Migraine Triggers and Management

Around 4.9 million Australians experience migraine, making it one of the most common neurological conditions in the country. Migraines are not just bad headaches. They are a complex neurological event involving changes in brain chemistry, blood flow, and nerve signalling. For the people who live with them, migraines can be genuinely disabling — costing workdays, social plans, and a fair amount of patience.

Understanding the different types of migraine, what triggers them, and how to manage them is the foundation of getting your life back from a condition that tends to run the show if you let it.

Types of Migraine

Not all migraines present the same way, and recognising your type helps guide treatment.

• Migraine without aura — the most common type. Moderate to severe throbbing pain, usually one-sided, lasting 4-72 hours. Accompanied by nausea, light sensitivity, or sound sensitivity.
• Migraine with aura — around 25-30% of migraine sufferers experience aura: visual disturbances (zigzag lines, blind spots), tingling in the face or hands, or difficulty speaking. Aura typically lasts 20-60 minutes and precedes the headache.
• Vestibular migraine — primarily causes dizziness, vertigo, and balance problems, sometimes without a significant headache. Often misdiagnosed as an inner ear condition.
• Menstrual migraine — occurs in a predictable pattern related to the menstrual cycle, typically in the two days before or three days after the start of a period. Driven by oestrogen withdrawal.
• Chronic migraine — defined as 15 or more headache days per month, with at least 8 meeting migraine criteria. This is where migraines stop being episodic and start being a constant background presence.
• Hemiplegic migraine — a rare subtype causing temporary weakness on one side of the body, mimicking stroke symptoms. Always requires medical assessment to rule out other causes.

Trigger Categories

Migraine triggers are individual, but they tend to cluster into recognisable categories. Most people have two or three primary triggers, and it is usually a combination — not a single factor — that tips the balance.

• Hormonal — menstrual cycle changes, oral contraceptive pill, HRT, perimenopause. Oestrogen fluctuation is one of the most potent triggers.
• Sleep — both too much and too little. Irregular sleep schedules, shift work, and jet lag are common culprits. The weekend lie-in migraine is almost a cliche because it is so reliable.
• Dietary — skipping meals (especially breakfast), dehydration, alcohol (particularly red wine), aged cheese, processed meats, chocolate, and caffeine withdrawal. The dose matters more than the food itself in most cases.
• Environmental — bright or flickering lights, strong smells (perfume, cleaning products, petrol), weather changes (particularly barometric pressure drops), and altitude changes.
• Stress — both during stress and in the let-down period afterward. The Friday afternoon migraine after a high-pressure work week is a well-documented pattern.
• Physical — intense exercise without adequate warm-up, poor posture (especially prolonged screen use), neck tension, and sexual activity.
• Medications — overuse of acute headache medications (including paracetamol, ibuprofen, and triptans) can paradoxically cause more headaches. This is called medication overuse headache.

Keeping a Migraine Diary

A migraine diary is the single most useful tool for identifying your triggers. Record the date, time of onset, duration, severity (1-10), associated symptoms, potential triggers (food, sleep, stress, weather, hormonal), and what you took for it. After 2-3 months, patterns typically emerge. Many people are surprised — the trigger they suspected is often not the main one.

Evidence-Based Prevention

If you are experiencing four or more migraine days per month, preventive treatment should be discussed with your doctor. Prevention does not eliminate migraines — a 50% reduction in frequency is considered a good response.

• Lifestyle modifications — regular sleep schedule, consistent meal times, staying hydrated, regular moderate exercise, stress management techniques. These sound basic because they are. They also work.
• Prescription preventives — beta-blockers (propranolol), anticonvulsants (topiramate, sodium valproate), antidepressants (amitriptyline), and candesartan. Choice depends on your other health conditions and side effect profile.
• CGRP monoclonal antibodies — newer targeted treatments (erenumab, fremanezumab, galcanezumab) available through neurologist prescription in Australia, with PBS listing for chronic migraine after failing other preventives.
• Supplements — magnesium (400-600mg daily), riboflavin (vitamin B2, 400mg daily), and coenzyme Q10 (150-300mg daily) have reasonable evidence. Not miracle cures, but worth trying with few side effects.
• Botox — TGA-approved for chronic migraine (15+ headache days per month). Injections every 12 weeks into specific head and neck muscles.

Acute Treatment Options

When a migraine hits, early treatment works best. The general principle: take something effective at the first sign, do not wait to see if it gets worse. It will.

• Simple analgesics — paracetamol or ibuprofen, ideally with an anti-nausea medication (metoclopramide or prochlorperazine) to improve absorption. Most effective if taken within the first 30 minutes.
• Triptans — sumatriptan is available over the counter in Australia for diagnosed migraine. Other triptans (rizatriptan, zolmitriptan, eletriptan) require a prescription. These target serotonin receptors and are the most specific acute migraine treatment.
• Anti-nausea medications — useful both for the nausea itself and to improve absorption of other medications. Metoclopramide and prochlorperazine also have independent anti-migraine effects.
• Combination approach — an anti-inflammatory plus a triptan plus an anti-emetic is often more effective than any single agent. Your doctor can advise on the right combination.

Medication Overuse Headache

This deserves its own section because it is common, under-recognised, and genuinely miserable. If you are taking acute headache medication on 10-15 or more days per month, the medication itself may be perpetuating your headaches. Triptans and opioid-containing analgesics are the worst offenders, but even simple paracetamol can cause it with daily use. The treatment is gradual withdrawal of the overused medication — which temporarily makes headaches worse before they improve. This is best done with medical supervision and a preventive medication in place.

When Imaging Is Needed

Most people with migraine do not need a brain scan. Imaging (usually MRI) is recommended when there are atypical features that suggest something other than migraine.

• New onset after age 50
• Sudden onset severe headache (thunderclap headache) — this is an emergency
• Progressive worsening over weeks despite treatment
• Neurological signs that persist between attacks
• Change in established headache pattern
• Headache that wakes you from sleep consistently
• First migraine with aura, particularly with prolonged or atypical aura

Specialist Referral and Workplace Accommodations

A neurologist referral is appropriate if you have tried two or more preventive medications without adequate response, your diagnosis is uncertain, you have hemiplegic or brainstem aura migraine, or you are experiencing chronic daily headache. Many Australian neurologists have long wait times (3-6 months), so a referral sooner rather than later is worthwhile.

In the workplace, migraines are covered under disability discrimination protections. Reasonable accommodations might include flexible start times, the ability to work from home during prodrome, access to a quiet dim room during attacks, screen filter software, and understanding that migraines are unpredictable. A medical certificate from your doctor can support requests for workplace accommodations if needed.