“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 comes from the Greek hemicrania meaning half a skull. Traditionally, Migraine pain was only thought to occur on one side of the head but we now know it can be on one side, both sides or not even consist of a headache at all!
Migraine is more than just a headache; but almost all headache is migraine.
Migraine pain is usually throbbing in nature and is accompanied with nausea (queasiness) or vomiting; and increased sensitivity 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) you almost certainly have migraine.
Migraine is a disorder of the brain where the nerves become over-stimulated and cause a cascade of chemicals to be released. It is not caused by a structural problem in the brain.
Migraine can be episodic (infrequent attacks) or chronic (more that 15 headache days per month).
Who gets migraine?
Migraine is common. It affects 1 in 5 women and 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 (20%) or without aura (80%). Some people have migraine aura without headache.
People who have attacks of migraine, are more prone to headache 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. “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 migraine.
What are the symptoms of an acute migraine attack?
There can be four stages, though fortunately not all patients get all stages:
1. Prodrome occurs hours or days before the headache. This can be mistaken for trigger. Changes in mood such as irritabilty or anxiety, or craving cheese or chocolate are due to changes which occur in this first phase. Yawning is a common feature and people are more sensitivite to their surroundings (light, smells and noise).
2. Aura 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 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.
3. Pain or pressure in the head or neck 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.
4. Recovery can take a day or two, when people feel generally unwell. A lot of people note “brain fog” where it is harder to concentrate or simple tasks take longer to complete.
Do I need any tests?
Not usually: the diagnosis of migraine is based on the nature and time-pattern of symptoms. Physical examination is normal. 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 and is not related to migraine.
What causes migraine?
Pain is an important alarm signal. Migraine is like a faulty alarm, when pain nerves at the back of the brain switch on when nothing is wrong.
This nerve error causes other changes such as to blood vessels and the gut making light seem too bright, noise too loud, and so on.
Migraine aura happens when these nerve changes trigger a wave (called depolorisation) that spreads over the cortex (outer lining, or nerve cell layer) of the brain. This causes the “positive” symptoms such as visual changes (often flashing lights), numbness and tingling. We describe this more in our factsheet about Aura.
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.
What are migraine triggers?
In many, but not all people it is possible to identify and avoid migraine triggers.
Migraine likes a regular routine.
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 ritual as in 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 containing contraceptive pill can sometimes worsen migraine (and should not be used if there has ever been aura).
Change in the weather can trigger migraine: but this is unavoidable.
One of the commonest causes of worsening migraine, is too many painkillers! 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 shared by headache specialists. Most of these are accounted for by cravings in the prodrome caused by a drop in blood sugar levels.
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. Try to take painkillers which are known to work in migraine and take them quickly. Many people cope well without seeing a health professional. The first step could be your local pharmacist or 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. You should include possible triggers (e.g. menstrual cycle or shiftwork pattern) and treatments, together with response.
What treatment can I take?
Drugs can be very effective at controlling migraine symptoms but not all pain-killers are equal.
Medications from the aspirin and Ibuprofen family (known as NSAIDs) work better than Paracetamol, and codeine is best avoided. A family of migraine specific painkillers known as Triptans (such as Sumatriptan, sold as Imigran) also work well and probably work 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 will not 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. Adding an anti-sickness drug, such as domperidone 10mg not only stops you feeling sick, but helps the medication be absorbed by reversing this gastric stasis.
If the drugs do not work individually, taking them all together as soon as possible at the start of the attack can be effective: e.g. taking sumatriptan, ibuprofen and domperidone at the same time (it is safe to take them all together).
If you get frequent or very severe attacks or the treatment for the attacks does not work well, you may need to use preventative drugs. These are medications you take every day with the aim of preventing or lessening the attacks. The trouble with preventatives is that no one medication will work for everybody. The aim is to reduce the number and severity of attacks rather than stopping them altogether. Some of the medications have side effects (like drowsiness). It is often 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”, the 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 14 days a month, triptans more than 8-10 days, or codeine related drugs more than 6 days a month, the headaches can start getting worse as a consequence. Recording it in your migraine diary will help keep an eye 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?
Do not take drugs that do not work. If your migraine attack 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 combinations of codeine and paracetamol, though any acute migraine treatment can do this.
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 unfortunately there is no cure.
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 and, if they cannot 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.