In the world, at least 1 adult in every 7 suffer from migraines. It is a neurological disease that recurs at irregular intervals and is very stressful for those affected. While some people only have a migraine attack once or twice a year, others have it several times a month.
Several studies have shown that the endocannabinoid system is involved in the central pain processing of the human body. (1) So, the cause of pain could be a temporary or permanent imbalance in the endocannabinoid system.
To this extent, treatment with cannabinoids such as tetrahydrocannabinol (THC) and cannabidiol (CBD), as well as other cannabinoids and ingredients from the cannabis plant, could be an alternative to traditional painkillers. Before the study situation is discussed in more detail, we will first look at the clinical picture.
What types of migraine are there?
Doctors distinguish between different types of migraine. These include:
Migraines without an aura are the most common and they take the form of sudden unilateral headaches that are made worse by physical activity. Other symptoms include nausea and sensitivity to noise and light. A single attack usually lasts between 4 and 72 hours. Doctors talk about migraine status if the headache attack lasts longer than 72 hours. In this case, medical treatment is needed.
If neurological symptoms occur before the headache phase, it is called migraine with aura (migraine accompagnée). Those affected suffer from visual disturbances such as flickering, flashes of light or seeing jagged lines. Other neurological symptoms include skin sensations, speech difficulties, discomfort, and dizziness.
The aura phase lasts about half an hour to an hour. The cause of the aura is thought to be a temporary lack of blood flow in the brain. This is probably caused by a vascular spasm in a certain area of the brain. After the aura phase, the headaches that are typical of migraines occur.
However, if there are no headaches, it is probably a so-called migraine sans migraine, i.e. an aura without headaches, or what doctors call this form of migraine an eye migraine.
Subforms of migraine with aura are:
- Hemiplegic migraine (“complicated migraine”): People who have hemiplegic migraine suffer from movement restrictions and are unable to move certain limbs, for example, and the symptoms usually go away after about an hour.
- Basilar migraine: This type of migraine mainly affects young adults. It is a headache in the back of the head. Other symptoms can include problems with speech, vision and movement, hearing loss, dizziness, paraesthesia and loss of consciousness.
There are also rare forms of migraine involving the eyes. These include ophthalmoplegic and retinal migraines, where vision problems are the most common.
Difference between aura and stroke
A stroke is associated with symptoms similar to those of the aura. However, while the symptoms of a stroke are sudden, an aura starts slowly and gradually increases in intensity.
Other forms of migraine
About seven percent of all migraine patients suffer from menstrual migraines, which occurs about two days before or two days after menstruation. Shortly before that, oestrogen levels drop sharply. This can be the cause of the headaches with or without an aura.
Acute migraine attacks usually last for a few hours or days. In between, the patients are symptom-free. If patients have migraine attacks for more than 15 days in a month over a period of three months, doctors assume that it is a chronic migraine.
Another form of migraine is an abdominal migraine, which mostly affects children. This is not usually a headache, but a dull pain around the navel. Children often complain of other symptoms like loss of appetite, nausea and vomiting. Doctors assume stress or mental strain to be the triggers of this type of migraine.
Then there are vestibular migraines, which affect the balance system. The main symptoms are vestibular disorders and dizziness. Headaches, on the other hand, are usually only slightly noticeable.
Migraine: symptoms in four phases
A migraine attack is divided into four stages phase with different symptoms: the pre-phase (prodromal stage), aura phase, headache phase and regression; each phase being of varying severity. In addition, not every person affected goes through all phases. The following symptoms can occur in the stages:
- Pre-phase: Many people have the first symptoms of a migraine attack a few hours or days before they have a migraine headache. This can be signaled by irritability, digestive problems, loss of appetite or ravenous appetite, difficulty reading and writing and frequent yawning.
- Aura phase: Here patients suffer from visual disturbances such as zigzag lines or flashes of light in the field of vision. They can also have visual field failures with grey or black spots (negative scotoma) or optical hallucinations (positive scotoma). Other possible symptoms include paralysis or tingling in the arms and legs.
- Headache phase: Headaches can last for several hours or even days. Both the intensity and duration of the pain can vary from attack to attack. Patients complain of a strong unilateral pain in a particular area of the head (e.g. behind the eyes, behind the forehead or at the temples). Common accompanying symptoms are nausea and vomiting as well as sensitivity to light and noise.
- Recovery phase: The symptoms gradually subside in this phase. People who have had a migraine attack often feel exhausted, tired and irritable. In addition, there is a loss of appetite and concentration problems.
What is the cause of a migraine attack?
A number of different factors are being discussed as the cause of a migraine attack. Apart from genetic factors, it could be caused by a circulatory disorder in combination with a malfunction of the neurotransmitters in the brain. The messenger substance serotonin (“happiness hormone”) seems to play a particularly important role in this. This is because it conveys certain information from one nerve cell to another nerve cell or to other organs. Finally, however, the effect of serotonin in a migraine attack has not yet been clarified. Nevertheless, it is assumed that the messenger substance plays a role in the brain (central serotonin) and outside the brain (peripheral serotonin). If this balance shifts in these two areas, it could trigger a migraine attack.
In some areas of the brain, circulatory problems, or rather the vessels in the affected area being narrowed, can be detected during an aura. The reason for this could be high serotonin levels.
What are migraine triggers?
Although the causes of the disease are not yet clear, trigger factors are known to trigger an attack. Which triggers these are in each individual case varies from person to person. Possible triggers could be:
- Stress and emotional strain
- Sensory overload
- Weather changes
- Changes in the sleep-wake rhythm
- Certain foods (e.g. citrus fruits or foods containing tyramine such as chocolate, bananas or red wine)
- Certain stimulants (e.g. nicotine or alcohol)
- Fluctuations in hormone balance
- Hormonal contraceptives (e.g. contraceptive pill)
To find out the individual trigger factors, patients should keep a migraine diary. The entries (date, time of day, duration and severity of headaches) often show a pattern.
Non-drug therapy for migraine
People can do a lot themselves to prevent migraines. These measures include avoiding trigger factors. It is also helpful to reduce stress, learn a relaxation technique (e.g. autogenic training) and take advantage of cognitive behavioural therapy. With the help of the therapist, patients learn to break through stressful and negative thought patterns.
Therapy with medication
The following drugs or active ingredients can be used in the medicinal treatment of migraine:
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, paracetamol, naproxen and acetylsalicylic acid (ASAA) are suitable for mild to moderate headaches. The Migraine Trust recommends preventative measures and ways to optimise pain relief on their website.
- Triptans (e.g. zolmitriptan or sumatriptan) are used for severe migraines. These drugs are serotonin receptor agonists that bind to the same receptors as the neurotransmitter serotonin in the brain. As a result, the messenger substance can no longer bind to these receptors, which reduces pain and nausea. Triptans also cause the blood vessels in the brain to narrow, which can also reduce headaches. You need to see a doctor before taking triptans, as these drugs are not allowed to be taken for a number of conditions like high blood pressure or coronary heart disease.
- Ergotamine (ergot alkaloids) is usually only given to patients if the migraine attack lasts for a particularly long time or if other drugs are not effective. Ergotamines can cause severe side effects and should not be taken by patients with cardiovascular disease.
Measures in acute cases and prophylaxis
At the first sign of trouble, it can help to retreat into a darkened room and switch off all sources of noise such as the television or smartphone. Sometimes it is also possible to stop a seizure by taking painkillers early on. But it is important that you do not take painkillers too often. This is because there is a risk that the drugs themselves could become the trigger (drug-induced headache).
The following drugs are available for preventive treatment:
Migraine prophylactics of the first choice:
- Anticonvulsants such as valproic acid or topiramate
- Beta-blockers such as propranolol or metoprolol
- Tricyclic antidepressants like amitriptyline
- Calcium antagonists such as flunarizine
Migraine prophylactics of the second choice:
- antidepressants (SNRI) like venlafaxine
- anti-epileptic drugs such as gabapentin
- Vitamin B2 and magnesium (riboflavin) in combination with omega-3 fatty acids, coenzyme Q10 and berry extracts
What role does the endocannabinoid system play in migraines?
Clinical and experimental studies suggest that a lack of regulation in the endocannabinoid system, or a lack of the body’s own cannabinoids (endocannabinoids), could trigger migraines. (2)
For example, in a group of migraine patients, the amount of the body’s own cannabinoid anandamide, which is produced by the body as needed, was reduced. Anandamide is then broken down by the enzyme FAAH (fatty acid amide hydrolase).
However, it is still unclear whether the body simply does not produce enough anandamide in migraine patients or whether FAAH breaks down the endocannabinoid too quickly.
Studies on migraine and treatment with medical cannabis
Italian researchers investigated whether medical cannabinoids are suitable for the prophylaxis or acute treatment of migraine. (3) A total of 48 people with migraines took part in the study, who were initially given two different cannabis preparations. While the first preparation contained 19 percent tetrahydrocannabinol (THC), the second preparation contained 9 percent of the non- intoxicating cannabinoid cannabidiol (CBD). However, doses of less than 100 milligrams each had no effect. Only from 200 milligrams onwards did the drugs have an analgesic effect.
In the second phase of the trial, the participants were given either the try-cyclic antidepressant amitriptyline (25 milligrams a day) or a combination of THC and CBD (200 milligrams a day) for three months as prophylaxis. For acute headaches, the volunteers took another 200 milligrams of THC-CBD.
The results showed that the frequency of migraine attacks decreased by 40.4 percent when they were treated with cannabis and by 40.1 percent when they were treated with amitriptyline. It is interesting to note that the cannabinoids THC and CBD reduced the intensity of pain by 43.5 percent.
In the summary, the researchers explained that medical cannabis might be an alternative therapy for the prevention of migraines.
In a recent study from 2019, researchers wanted to find out whether inhaling cannabis can reduce migraines and headaches, and whether gender, type of cannabis (concentrate vs. flower), delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD) or dosage contribute to changes in these assessments. (4)
The researchers obtained the data from the medical cannabis app Strainprint. This allows patients to track their symptoms before and after using different cannabis strains and doses. Data from 12,293 sessions using cannabis for headache treatment and 7,441 sessions for migraine treatment were analysed.
The results show that headache and migraine values decreased significantly after cannabis use. Men reported a greater decrease in headaches than women. In addition, the use of concentrates was associated with a greater reduction in headache than the use of cannabis flowers.
It is also reported that inhaled cannabis reduced the severity of headaches and migraines by about 50 percent. However, the effect seemed to diminish over time, so patients had to increase the dosage. This suggests that tolerance to the effect might develop with continued use.
Unfortunately, there are hardly any clinical studies that provide clear evidence of treatment with cannabis-based drugs for migraine attacks. However, many migraineurs report a positive effect or pain relief. The frequency of migraine attacks also seems to be reduced by the use of THC and CBD. From experience reports, it is also known that taking freely available CBD oil can have a positive effect on the disease.
In order to better assess the actual effect, and to determine which cannabis preparations are suitable in which dose, randomised and placebo-controlled trials still need to be carried out.
(1) Schneider, U., Seifert, J., Karst, M. et al. Das endogene Cannabinoidsystem. Nervenarzt 76, 1062–1076 (2005). https://doi.org/10.1007/s00115-005-1888-7
(2) Greco R, Demartini C, Zanaboni AM, Piomelli D, Tassorelli C. Endocannabinoid System and Migraine Pain: An Update. Front Neurosci. 2018;12:172. Published 2018 Mar 19. doi:10.3389/fnins.2018.00172
(3) Bryson C. Lochte, Alexander Beletsky, Nebiyou K. Samuel, Igor Grant, The Use of Cannabis for Headache Disorders, Cannabis Cannabinoid Res. 2017; 2(1): 61–71. Published online 2017 Apr 1. doi: 10.1089/can.2016.0033
(4) Cuttler C, Spradlin A, Cleveland MJ, Craft RM. Short- and Long-Term Effects of Cannabis on Headache and Migraine [published online ahead of print, 2019 Nov 9]. J Pain. 2019;S1526-5900(19)30848-X. doi:10.1016/j.jpain.2019.11.001