievers at least 15 days of use. The international classification speaks of this headache when, in a pre-existing headache disorder, headache occurs on at least 15 days per month and the overuse has lasted for more than three months. A review around Diener gives a 1-year prevalence of 1 to 2 percent, more common in women and in people with depression, anxiety and other chronic pain. Imagine a smoke detector that becomes so sensitive from constant testing that it goes off as soon as you make toast.

Preventive medication and the migraine injection

For frequent attacks, attacks with pronounced symptoms or prolonged aura, the guideline says that drug prevention should be offered in addition to information and behavioral change. As effective, it names the beta blockers propranolol and metoprolol, the calcium antagonist flunarizine, the anticonvulsants valproic acid and topiramate, and the antidepressant amitriptyline. Topiramate is contraindicated during pregnancy and in women of childbearing age without highly effective contraception, and valproic acid must not be used in women of childbearing age. In migraine prophylaxis, according to the guideline, valproic acid is “off-label”, that is, outside its approved use. [Guideline]

CGRP antibodies, colloquially the migraine injection, target CGRP or its receptor. According to the guideline (as of 2025, chapter 4.10), the monoclonal antibodies eptinezumab, erenumab, fremanezumab and galcanezumab are approved in Germany for migraine prophylaxis in adults with at least 4 migraine days per month. The rates for at least halved migraine frequency after three to six months were between 30 and 62 percent, and with placebo between 17 and 38 percent. They are not to be used during pregnancy and breastfeeding, according to the guideline they should not be used in women without adequate contraception, and caution is required in vascular diseases such as coronary heart disease, stroke or Raynaud's syndrome. On cost coverage, the guideline, as of 2025, states (translated from German) that all CGRP antibodies in Germany are “fully reimbursable within the scope of their approval”, but that prescriptions may be subject to an economic efficiency review, and that when switching, “the differences in reimbursability with regard to previous therapies must be taken into account”. At the same time, the guideline describes that the Federal Joint Committee (G-BA) found an added benefit for erenumab, fremanezumab and galcanezumab only in certain subgroups, and it calls for careful documentation of migraine days and previous therapies. This is a statement from the guideline and not a promise of cost coverage. Whether the requirements are met in an individual case is clarified by the prescribing practice. The European Headache Federation recommends the antibodies for episodic and chronic migraine.

Gepants are small molecules that block the CGRP receptor. According to the guideline, rimegepant is “effective and approved in the prophylaxis of episodic migraine”, and according to the guideline the EMA granted European marketing authorization in April 2022, for prophylaxis in adults with at least 4 migraine attacks per month. The guideline describes atogepant as effective in episodic and chronic migraine. In the manufacturer-funded pivotal trial around Ailani, migraine days decreased by 3.7 to 4.2 days with atogepant and by 2.5 days with placebo, so the difference from placebo was 1.2 to 1.7 days. A network meta-analysis around Haghdoost found that all CGRP drugs studied except a low eptinezumab dose significantly reduced migraine days compared with placebo, with the higher response rates being significant for the injected or infused drugs, but not for oral administration. According to the guideline, onabotulinumtoxinA is only an option in chronic migraine.

And now you know why the question of quick relief deserves an honest answer that begins with an early medication and continues with a plan for the days between attacks. If you would rather not sort this out on your own: below this article you will find the option to book an appointment.

Frequently asked questions about migraine

Where migraine connects with other topics

Migraine is linked to sleep, hormones, nutrients, physical activity and mood. Here are twelve paths that lead on from this article.