As anyone who’s suffered from a migraine can tell you, once one strikes, it’s pretty much game over when it comes to the rest of your day. A condition that is as debilitating as its effects are far-reaching, what are the best ways to prevent and cure them?
From migraine symptoms, aura, causes, treatment and prevention, we asked the National Migraine Centre, a charity clinic at the forefront of primary headache research and treatment of sufferers for over 30 years for their advice and top tips for making sure you’re prepared for whenever one strikes. Here’s what we found out...
GTG: What are the main migraine causes?
Pain is an important alarm signal; a migraine is like a faulty alarm, when pain nerves at the back of the brain (the brainstem) switch on when nothing else is wrong.
This nerve error causes other changes, including to blood vessels and to the gut; light seems too bright, noise too loud, and so on.
Migraine aura happens when changes in the brainstem trigger a wave of nerve suppression that spreads over the cortex (outer lining, or nerve cell layer) of the brain.
The underlying cause is not yet certain, but most experts think there is an error in ion channels on nerve membranes, which makes the nerve malfunction. The ion channel disorder is presumably genetic, but the triggers of attacks are environmental.
Migraines also associate with a relative shortage of the brain chemical serotonin (also called 5-hydroxytriptamine or 5HT), in the brainstem. The same chemical change in the mid-part of the brain causes insomnia and fatigue; and at the front of the brain causes stress. This is why migraines associate with stress, but are not caused by stress.
GTG: What is a migraine with aura?
Aura usually happens just before the headache. Each aura symptom (there can be more than one) lasts up to an hour, typically affecting vision, though it can cause numbness, dizziness, paralysis, speech difficulty, memory loss, or collapse. Visual aura normally begins off-centre asymmetrically in both eyes and gradually enlarges with blackness, zigzags, lights or patterns which can affect half or all vision. It can be helpful to cover or close one, then the other eye to check that vision from both eyes is affected.
GTG: What are the main migraine symptoms? How does a migraine differ from other types of headache, including a tension headache?
A migraine is more than just a headache. Migraine pain normally comes with nausea (queasiness) or vomiting; and oversensitivity to light, noise, movement, or smell.
If you have attacks of a bad head lasting hours or days, with queasiness or a preference for rest (even if you can carry on, with an effort) you almost certainly have a migraine.
Many headache experts think “tension headache” is simply a featureless form of migraine. “Icepick pain,” is an instantaneous stabbing pain in any part of the head. Alcohol hangover headache, travel sickness, and vertigo are more often suffered by people with migraines.
GTG: How common are migraines?
Extremely common. Migraines are more prevalent than diabetes, epilepsy and asthma combined. It affects 1 in 5 women, 1 in 15 men.
GTG: What over-the-counter drugs and treatment for migraines would you recommend?
Drugs can be very effective at controlling migraine symptoms – if it’s the right drug at the right time!
Acute treatment can be with painkillers or triptans. Not all painkillers work well for migraines: most find aspirin or ibuprofen better than paracetamol or codeine. Triptans are not painkillers but usually work well for migraines, because they mimic serotonin: sumatriptan is available without prescription. Other useful drugs include stronger versions of ibuprofen, called non-steroidal anti-inflammatory drugs (NSAIDs), and anti-sickness drugs.
During a migraine attack the stomach can stop working, so drugs are not well absorbed. Ways around this include using large doses of drugs (e.g. aspirin 900mg or ibuprofen 600mg), dissolving the drug in water (some recommend a fizzy drink) and adding an anti-sickness drug that also promotes the normal emptying of the stomach, such as domperidone 20mg (available without prescription as Motilium).
The combination of a triptan, plus domperidone, plus either aspirin or ibuprofen, all taken together at the start of an attack, can be better than the same drugs used one after the other over a few hours. Another way to avoid poor drug absorption (or vomiting of drugs) is to use suppositories.
GTG: Is there a way to prevent a migraine?
Migraine needs early acute treatment: there is a “window of opportunity,” that can take some time and experimentation to establish, for each patient. Sometimes aspirin or NSAIDs work well at prodrome (warning) or aura stage, but triptan use may need to wait until the headache begins. When you know what works for you, always keep a small supply with you.
GTG: Is it bad to take forms of triptan medication quite regularly e.g. 2-3 tablets in occasional weeks? Would this cause medication overuse or immunity to the drug?
People with migraines know that early treatment of an attack works better than late treatment. It’s easy to take medication “just in case” but the more you take for a short term or rescue treatment for migraine, the more it tends to come back after the medication wears off.
How much is too much? The official definition requires three months of head pain at least as often as not, with 15 doses a month of ordinary painkillers like aspirin, paracetamol, or ibuprofen; 10 doses a month of triptans, opiates, or combination drugs (e.g. paracetamol and codeine).
The surprising thing is that you only have to take paracetamol once every other day, or a triptan every third day, to get medication overuse headache, if you also have a migraine.
Pattern of use is important. Short term high usage can be OK; the steady drip drip drip of painkillers or triptans over many months is not.
Which medications cause it? Most people with 'medication overuse headache' are taking combination drugs, particularly paracetamol/codeine combinations. But any drug used in the short term to abort migraine, can cause medication overuse headache. Some drugs such as naproxen, diclofenac and indometacin can cause it when used as and when required; but the same drugs taken absolutely regularly three times a day, can be helpful.
GTG: Do you have any lifestyle tips for a migraine sufferer?
Think about triggers and how to avoid them; keeping a diary will help you to identify these.
Migraines like a regular biorhythm. Irregular or skipped meals should be avoided. People with migraines should take a fibre-containing breakfast within an hour of getting up, before leaving home for work or school. Eat little and often.
Some people think dehydration can trigger migraine. This is easy to avoid.
Try to have a regular body clock, with the same or similar time for sleep and for getting up every day. Avoid shift work, or try to stay on the same shift all the time. On weekends or days off, stick to the same daily ritual as in the working week.
The let-down from stress is another reason for migraines at the weekend – try to keep stress levels relatively constant, or change gradually.
Unaccustomed exercise can trigger migraines – try to exercise regularly at the same time every day; build up fitness gradually.
In women, a falling oestrogen level can trigger migraines at menstruation, or after childbirth. The oestrogen contraceptive pill can sometimes worsen it (and should not be used if there is aura).
Change in the weather can trigger migraines: but can’t be avoided.
Travel is a common migraine trigger. Many of the above triggers can contribute to migraines on holiday.
Some people think that foods such as cheese, chocolate, citrus fruits and tyramine-containing foods trigger migraines. This opinion is not often shared by headache specialists.
Finally, anything that causes headaches, will trigger migraine attacks in the susceptible. Head injuries and alcohol are the common culprits.
GTG: Are there any non-drug related alternatives for migraine treatment?
“There are several fairly new technologies on the market at present,” says specialist doctor Dr Judith Pearson of the National Migraine Centre. “The National Institute for Health and Care Excellence (NICE) recently approved the transcranial magnetic stimulation (TMS) device for further testing in the UK. This has been shown to reduce attacks of migraine with aura in a small trial of around 160 people, and is being more widely used since the NICE guidance was issued.
“We are excited to follow the progress of further trials. There are other devices available, like cephaly, which stimulates the trigeminal nerve where pain signals are generated. Trials are underway into a new device which stimulates the vestibular nerve within the ear too. These devices are based on cutting edge science and are as yet unproved, but may show promise for the future treatment of patients with migraines without resorting to medication.
GTG: What advice do you have for recovering after a migraine?
“Patients often describe feeling like they've been ‘hit by a bus’ or are ‘wiped out’ the day after a migraine attack,” says Dr Pearson. “Medically we refer to this period as the ‘postdrome,’ and it is still considered part of the migraine attack. We advise rest, and plenty of fluids to aid their recovery. If the patient feels like eating, then this can also help.”
GTG: If you suffer from constant migraines, could that be an indication of any other underlying health issues?
“Chronic migraines (on more than 15 days a month for the past three months or more) may be due to medication overuse. This can occur in anyone taking acute treatments on more than 2-3 days per week,” advises Dr Pearson.
“Diary cards are useful in identifying how often a patient is taking medication to treat their symptoms. Occasionally chronic migraines may be an indicator of another underlying health issue, and so patients with worsening headaches or migraines should see a doctor for assessment including an examination of their blood pressure and neurological system.”