“When I get a migraine it makes me very ill and really puts me out of action. I can feel it coming on and then the full blown migraine emerges and I feel terrible. As the second day progresses, the pain finally begins to lessen. The third day leaves me with a vague pain and feeling absolutely shattered but otherwise okay.”
What is migraine?
The word migraine can mean the attack, or can mean the underlying disease that causes the attacks. The Greek word for half is hemi and for skull is kranion, hence hemicrania: so some prefer to pronounce it “mee-graine”, though “my-graine” is fine. Migraine pain can be just on one side of the head though can be on both sides, swap sides, or asymmetrical.
Migraine is more than just a headache; but almost all headaches are migraine.
Migraine pain normally comes with nausea (queasiness) or vomiting; and oversensitivity to light, noise, movement, or smell.
If you have headache attacks lasting hours or days, with queasiness or a preference for rest (even if you can carry on, with an effort) you almost certainly have migraine.
Migraine is a disorder of the brain. If the brain is a computer, migraine is a software not a hardware problem.
Migraine can be acute or episodic (infrequent attacks) or chronic (symptoms more often than not, for three months or longer).
Who gets migraine?
Anyone can get migraine. It affects 1 in 5 women, 1 in 15 men. It usually begins in early life, though diagnosis may be delayed or overlooked until it becomes a problem, often in working or middle age. Migraine usually gets less troublesome in older people, though it can begin at any age.
What are the different types of migraine?
Migraine can be acute (90%) or chronic (10%); with aura (10-30%) or without aura (70-90%). Some people have migraine aura without headache.
People who have attacks of migraine, are more head-achy than people without migraine, but not all these headaches are typical migraine attacks. Many headache experts think “tension headache” is simply a featureless form of migraine. “Ice-pick 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 migraine.
What are the symptoms of an acute migraine attack?
There can be four stages, though fortunately not all patients get all stages:
- Prodrome is mood change hours or days before the headache. This can be mistaken for trigger: “stress/chocolate causes my migraine” when in fact the prodrome causes irritability, or makes you crave chocolate
- 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 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.
- Head pain or pressure is typically thumping or pulsing. It can affect any part of the head, including the face or the neck. It can feel just like “sinusitis”. It lasts hours or days, not minutes or weeks. If head pain is mild or absent, the diagnosis is difficult.
- Recovery can take a day or two, when there are no particular symptoms other than feeling ill.
Do I need any tests?
The diagnosis of migraine is based on the nature and time-pattern of symptoms. Physical examination is normal. Most people with migraine need no tests. Treatment response does not diagnose migraine.
A normal brain scan does not confirm a diagnosis of migraine. One in four healthy people (which includes people with migraine) have a technical abnormality on a brain scan, which can be worrying.
What causes migraine?
Pain is an important alarm signal; migraine is like a faulty alarm. 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.
Migraine also associates 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 migraine associates with stress, but is not caused by stress.
What are migraine triggers?
In many, but not all people it is possible to identify and avoid migraine triggers.
Migraine likes a regular biorhythm.
Irregular or skipped meals should be avoided. People with migraine 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 rituals as during the working week.
The let-down from stress is another reason for migraine at the weekend – try to keep stress levels relatively constant, or change gradually.
Keeping physically fit makes you more resistant to migraine (although for some people vigorous exercise can bring on an attack).
Unaccustomed exercise can trigger migraine – try to exercise regularly at the same time every day; build up fitness gradually.
In women, a falling oestrogen level can trigger migraine at menstruation, or after childbirth. The oestrogen contraceptive pill can sometimes worsen migraine (and should not be used if there is aura).
Change in the weather can trigger migraine: but can’t be avoided.
One of the commonest causes of worsening migraine, is too many pills! See the fact sheet on medication overuse.
Travel is a common migraine trigger. Many of the above triggers can contribute to migraine on holiday.
Some people think that foods such as cheese, chocolate, citrus fruits and tyramine-containing foods trigger migraine. This opinion is not often shared by headache specialists.
Finally, anything that causes headache, will trigger migraine attacks in the susceptible. Head injury, and alcohol, are the common culprits.
What can I do to help myself?
The main thing is to plan carefully. Don’t just take random painkillers. Many people cope well without seeing a health professional. First step could be your local pharmacist; next, your GP. Only a minority of people with migraine have to see a headache specialist.
Keep a diary
The more you’re bothered by migraine, the more important it is to keep a record of attacks of headache and other migraine symptoms, including also possible triggers (e.g. menstrual cycle; shift-work pattern) and treatments together with response.
What treatment can I take?
Drugs can be very effective at controlling migraine symptoms – if it’s the right drug at the right time!
Pills from the aspirin and Ibuprofen family (known as NSAIDs) work better than Paracetamol, and codeine is best avoided. A family of drugs known as Triptans (such as Sumatriptan, sold as Imigran) also works well – and probably works by reversing the changes in the brain that cause migraines.
The most important thing is to act quickly: There is a ‘window of opportunity’ during a migraine attack before the stomach stops working effectively (called ‘gastric stasis’) when any drugs you take won’t be absorbed properly. To help your stomach absorb the medicines better, take a large dose of the painkiller (e.g. 900mg of aspirin or 600mg of ibuprofen) and try to choose a soluble form which you can dissolve in water. Adding an anti-sickness drug, such as domperidone 20mg (available via prescription from your GP) not only stops you feeling sick, but helps the medication be absorbed.
If the drugs don’t work individually, taking them all together as soon as possible at the start of the attack is a better plan: eg., taking sumatriptan, ibuprofen and domperidone at the same time (if you are OK taking each of the drugs separately, you are quite safe taking them all together).
If you get frequent or very severe attacks or the treatment for the attacks doesn’t work well, you may need to use preventative drugs. These are drugs you take every day with the aim of preventing or lessening the attacks. The trouble with preventative drugs is that they don’t work for everybody, and they usually reduce the number and severity of attacks rather than stopping them altogether. You also often have to put up with some side effects (like drowsiness) from the preventative drug. So it’s best to start with acute treatment and keep a migraine diary, to help you and your doctor see how it is working.
Even more important for prevention, is dealing with the migraine “triggers” and lifestyle choices, which can really improve migraine. These are listed above.
One of the most common reasons for worsening migraine is overuse of painkillers: if you take ordinary painkillers more than 15 days a month or triptans or codeine related drugs more than 10 days a month the headaches can start getting worse in consequence. Recording it in your migraine diary will help keep a check on this. It’s a good idea to seek advice from your GP who can guide you through the different treatment options and if necessary refer you to a specialist migraine clinic for further help.
What if drugs don’t work?
Don’t take drugs that don’t work. If your migraine is going from bad to worse it is often important to stop taking acute treatments for a while. This is hard to do if you have a busy life. The single commonest reason for worsening migraine, moving from acute to chronic pain, is the overuse of acute treatments. This is a big problem for people who take random painkillers, particularly combinations of codeine and paracetamol, though any acute migraine treatment can do this. When you’re in a hole, stop digging!
Will it get better?
Yes. Almost everyone finds that migraine improves naturally with time. While waiting for this to happen, migraine can be controlled, treated, and managed – but not, in the strictest sense, cured.
Think about triggers and how to avoid them; avoid traps such as medication overuse or the wrong sort of contraceptive pill; keep a diary, consider a preventative; consult your pharmacist and GP: if they can’t help, consider seeing a specialist.
This information is provided as a general guide only. If you have any queries or concerns about your headaches or medications please discuss them with your GP or your National Migraine Centre Doctor.