Introduction

Migraines are an unpleasant surprise to wake up in the morning, especially troubling when they come back time and time again. Several factors can contribute to recurrent morning migraines, some of which are poor sleep, mental health, hormonal imbalances, medication overuse, digestion issues and environmental factors.

Migraines are, in a sense, the body’s way of saying it wants to feel balanced. The literature overall suggests that they appear when there is a change, whether internal or external. If this lack of balance is long-term, people can experience recurrent migraines day and night, multiple times a month. Usually, the best course of action is to seek the advice of a doctor, maintain a healthy balanced life, and try not to worry about things you cannot control.

Read on to find out more about how to identify a migraine, factors triggering recurrent morning migraines, and ways to help prevent them.

What are migraines?

Prevalence of migraines

Migraines are common, with a reported 1.1 billion cases worldwide in 2019 and continue to increase.¹ It occurs twice as often in females (17,902 per 100,000 people) than in males (10,337 per 100,000 people).¹

Symptoms of a migraine

Migraines are characterised by a throbbing headache on one side of the head, either the left or right side. Migraines have 4 stages: prodrome, aura, headache, and postdrome.² This can occur over a few hours or several days, varying in frequency from person to person. If you find yourself waking up with a migraine, it is possible you have already undergone a part of these stages while asleep.

Stages of migraine

Prodrome phase

The prodrome phase can begin a few hours or even 3 days before the aura or headache phases.² Symptoms vary and can include:

• Tiredness
• Yawning
• Neck stiffness
• Gastrointestinal problems
• Food cravings
• Mood changes
• Sensitivity to light

Aura phase

Aura precedes one-third of migraine headaches.² This is where temporary disturbances can last up to 1 hour before gradually developing into a migraine headache. Sometimes the aura co-occurs with the headache phase. Aura symptoms can affect:

• Vision – seeing flashing lights or zig-zag lines
• Speech and language – slower to speak, not finding the right words
• Motor function – such as a looser grip in your hands, causing you to drop things
• Cognitive abilities – brain fog, cannot perform simple mental tasks well
• Dizziness
• Numbness or tingling

Headache phase

This stage is what most people think of when they hear about ‘migraines’. Characterised by a debilitating pain on one side of the head, the headache phase² can last anywhere between 2 hours and 3 days. You may also experience:

• Nausea
• Vomiting
• Thirst
• Runny nose
• Increased tear production
• Nasal congestion
• Sensitivity to light
• Sensitivity to sounds

Migraines sometimes present with or without the headache or aura phases:

• Headache without aura – no warning aura symptoms
• Headache with aura – aura symptoms occur before or during the headache
• Aura without headache – only aura symptoms

Postdrome phase

This is the aftermath of the migraine attack and can last between 24 hours and a few days. Symptoms during the postdrome phase can include:

• Feeling drained
• Stiff neck
• Body aches
• Brain fog and difficulty concentrating
• Digestion problems
• Mild headache
• Suddenly feeling very hungry or thirsty
• Feeling full of energy

Causes of recurrent morning migraines

Sleep patterns and disorders

Migraine and sleep disorders tend to co-occur, and there are extensive studies trying to understand their association. Does low-quality sleep induce migraine? Does migraine disrupt sleep? Or are they symptoms of a different medical condition? A review by Tiseo et al. (2020) described how migraine is related to sleep disorders, with some of the points summarised here.³

Insomnia and migraines have a synergistic relationship, where the accumulating sleep deprivation caused by insomnia worsens migraines, and migraines occurring at night impede restful sleep. The presence of insomnia also increases the pain intensity in migraines, the frequency of migraine attacks and the risk of migraines becoming chronic.³ This means that insomnia can increase the likelihood of recurrent morning migraines.

Obstructive sleep apnoea is characterised by abnormal breathing during sleep that results in briefly waking up multiple times throughout the night, disrupting sleep quality. These can be partial or complete obstructions of the airways, with obesity being a high-risk factor for developing sleep apnoea.³ People with this condition frequently experience headaches or migraines upon waking.⁴ Treating it improves sleep quality and reduces migraine frequency and intensity.⁵

Mental health conditions

Depression, anxiety and stress are associated with migraine and commonly present together. These three factors can provoke migraine attacks or be induced as a result of frequent or severe migraines.^6,7,8

Waking up in pain from a migraine can make mornings difficult, affecting your depression. Depression can also affect your sleep habits, which creates higher chances of morning migraines. Anxiety and stress regarding plans you had made for the day that now need to be cancelled can also increase the likelihood of migraines.

Stress can be physical or psychological. It triggers a biological reaction inside the body and changes the normal balance to get ready to react to perceived threats.⁸

Examples of stressors:⁸

• Death
• Divorce
• Loss of loved ones
• Losing a job
• Illness
• Fatigue
• Demanding tasks
• Minor daily hassles
• Fear of getting a migraine

There is evidence supporting migraine attacks happening once you relax after a stressful event. For instance, stress in the evening may result in waking up with a migraine in the morning.⁹

Stress treatment

Recommended things to do:⁸

• Stress management techniques
• Learning to cope with stress
• Solving the issue causing stress
• Having support from trusted family, friends or a professional
• Relaxation training (e.g. muscle relaxation)
• Making changes to your lifestyle or situations going on in your life
• Exercising
• Avoiding situations that make you feel severely stressed or anxious

Hormones

Around 35-50% of female migraineurs are likely to have an attack in the week before their monthly periods due to lower-than-normal levels of the hormone oestrogen.¹⁰

Some women have fewer migraines during pregnancy because lactation has a protective effect, which returns after delivery.¹⁰

During the beginning of menopause, women may experience worsening migraines because of fluctuations in hormones, but once the oestrogen levels reduce and the oestrogen cycles end, migraines improve or can stop altogether.¹⁰

Medication

Medication overuse headache occurs when certain acute medications are taken too frequently within a short space of time.¹¹ For example:

• Simple analgesics or non-steroidal anti-inflammatory drugs (NSAIDs) like paracetamol, aspirin and ibuprofen for 15 or more days per month
• Opioids, mixed analgesics, triptans or ergot alkaloids for 10 or more days per month or for more than 3 months

With the exception of opioids, these medications are routinely used to treat migraines, making it difficult to strike a balance between when to take them and when to omit them. Medication overuse can lead to chronic migraine,¹¹ meaning you may find yourself having migraines seemingly day and night.

Treatment of medication overuse headaches

Ways to deal with it:¹²

• Learning when acute treatment should be taken
• Migraine prevention medication to treat frequent or severe prolonged migraines
• Discontinuing overused medication
• Speaking with a therapist and using behavioural techniques to overcome the fear of migraine attacks¹³

Digestion

Dietary habits and certain food items can trigger migraine.⁸ For example, after a night of fasting and waking up hungry, you are more likely to have a morning migraine.

The amount you eat and what time of day you eat can impact the potential for a migraine to happen.⁸ It is recommended to have smaller, frequent meals rather than heavy meals, and to reduce the amount of triggering foods in the evening to help prevent a morning migraine.⁸

Unfortunately, there is no particular diet recommendation for migraineurs.⁸ Below are some food items and eating habits that may have an impact on recurrent migraines.

Habits to improve:

• Prevent hunger and fasting
• Have regular meals throughout the day
• Preferably have smaller, frequent meals (5-6 per day)
• Eat slow-digesting foods that will provide stable blood glucose levels, particularly in the evening before you sleep
• Eat home-cooked meals rather than processed or fast food items, which tend to spike blood glucose levels
• Stay hydrated throughout the day
• Maintain a low-fat diet

Foods to identify as potential triggers and avoid, by keeping a food diary and noting whether a migraine followed ingestion:

• Red wine and alcohol
• Chocolate
• Caffeine – coffee, tea, coca-cola and chocolate. Particularly triggering when consumed in the long-term and experiencing withdrawal overnight + rebound effect when overused. It is recommended to have a maximum of 200 mg of caffeine in a single day.
• Processed food
• Seafood
• Fish
• Ice cream
• Foods containing nitrates – e.g. bacon, hot dog, ham, and salami
• Foods containing tyramine – e.g. aged cheese, cheddar cheese, beans, smoked fish, non-fresh meat, citrus fruit, avocados, bananas, and onions
• Foods containing monosodium glutamate – e.g. dried soups, salad dressing, processed foods, some sauces, snack foods, and canned or frozen food items

Environmental factors

Migraineurs are not only affected by internal changes as described previously but also by external changes:⁸

• Weather – changes in atmospheric pressure, temperature, and humidity
• Altitude – low atmospheric pressures during climbing, flying by aeroplane
• Travelling by car or plane – atmospheric pressure changes, diet changes, unrestful sleep, uncomfortable seats
• Climbing – less oxygen at higher altitudes, cold temperatures, high physical activity, changes in sleep, and food-related problems
• Lights – bright, flickering lights are a known migraine trigger
• Odours – cleaning products, perfumes, cigarette smoke
• Noise – loud noises or prolonged exposure to noise: traffic, vehicles, even footsteps sometimes
• Nicotine withdrawal – a gradual quitting plan is recommended for migraineurs

Sometimes, one trigger alone is enough to start a migraine. Other times, 2 or more triggers need to be present to induce an attack.

Treatment

Personal experience will teach you what your environmental triggers are. It may be helpful to keep a diary to identify these, and then learn to avoid or cope with these factors.⁸

Treatment options

There are several ways to treat or cope with recurrent morning migraines, involving both pharmacological interventions with the help of a doctor and things you can do at home.

Acute medicines:

• Simple analgesics – paracetamol and ibuprofen
• Anti-emetics – to treat nausea and vomiting
• Triptans – specifically designed to treat migraines
• Gepants – a newer, migraine-specific medication

Preventative medicines:

• Angiotensin II blockers control hypertension
• Beta-blockers control high blood pressure
• Anti-convulsants are known for treating epilepsy and also help reduce migraines
• Anti-serotonergic drugs are known for treating depression and also help with migraines
• Calcitonin Gene-Related Peptide Pathway Monoclonal Antibodies (CGRP MABs) were recently made medication-specific for migraines
• Calcium channel antagonists block dopamine receptors in the brain
• Tricyclic antidepressants are used to treat depression and difficulty sleeping

Behavioural remedies:

• Avoid known triggers, such as specific foods
• Stay hydrated
• Reduce caffeine and alcohol intake
• Maintain a healthy weight
• Maintain a regular meal schedule
• Keep a regular exercise schedule
• Keep a consistent sleep schedule
• Manage stress

Summary

Having a balanced life is key to migraine prevention. Keeping things stable through better stress management, maintaining good sleep habits, having a healthy diet by avoiding triggering foods, being careful not to overuse medications, and getting treated for any existing mental or physical conditions are crucial in preventing recurrent morning migraines.

Some things frustratingly are outside your control, like hormonal imbalances in female migraineurs or environmental changes. In this case, it is best to focus on what you can control.

There are preventative pharmacological treatments for migraine and several behavioural techniques to consider. Consulting a doctor and maintaining optimism is the best thing you can do when dealing with recurrent migraines.