Over the last decade, the understanding of migraines—devastating primary headaches—has grown enormously, alongside treatment options. Historically, remedies ranged from fried catfish in ancient Egypt to blood-letting by Galen, and later, blame on repressed emotions in women. As recently as 20 years ago, the vascular theory dominated medical teaching. Today, science reveals migraines stem from activation of the trigeminovascular system, specifically the trigeminal nerve releasing CGRP (calcitonin gene-related peptide), which activates the brain's pain network.
Primary vs. Secondary Headaches
Headaches fall into two categories: primary (no underlying structural cause) and secondary (caused by stroke, meningitis, tumour, etc.). Migraines are primary but often mistaken for secondary. "As doctors, we're taught to ask the right questions to determine which type of headache it is," says Alexandra Sinclair, professor of neurology at the University of Birmingham and chair of the British Association for the Study of Headache. "Generally, a headache that is moderate to severe, where a patient wants to lie down, avoid light and noise, keep still, feels nauseated, and has pounding pain often on one side—that's most often migraine."
Four Phases of Migraine
Migraines typically occur over four phases: prodrome (warning period with yawning, urination, fatigue, and food cravings—not the cause but a symptom), aura (about 30% of sufferers experience visual disturbances, numbness, or speech difficulties), the migraine itself (lasting 4–72 hours), and postdrome (exhaustion up to two days). Functional brain imaging shows that cravings occur before pain, reversing old victim-blaming narratives. "The research has completely turned that upside down," says Prof Sinclair. "You didn't cause the migraine—the migraine caused the craving."
Evolutionary Advantage and Modern Stigma
The trigeminovascular system may have evolved to alert us to brain injury or infection. "Back in our caveman days, if you were primed to have migraines, you'd be quite vigilant to noise, light, or movement—those genes might have stayed with us by giving a survival advantage," notes Prof Sinclair. Today, however, migraines are disabling: the World Health Organization lists migraine in the top 10 most disabling diseases globally. About twice as many women suffer from migraine as men, due to hormonal differences and brain susceptibility. "For some people, their ability to function properly is impaired for much of the month—and there's stigma around it not being a 'real' issue," says Prof Sinclair.
Triggers and New Treatments
Triggers include lack of sleep, too much sleep, caffeine withdrawal, dehydration, and significant stress. Screen time's link is unclear. The good news: identification of CGRP has led to targeted treatments. "We have Gepants, taken as tablets, that block the CGRP receptor, and CGRP monoclonal antibodies (Mabs) administered via monthly injection. They have truly revolutionised headache care over the last four or five years," says Prof Sinclair. However, these treatments are expensive and access is limited. "We need more healthcare professionals able to provide headache management and a simpler prescribing process," she adds. "Effective management can sometimes be the difference between losing your job or keeping it. If you're a migraine sufferer, things really have changed."
