S3 E7: Migraine and Men

A National Migraine Centre Heads Up Podcast transcript

Migraine and Men

Series 3, episode 7

[00:00:00] Did you know about 9 per cent of men get migraine, but they often don’t ask for help or get a diagnosis. If you are getting headaches, talk to a headache specialist doctor to work on a personalised treatment plan to reduce the impact of your migraine. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr Katy Munro [00:00:30] Hi there. I’m Dr. Katy Munro and I am here today to talk about migraine in men with two men who I think both have migraine. Professor Paul Booton and Dr Richard Wood. So we’re going to talk a little bit about why we’ve chosen this particular topic. But first of all, would you like to introduce yourselves a little bit? So, Paul?


Prof Paul Booton [00:00:54] Hi, I’m Paul Booton as you’ve just heard, I had an interest in headache medicine for a long time and worked at the National Migraine Centre until my fairly recent retirement. I do get migraines. I don’t get particularly serious migraines so I’m glad to say, althought I get an awful lot of the symptoms of them. And no doubt we’ll talk about what we each individually get as part of discussing that today.


Dr Richard Wood [00:01:22] I’m Richard Wood, I’m a GP, but I’m also a headache specialist. I work for the local hospital trust in Oxford running a headache clinic. I’ve also designed the headache pathway for Oxfordshire as well for treating patients mainly with migraine. And I see a lot of patients with migraine. I also do some work for the National Migraine Centre as well.


Dr Katy Munro [00:01:42] So do you think that everybody that works in headache tends to get there because they have migraine or headaches themselves? That’s certainly what drew me towards the work. And I seem to find that a lot of neurologists who work in headache clinics have migraines as well. Is that what happened with you?


Prof Paul Booton [00:01:57] Well, not with me, no. I got into the National Migraine Centre because I happened to be writing a book on general practise at the time and I got the job at writing the headache chapters, so I thought I better find out what I’m talking about and then gradually got inveigled into it from there.


Dr Richard Wood [00:02:18] So for me, it was I think I have my wife to thank for this, actually. So we were at a headache centre opening day, a research centre, and we thought we’d go together just because we could have lunch together. And one of the consultants there was asking if there was a GP who would be interested in being trained up to run a community headache clinic. And they never really passed my mind, but my wife stood up and said, oh, Richard, will do that. And seven months later, there I was running a clinic. And it actually is only after learning about headache really falling in love with the field as much as you can fall in love with headache. But I realised that I was getting a lot of migraine symptoms, especially those migraine with aura without headache, which is very curious.


Dr Katy Munro [00:03:00] That’s interesting.


Prof Paul Booton [00:03:02]  That’s quite interesting because I was doing the migraine clinic for maybe five years when suddenly it occurred to me one day that an awful lot of problems that I’ve been having were actually related to migraine, which I think illustrates the point. It is a bit of an iceberg thing isn’t it. There’s a lot more to it than just the pictures you get on headache tablet packets of a young woman clutching her temples.


Dr Katy Munro [00:03:28] Yeah.


Dr Richard Wood [00:03:29] Absolutely.


Dr Katy Munro [00:03:30] I mean, took me ages to realise that I was a migraine sufferer when I was working in general practise. But I think I was reading a paper the other day about the obstacles to people getting any help for their migraine. And the first one is that they don’t go and ask for help because they don’t recognise they are having a problem that might be able to be helped. So I think one of the reasons we wanted to do this particular episode, was firstly because it’s November, Movember, and one of the themes is health of men and in particular mental health. And I think we’ll come on to talk about mental health and migraine because there’s a really significant impact on mental health from people who are getting migraine, especially chronic migraine. But I think it’s also we didn’t want to be too gendered, but I think there is a tendency for men to kind of put up with things and not seek help. So hopefully this will give some general good information to everybody who gets migraine. I also think that an awful lot of men need to know more about migraine, not just for themselves, but because they may well be either knowing a friend or a wife or sister or somebody who gets migraine and to understand that is really helpful. And then the other way round, I want women to listen to this because they need to understand how it might impact on the men who get it. And Paul, you were saying about, you know, men may need to know as an employer, although this obviously applies to women as well, the role of employers, understanding.


Prof Paul Booton [00:05:05] Yes, absolutely. I mean, working in the clinic, you are struck by the amount of bad employment practices there are. And in current society, where it’s more likely that men will be employers of women, it’s probably worth having a chat about that as we go.


Dr Katy Munro [00:05:20] Yeah. So, Richard, do you want to give us a few stats about migraine in men?


Dr Richard Wood [00:05:26] Yeah, absolutely. So it’s curious, migraine tends to affect women more than men. And I mean, that probably explains why a lot of the media you see a picture of a woman clutching their head as a demonstration of migraine. But actually it does happen to men very much too. Between both the sexes it’s about one in seven people get migraine, but it’s three times more common in women than men. But of course, men suffer the disease experience just as much as women do. And pre puberty, the sexes are actually equal. So men are just as likely to get it as women in childhood, for example. If you look at prevalence studies in Europe, about 12 percent of adult men between the age of 18 to 65 get migraine, and one percent of all men suffer from a form of migraine called chronic migraine. Now chronic migraine is when you’re having a headache most days, but at least half of your days and half of those of which are migranous headache. And one percent might not sound very much to you if you’re listening now but actually, if you think about walking around, going shopping in the supermarket, for example, you could easily pass one hundred people in a supermarket trip and you can guarantee that one of those will probably have chronic migraine. And that’s actually reasonably prevalent, that’s quite a big burden for society.


Dr Katy Munro [00:06:56] And that gives much more of a tendency as well for people to be taking too many medications, doesn’t it? So we also see quite a number of people with chronic migraine who are having this overlapping condition of medication overuse headache, which we have talked about in previous episodes. I was a bit shocked- I was looking up the global burden of disease surveys, which is a big survey worldwide of the impact of all sorts of different diseases and the disability that they cause. And I know the 2016 report found that migraine was the second cause of disability after low back pain, which is incredible, I think not generally known. And then there was a recent one-


Prof Paul Booton [00:07:39] Yes it’s a huge effect, isn’t it? A lot of people don’t recognise that.


Dr Katy Munro [00:07:43] And when they looked at all the headache disorders in the most recent one, which was only published in October, migraine made up 88 percent of the burden of headache disorders in the world. So most, I mean, coming back, we’ve talked, Paul, about the landmark study in the past, haven’t we about-


Prof Paul Booton [00:08:02] One of my favourites.


Dr Katy Munro [00:08:03] Yeah go on you say it because, you know, the figures. I always forget the figures.


Prof Paul Booton [00:08:09] I was just thinking i can’t think of the figures on hand.


Dr Katy Munro [00:08:09] Put you on the spot.


Prof Paul Booton [00:08:09] The bottom line is that for people who go to their GPs with recurrent headaches and most people don’t go to their GP saying, ‘please save me from this mild headache’, you only go if you’ve got a headache worth making an appointment for. But the majority, the overwhelming majority, 97 percent, in fact, of people who go to their GPs with a headache have got migraine and whether it’s diagnosed or not, that’s actually what the science shows they’ve got. So there’s a huge amount of it out there and we’re GPs and as GPs, we see a huge amount of headache and almost all of it is migraine.


Dr Richard Wood [00:08:50] Yes, that’s very true. And I think- I do a lot of teaching for GPs and other clinicians locally and beyond, and the message we really try and give our clinical colleagues is that if someone is presenting to you with episodes of headache and they’re okay in between the headaches but during the headache, that they’re pretty wiped out with it, but they’ve got a normal examination, you examine the neurological system, then really you have to assume it’s migraine until proven otherwise. And that way you will actually treat a lot more headaches effectively and get people the therapy they need.


Dr Katy Munro [00:09:26] Yeah, we quite often hear about people being told, ‘oh, it’s just a tension headache, it’s just stress’, and I had a very useful tip years ago when I was listening to Dr. Anish Bahra giving a lecture. She’s a neurologist at Queen Square. And she was saying basically, if a person has a headache and it gets worse when they move their head, then it’s probably migraine because it’s that sense- so the tension headache is a very featureless headache, whereas a migraine headache tends to have these associated sensitivities to light, sound, movement, in particular, and smells and sometimes touch because we’re talking about migraine as a headache condition but of course, some people don’t get headache, they get dizziness or they get weakness down one side or their most bothersome symptom isn’t the headache. So that’s the other thing that confuses people, I think, isn’t it? And they don’t get diagnosed if their headache is relatively mild, but the other symptoms are more predominant.


Dr Richard Wood [00:10:31] And curiously, Katy, tension type headache, it responds to migraine treatments. So, for example, people who have tension type headache and they take a triptan, for example, they can get some relief. And migraine preventers such as amitriptyline can also treat tension type headache. And I think headache specialists tend to divide themselves into two camps, lumpers and splitters. And you’ve got the splitters who will really separate out the different types of headache on the basis of when to prevent and the presence or absence of particular symptoms. And they might separate out tension type headache for migraine. And then you’ve got the lumpers and I’m probably Lumper.


Dr Katy Munro [00:11:09] Yes so am I.


Dr Richard Wood [00:11:09] And lumpers actually say, well, actually, if someone is presenting to me with a disabling- an episodic disabling headache, I’m going to treat it as migraine. And we begin to see tension type headache more like migraine but with the volume turned down and turn it up and get more more migranous features. So there’s a lot of debate amongst the headache specialists about is this a spectrum disorder, for example?


Dr Katy Munro [00:11:33] Yes. Yes. No, I really agree. I also think it’s sometimes confusing when patients are told, ‘count up your headache days and count up your migraine days’. And I just say to them, just count up all the days, call them migraine, some are mild, some are severe, some are moderate because it gets too confusing because they think ‘well should i take this or should i wait or whatever’.


Prof Paul Booton [00:11:53] And it can give you a very false impression to the doctor- the number of patients who’ve told me ‘I get about three headaches a month or three migraines a month’. And you say, ‘well, are they the only type of headaches you get?’ and they’ll say, ‘oh, no, no, no. I get lots of other headaches, but they’re ordinary headaches’. And actually, it’s probably all migraine. It Is probably all migraine. You get mild migraine and you get severe migraine. So when you’re talking to your GP, if you’re going to see your GP about headache, do tell them about all your headaches, whether you think it’s important or not, because that’s all part of the picture they need to see so they can get to the bottom of this.


Dr Katy Munro [00:12:32] But then coming back to sort of nominal topic about men and migraine, one of the reasons we wanted to talk about this in particular was because of all the impact that the migraine can have on somebody’s life. So it can lead to a lot of life changes, some losses that mean people often are concerned about revealing it to their employer, they may think it’ll impact on their job prospects, may have a financial impact. We certainly see a number of people who’ve had to cut down their hours or even had to go off sick or take medical retirement if they’ve got chronic migraine. The other thing that kicks in a lot is the sort of disciplinary processes at work which penalise people who have short, repeated absences, isn’t it? And if it’s not diagnosed, if people haven’t got good strategies, then the impact can build up, ripple out to their friendships, relationships, curtail their social activities as well as their work things. And lead onto mental health issues like anxiety and depression. I’m sure we’ve all seen examples of that.


Prof Paul Booton [00:13:40] It might be worth talking about the different stages of a migraine headache because they can all affect you in different ways and affect your ability to work. So usually with a lot of people they get a thing called a prodrome at the beginning of the headache, which is a funny thing, people sometimes get the munchies, they sometimes feel very sleepy. I get very sleepy. I sometimes find myself in the evening sitting on the sofa watching telly with my head sort of lolling forward. My wife would tell you that that’s most days actually. Although sometimes when I just can’t keep my eyes open, I go to bed the next morning, I’ve got a migraine. Some people I can remember one patient said ‘suddenly I get an urge to do the housework and the next day I always got a migraine. I must be overdoing it.’ And the answer is, she wasn’t overdoing it. It was just that she got this sort of energy spurt just before she got a migraine. And that doesn’t happen to me that but it caused her to rush around doing the housework.


Dr Richard Wood [00:14:44] And that’s very interesting that correlation and not necessarily being causation. So another example is some sometimes quoted is that people think that- some people may identify particular foods, for example, which they see as a trigger for migraine. And of course, that is entirely possible. Some people do have foods which are triggers for them, but equally possible it might be that actually that they’re having a prodrome of a particular craving for a particular food, which is a sign that their migraine is coming and they’re associating it as a causal thing. But it’s not, it’s just part of the prodrome, if you like.


Prof Paul Booton [00:15:18] The chocolate bar thing, isn’t it?


Dr Richard Wood [00:15:19] Exactly.


Prof Paul Booton [00:15:20] Your migraines coming on. You want to reach for something sweet. What do you reach for? It’s a chocolate bar. The next day, you’ve got a migraine. The chocolate gets blamed, it was the migraine all along.


Dr Richard Wood [00:15:30] Exactly.


Dr Katy Munro [00:15:32] If you go back to your phases, the prodrome is then often in about a third of people, followed by an aura phase which is usually defined as neurological symptoms, commonly visual, that come and go within an hour before the headache starts but that can also be visual blurring, double vision, blind spots, classically that sort of zigzag that people draw in the air sometimes isn’t it. And sometimes coloured, sometimes black or white. And that can be a real nuisance.


Prof Paul Booton [00:16:06] It is a real nuisance. And the thing that I get, most of my migraines are auras. Now, you might say that that’s just because you’re getting older and people who are older tend to get more visual auras but actually, that’s what I’ve had all my life. And it’s quite bad if you’re out somewhere- I was out on my bike the other day and suddenly I could see these flickering zigzags in the corner of my eye, big sort of coloured halos appearing around things, and I had to stop and get off my bike because it just wasn’t safe to carry on down the road. It wasn’t that I couldn’t see, but I didn’t know what I could see, and that can be- to some people I’ve met that’s the big problem with migraine, is they get one of these auras, they’re driving the car, they’re going to pick up the kids or something like that. And you’re then sitting there for 40 minutes while this wears off. If you’re lucky then, you might have a pause of half an hour or something before the headache starts, but it’s a bit like the eye of the storm. It’s a gap in the middle of the migraine when you might just be able to do something.


Dr Richard Wood [00:17:14] Absolutely. That raises two points, Paul, I think, that are really important. The first thing is, is actually when it comes to driving, for example, we all have a responsibility as drivers to feel that we are safe and capable of and be able to command control of the car at all times. And if for any reason you feel that you can’t do during a migraine attack, you should stop until you feel safe to do so. The second thing is, actually is I think we need to be aware of that actually, there’s lots of different types of aura out there. It’s not just visual aura affecting your vision. So I use the- when I explain this to patients, I describe it as a funny wave of electrical activity, which moves slowly over the surface of the brain. Now, for most people, it moves over the seeing part of the brain so you get zigzag lines, flashing lights, black blocks, or even loss of vision temporarily. But if it moves over the feeling part of the brain, you’re going to get numbness or tingling moving up an arm or down over your face or a leg or something. If it moves over the balance part of the brain, you’re going to get dizziness or some type of vertigo, the world spinning around you. If it moves over the thinking parts of the brain, you can get auras like unable to find your words or being unable to orientate yourself around a familiar environment so there’s lots of different symptoms you can get a whole vast array of symptoms from aura depending on what part of the brain is being affected. Now, it’s not dangerous. It’s very curious, but it can be blooming annoying.


Dr Katy Munro [00:18:45] It really can interrupt your day, can’t it. It really can and it certainly put Paul off his bike. And it takes quite a lot to get Paul off his bike I have to say.


Prof Paul Booton [00:18:57] But also, Richard can tell me which part of this brain this is, it affects the stupidity centre of my brain. I’m unable to do anything, I sort of stand there looking like a right chump and feeling like a right chump and in fact, being a right chump. I don’t know quite where I am I don’t know where I’m going, I don’t know what I’m doing. Many of my colleagues would say that’s not very different from normal but that’s how I know it’s the start of a migraine.


Dr Katy Munro [00:19:23] I had a friend who was a GP who worked with me and she used to get aura very occasionally that would just obliterate the face of the patient she was talking to. So she just had to stop her morning surgery because she couldn’t see the patient anymore and she couldn’t see the screen and she had to stop, get them to go out, take some medication. And luckily, she hardly ever got a bad headache afterwards. But it did impact on her daily working life for at least up to an hour before she could get back into the swing of things again.


Prof Paul Booton [00:19:54] So that’s a very well recognised migraine symptoms called a scotoma technically, when you can’t see what’s straight in front of you. Other people get this thing called tunnel vision where you can’t see the peripheries so you can see what’s straight ahead of you but you can’t see to either side. And that’s all part of this different spectrum of visual problems you get. Visual and other problems you get as part of an aura.


Dr Katy Munro [00:20:17] Then the headache phase comes, in people who get headache and of course we know there are some people who don’t get headaches, but in most people with migraine will get a headache of some severity at some stage along the way. And that phase can be anything from, you know, a couple of hours lasting over three days. And I think quite often people haven’t realised that they haven’t had three migraines on Monday, Tuesday, Wednesday, they’ve had one migraine, that the headache phase has lasted over that length of time. And the headache can come along, of course, with the other symptoms, which often people complain of, which is nausea, vomiting. Again, that sort of brain fog, that word finding problems, fatigue is awful isn’t it. People often just want to go to bed with it.


Dr Richard Wood [00:21:03] That’s very true. And so it’s not just a headache, is it? I mean, it’s the headache itself can be severe, sometimes moderate. But it stops you in your tracks. But it’s the sensitivity around it, sensitivity to light or sounds or generally aggravation by just moving around, this routine physical activity. But it’s important for people to know whether you’re an employee or employer, is that it really can affect the way people can function in the workplace or at home. It is very, very difficult to do even just simple tasks like the housework or thinking hard when you have a migraine. It’s something which takes you out of your routine business when you’ve got it.


Prof Paul Booton [00:21:47] And at work, this often comes as what’s known as presenteeism. Is that the right word?


Dr Katy Munro [00:21:55] Yes.


Prof Paul Booton [00:21:55] That you’re kind of sitting there in front of your Excel spreadsheet, but nothing’s coming in and nothing’s going out. You’re really not able to cope with it all.


Dr Richard Wood [00:22:04] Oh, yeah, absolutely. So there was a study done in 2003 by an author, Richard B Lipton, who found that 83 percent of men reported a moderate or greater reduction in their ability to just do routine work around the house. 43 percent thought that without a headache, they would be a better parent, that it was affecting their self-perceived ability to be a parent. 50 percent felt less able to engage with their children. So this is a condition which is not just affecting the workplace, but some really, really important parts of a man or woman’s life at home.


Dr Katy Munro [00:22:45] I thought that was really interesting, a really interesting study, because it just illustrates that rippling out effect on other family members, it’s not just the person who can’t function, they can’t look after their kids as well as they would want to.


Prof Paul Booton [00:23:02] So a good number of patients I’ve seen would get a migraine that would last two or three days, during which time they’re unable to do anything except be in bed and it meant their partner or one of their parents had to come and look after the kids for that time. And of course, that’s a pretty terrible effect on the children, you know, mum or dad lying there in bed, not having any contact with them, which is very important, particularly for younger children who don’t really understand what all that means.


Dr Katy Munro [00:23:33] And I think it’s quite scary for kids witnessing somebody in a bad migraine attack, one of their parents or something. We need to often think about how we explain what’s happening to the children at an age appropriate level so that they can understand that this will go and the parent will get up and be back to normal again. That’s the thing about episodic migraine in between, attacks person comes back to normal, completely back to normal by definition. But the more high frequency you’re getting them the migraine attacks, then the more impact and the more that they start to run in together. And then we unfortunately see a number of people who get chronic migraine where the breaks in between a very, very short and they may even have some symptoms every single day. A horrific impact once that’s happening.


Prof Paul Booton [00:24:26] So we were talking about the stages of a migraine, weren’t we. I wonder if we should move on to talk about the postdrome because that’s I think also a very important part of it, which isn’t talked about so much. People talk about it as they’re sort of hanging over, their brain fog days. But at the end of a migraine, it doesn’t just end usually, you don’t just sort of go DINK and you’re back to normal again. But you often have a number of hours, often a whole day when you’re really not up to snuff and you sort of wander around in a bit of a coma I call it. Not a proper coma, of course. And that’s actually the tail end of the migraine. That’s all part of the migraine still. And again, it affects your ability to work at home, it affects your ability to work at work. All the things you need to do are adversely affected by that. It can affect your ability to get around to drive the car, for instance, if you’re not really quite up to making the decisions you need to make, and it’s an important and poorly recognised part of the migraine attack.


Dr Katy Munro [00:25:34] Not easy to treat either, really, that part, is it?


Prof Paul Booton [00:25:38] No.


Dr Katy Munro [00:25:39] We haven’t got any medications that we can say ‘well take this in the postdromal phase’. It’s a question of really trying to get into that treatment of the headache phase as early as possible and hope that that will shorten all of the subsequent stages.


Prof Paul Booton [00:25:52] And in fact, it’s an issue with migraine treatment generally, is that over the years we’ve mainly focussed on treating the pain, but there are quite a lot of other symptoms as well. And the treatments for dealing with those are much less well advanced than treating the pain.


Dr Katy Munro [00:26:11] One of the ways, of course, to get any treatment plan for yourself is, first of all, to go to the doctor and have a chat about the headaches you’re getting. And I was interested in looking- and when researching for this, we know generally that men are less likely to consult health services. And in particular, I was finding some research that indicated that was particularly the case around headaches. So when men were getting headaches, they would tend to push on through and cope and maybe buy themselves on medication from the pharmacist or something, whereas if they’ve got a back pain, they were much more likely to go to the doctor about it. Any thoughts around that? Why that would be?


Dr Richard Wood [00:26:55] Yeah, it’s curious, I mean, there are a number of different theories, proposals, if you like, it may be that men feel less readily able to take on a sick role. Is it perceived as a sign of weakness, for example? Is that a cultural thing? And certainly that theory won’t resonate with everyone, but it might resonate with some people. I was curious about marketing approaches to the over the counter treatments. So it’s curious that if you look at the commercials for over the counter medications, the story might be an active man who is suddenly impeded by an inconvenient headache and then is saved by this miraculous pill. And this might reinforce the idea that actually you should just take a pill and get on with it, when actually the reality of migraine is much more complicated than that and you can still have disability despite trying, especially if you’re not doing it in quite the right way, and the importance of- this to me emphasises the importance of actually going to a health professional and getting advice about how to take the treatments correctly and which ones to take, some are much better than others.


Prof Paul Booton [00:28:14] So I think the Take-Home message from this, though, is that we know that men are less good at going to the doctor about a whole range of things, but they seem to be particularly bad at going to see the doctor about headaches. And I think what we’d all encourage you to do is say if you’ve got a headache, which troubles you for whatever reason, if it’s stopping you getting on with your life, then do go and see the doctor, because there’s an awful lot you can do about it. And you don’t have to just grit your teeth and put up with it. Take some action.


Dr Richard Wood [00:28:42] Absolutely. I would totally agree with that. And also, I think it’s worth pointing out, although lots of people get migraines, we never find out a reason what triggers it. But for some people, there are actually triggers which are important. So migraine becomes slightly more common if you’ve got a rising blood pressure, for example, and sometimes you can get increasing migranous-like headaches because the kidney function is going off or there’s some other disruption of your natural balances in your general health. So although those circumstances are slightly more unusual, they can definitely happen. And it’s definitely worth getting that assessment with the GP. The migraine for you or your headache for you could be a sign that it’s time to look at your lifestyle, look at your health and your lifestyle.


Dr Katy Munro [00:29:30] Just to take care of yourself. I think sometimes there is this sort of dismissal of headaches as, ‘well, yeah, I just get the normal headaches.’ I hear this quite a lot in people saying, ‘oh, yeah I get these migraines, but then I get the just the normal headaches as well’. And sometimes I think with men maybe they’re thinking, well, everybody gets headaches so you just have- there’s nothing they can do about them. You know, that feeling that it’s an inevitable part of normal life. And that’s really not right. I mean, it’s not only it’s migraine that people need to seek help for, but men do actually get other kinds of headaches which are equally impactful if they’re not treated properly. I’m thinking particularly about cluster headache now, because cluster headache is more common in men than in women, is really severe pain one sided with watering eye, they get very agitated with it. Some women do get this as well, but there are some really good treatments. And if you just put up with it thinking it’s just a normal bad headache and don’t ever go and ask, ‘what do you think this is’, then people are going to suffer for years and years without the right help.


Prof Paul Booton [00:30:42] And people do suffer for years and years because we know from the published statistics and we know from what we see in the clinic is that people often go for several years without a diagnosis. So it’s important if you have got headache symptoms, go talk to your doctor to find out what it is in your case, which is causing your headaches.


Dr Richard Wood [00:31:02] I wonder if it’s worth also just highlighting what are some of the biggest triggers that we know for migraine in particular? And the big ones which stand out for me, and I think for all of us, is the first one by far and away is stress. It’s a massive trigger for both men and women. I think that’s followed quickly by disrupted sleep schedule and not sleeping enough or in fact, for some people sleeping in too long. If you sleep in for an extra hour on a Saturday morning, you might get a migraine is called Saturday morning migraine. Skipping meal times as well. The brain doesn’t like fluctuations in anything. The migraine brain wants balance and a nice regular meal time and regular energy input and also dehydration is a big trigger for migraine for some people, which could also be why some people get a migraine after exercise, for example, that might be related to dehydration. So in addition to just some unusual medical problems, actually the basic things of treating yourself well are really, really important to be addressed when it comes to migraine.


Prof Paul Booton [00:32:10] I suppose while we are talking about triggers and we’re talking about men. In the workplace, lighting and computer screens can be an important trigger for some people. And so if you work in one of these big offices with strips and strips of artificial lighting, that for some people is a very potent trigger, staring at your screen all day, filling in boxes on an Excel spreadsheet. Again, those long hours spent doing that, can trigger some people’s migraine. And there are things, simple things you can do about that, such as regularly getting a break from your screen or getting your desk moved to somewhere which has got natural light so that you’re not so affected by the artificial light all the time. Like all these triggers that’s not true for everybody. But if it does affect you, there are things you can do about it.


Dr Richard Wood [00:33:00] There certainly are and I mean, I know employers who will have anti glare screens to cover their computer screen, which is really simple to get and can be effective for people. And there are also filters that you can put over those fluorescent lights, which tend to have a flicker which is a potent trigger for migraine, for some people, and there are definitely adaptions which don’t have to be complicated and can make a big difference to people.


Dr Katy Munro [00:33:24] I think the other sort of senses can be affected, too. So if it’s a very noisy environment, there’s a lot of machinery noises or the clanging or banging, if you’re on the brink of having a migraine that can push you into having the attack. And then things like smells and of course that might be in an enclosed workspace, that might be somebody’s perfume or aftershave or it might be that they’ve made their lunch in the office microwave and there’s a strong smell of fish or curry or something like that. But it could be other things more related to workplaces. So maybe smell the diesel or other things like that. So it’s being aware, really, isn’t it? And it’s also recognising that it’s not just one thing, it’s an additive thing with triggers. So it may be that if you have had a really good night’s sleep, you’ve been eating regularly and you go into a noisy or glaring light situation, your brain will manage to not go into a migraine attack. Whereas if you’ve actually been sleeping very badly and you’re really stressed about an upcoming presentation or a work deadline or something like that, and then you think, oh, I’ve got too much to do, I’m skipping this meal, I’ll just work on through and stay up really late at night looking at my computer, you’re much more in a high risk situation to get an attack because those things have added together. So it’s looking at what you’re doing, being a detective. I say to patients ‘be a detective about the kind of things that add together to push your brain into that sort of super irritable state’.


Prof Paul Booton [00:35:00] I had a young man come to the clinic one day and he was very, very miserable. He’s got a girlfriend but he said, ‘every time I have sex, I get a migraine. I’ve got migraines caused by sex’. And we looked at what he was doing. I mean, not the sex bit, that would be a bridge too far. And his lifestyle, he was a sort of busy bee in the city, running around, making deals and all the rest of it. So he had a frenetic lifestyle during the week, he didn’t eat very much. He didn’t drink very much during the week. He was just sort of on the go all the time. And then he’d come over on Friday, he’d drive over to his girlfriends. They’d sit down and have a relaxing meal together and have some glasses of wine. And then they go to bed and I prone to say, yes, they did indeed have sex. And the next morning he’d wake up with a migraine. What I was able to say to him, ‘look, that’s nothing to do with sex. What that’s to do with is the lifestyle which leads up to it’. There’s all those different triggers in his life which are causing that. And so I I hope as a result of that, he was able to sort of balance out the things he was doing in his life a bit more. And as a result, that should have helped him prevent getting the migraine at the weekends when he relaxed. And we talked about stress as a cause of migraine, but actually often you cope with things while you’re stressed and the minute you relax, you get the migraine. So a lot of people, for instance, will get migraine, having bustled around, getting ready, gone on holiday, get off the plane, the next morning, they’ve got a blinder.


Dr Richard Wood [00:36:36] Yeah, that’s a great example, Paul. And actually, that’s a very common example. I have many patients who would fit that description. It raises something very interesting about what migraine actually is and the fact that it’s a genetic disorder. So to put it another way, we all have the migraine machinery in our brain, if you like. It’s what’s called the trigeminal system. But for some people, it just seems to turn on- the migraine machine turns on much more readily than the people who don’t get migraine. And that’s your genetics. So you’ve probably inherited the cluster of genes down the family line, which means it’s just easier to switch your migraine machinery on, to put it another way the threshold for it firing off is lower. So for someone who doesn’t get migraines very much at all or ever, they might need to be stressed and dehydrated and lack of sleep and a whole host of other triggers in order to get a migranous headache. But actually, if you’ve inherited the genes from your family, you might only need one or two of those to get a migraine.


Prof Paul Booton [00:37:41] And I think you see that with some people who complain about hangovers. I think there’s a case for saying that hangovers are a form of migraine.


Dr Richard Wood [00:37:50] Yes.


Prof Paul Booton [00:37:51] That actually, if you push the triggers hard enough, then pretty much anyone could get a migraine. If you do all the wrong things for long enough, you can give yourself an attack.


Dr Katy Munro [00:38:01] I’m sure that’s true. Yes, I quite often say to patients that I think hangovers are actually migraine, a form of migraine.


Prof Paul Booton [00:38:13] I thought you were thinking about your own drinking habits.


Dr Katy Munro [00:38:16] No no I’m very pure. And going back to what you were saying about the hereditary nature of migraine, is when I’m asking patients about family history, I always ask them to think about their children as well. And quite often you can pick up that their 10 year old or their 14 year old is beginning to have either abdominal pain recurrently or headache recurrently. We know that children have abdominal pain and sometimes boys can be very bothered by tummy pains that come and go and they might get it after football training or they might get it in the middle of the day when they’ve been in a particularly stressful maths lesson or whatever, and they get tummy aches and then they get sent home and then they may get investigations. And in some rarer cases they may even have their appendixes out. I heard there was a study that showed about five percent of kids had their appendixes out when actually it was abdominal migraines. So I’m always saying to parents, you know, think about your descendants as well and keep an eye on your kids, if you get migraines.


Prof Paul Booton [00:39:21] It’s also often not clear that people’s parents and grandparents were often migraine sufferers. Again, on a number of occasions, I’ve said to patients ‘well anyone in your family get migraine’ and they say ‘no’. And then you chat a bit more about it and they say, ‘oh, my grandmother, she used to go to bed for three days every month’. And almost certainly that was migraine they were getting.


Dr Richard Wood [00:39:48] Absolutely.


Prof Paul Booton [00:39:49] Some quite striking examples of people whose parents or grandparents were really unwell for a lot of the month, yet no one ever made the diagnosis.


Dr Richard Wood [00:40:01] Yes. The classic line is that ‘no, migraine doesn’t run in the family. I mean, I’ve got people who are really headachy people, but I don’t think migraine runs through’ and this goes back to the lumper vs splitter camp. Actually if it was episodic disabling headache it is probably migraine. ‘Oh, well, that means there are others.’


Dr Katy Munro [00:40:17]  Then, of course, their ancestors may have had the milder form of migraines. They may have not triggered the migraines that often. And so they never actually went to the doctor. So if they were the kind of person that has episodic migraine two or three times a year, they may have never have bothered mentioning it to anybody. So if you search, there’s often a family history there. So should we talk a little bit about treatments of the attacks, so I tend to think about lifestyle as being a treatment, lifestyle and self-management, which is what our podcast which is out today is all about self-management. And we talk a bit about routine regularity of sleeping and eating, possibly adding in some supplements like magnesium or vitamin B2, riboflavin that is, or coenzyme Q10. Those are the three that have some evidence in the studies and that we’ve done a podcast episode way back in series one that goes into those in a bit more detail about doses and things like that. But then coming on to the acute or rescue treatment, what would your guidance be first off for that?


Prof Paul Booton [00:41:31] Well, I think the important thing with that is that if you’re going to treat it, you want to treat it early and you want to treat it hard. So you’re trying to knock it for six. An awful lot of people who sort of do a drip, drip, drip bit of paracetamol, bit of something that’s not likely to work. And if you know you suffer from bad headaches at the first sign that you’re getting it, then you want to take a big hit of a painkiller and the ones which work best so usually the ibuprofen family or aspirin. Paracetamol is a fairly poor substitute and the codeine family don’t work very well at all, and there are additional problems associated with those which might come on to. Alongside that, particularly if you suffer from nausea, some people who don’t have much nausea, taking an anti sickness tablet, which not only prevents the nausea, but also helps you digest the other tablets because it speeds up the contraction of the stomach and the way the pills pass through your system, that can be really helpful. In fact, I was talking to my sister the other day who gets quite bad migraine and she said, you don’t hear this very often in my family. She said ‘I did what you said and it worked’. She started taking an anti sickness pill with her headache medicines, and her migraines have been much better since.


Dr Katy Munro [00:43:02] There was a study that showed that if you take paracetamol with an anti nausea tablet, it makes paracetamol work much, much better than if you just take it on its own as well. I think I often have patients who come back and say, ‘oh, I didn’t take the anti sickness tablet because I didn’t feel sick.’ And I said to them, ‘it’s not really about that. It’s about that effect of the migraine on the vagus nerve, which is the wandering nerve from the brain down to the stomach that causes the stomach to stop functioning, stop emptying properly, it’s a thing called gastricstasis, which is part of the migraine’. We know that happens.


Prof Paul Booton [00:43:37] The take-home message is whatever medication you’re taking will work better if you take an anti sickness pill with it.


Dr Richard Wood [00:43:43] And early. I mean, the analogy I use with my patients is it’s a bit like a fire in a room. When a fire is burning in a bin in the corner of the room, you want to throw everything you’ve got at it to put it out, because once that fire burns around the rest of the house it’s gameover. You’ll never put it out. House burns down. Now it’s the same with migraine and migraneurs listening to this will probably be nodding their heads. You have to get it early. You go in with your ibuprofen or paracetamol with an anti sickness. And often actually we advise adding in another medicine, don’t we, a migraine turner offer, if you like, called a triptan. So triptans, you can actually buy one of them is called Sumatriptan over the counter but it’s quite expensive. Some people get it from their GP prescription and there are about seven to choose from in total, which are availiable from the GP and those especially in combination with something like ibuprofen or aspirin are very effective at turning off migraine.


Dr Katy Munro [00:44:37] They are and interestingly, if you try one and it doesn’t seem to work, try it for two or three attacks, I normally say to people, make sure you take the recommended dose for the first day. Quite often people have taken a small dose, especially of sumatriptan. They’ve only tried a 50 milligram when actually you can take quite a lot more than that. If you feel that it doesn’t really work for you or you get side effects then try one of the others because they’re very individual and it can be really helpful to work through them till you find the one that suits you.


Prof Paul Booton [00:45:11] And you may have to push quite hard to try the others, in the present health service GPs are given a formulary to work from and it may only include one of the triptans in it, I don’t know if you find that, Richard, since you run the system, you may have changed it all there. But certainly my practise used to shout at me when I’d prescribe anything other than the ordinary on triptans. But you need to because one triptan may not work, whereas another one will. That’s important.


Dr Richard Wood [00:45:41] That’s very important. Yes. When I wrote the local guidelines, I made sure that actually the guidelines said a GP could try any of the seven in the BNF, in our prescribing manual, because if one doesn’t work, it doesn’t mean they all won’t work. It’s not a class effect, if you like. So it’s very important for GPs to offer another one.


Prof Paul Booton [00:46:00] Yeah, absolutely.


Dr Katy Munro [00:46:01] I think the other thing to talk about is the formulation, because I sometimes say to patients, ‘well you may need to try a different formulation for different scenarios’. If you’re about to go off and you’ve got a big work meeting or something, or you’ve got to go and get the kids and you feel a migraine coming on, you can possibly take a nasal spray formulation or a melt formulation, which might work quicker for you, whereas if you have got time and you’re at home then a longer acting triptan like frovatriptan or naratriptan may last a bit longer and keep your migraine away, if you’re the kind of person that gets a migraine, it goes that comes back the next day, then it goes then it’s often better to have a longer acting one. There are injection formulations too, sumatriptan.


Prof Paul Booton [00:46:58] And a nasal spray you can get, which is available in a couple of them. Some people get given those for not very good reasons. The reason I used to use them was for people who vomited very early in the attacks when of course, it’s very difficult to take any tablets which work. But in those situations, an injection or a nasal spray may actually stop the attack and allow you to carry on.


Dr Katy Munro [00:47:20] They do taste revolting. I don’t know if you’ve ever used one but I used to take the nasal spray in surgery when I could feel a migraine coming on and I was about to call in the next patient and the taste is BLEUGH. But they work in 15 to 20 minutes so that was very handy.


Prof Paul Booton [00:47:37] What are your patients must have thought seeing you slipping up something as they walked in.


Dr Richard Wood [00:47:45] But talking about formulations, it is actually quite important and this is going back to the point Paul was saying earlier about the importance of actually going in early and the slightest whiff of something coming on, take something and you go in big. And there are lots of different formulations of the triptans, a nasal self injection, the melts, tablets, et cetera. But also there are different formulations of things like ibuprofen or aspirin over the counter. And it’s probably one of the few times as a GP, I might actually recommend going for the expensive ibuprofen. Now the gel caplets, the ibuprofen lysine, something which is absorbed very, very quickly. Or if you go for aspirin, if it works better for you, then the dissolvable aspirn because you want a formulation which is rapidly absorbed to get to your brain as quickly as possible.


Dr Katy Munro [00:48:37] Our patients have often told us is that they dissolve their soluble aspirin into CocaCola because the fizz and the sugar and the caffeine can help it work more quickly. Not that I have shares in Coca-Cola, I don’t like the taste of it. But also a lot of the tablets you buy over the counter may have caffeine added to them because caffeine can work with those painkillers to give them a bit of a boost. But a caution, of course, we are just giving general advice on this podcast. And if individuals are wondering which one to choose, they need to go and see their own doctors. So if you’re listening, please go and check that you’re alright to take some of the things that we’ve suggested, because there may be reasons why people shouldn’t.


Prof Paul Booton [00:49:24]  Whilst we’re doing the cautions, another thing to beware of are these combination painkillers. So when you go to the chemist, you’ll see row upon row of sort of patent painkiller and headache remedies which contain a mix of different painkillers. On the whole, we’d say don’t use those because most of them don’t contain a full dose of the particular painkiller and so you’re taking bits and pieces of everything. An awful lot of them also contain codeine or one of the codeine family, and they can be actively unhelpful, they can make the sickness worse, and you’re much more likely to get the so-called medication overuse headaches from those. So be very wary of these things, even if it says, as one popular brand does, the strongest available medicine for migraine or something like that, it isn’t. And it’s not particularly effective. You’re much better off taking a decent dose of straightforward ibuprofen, straightforward aspirin, plus an antisickness plus a triptan if you need it, than taking bits and pieces in a combination pill.


Dr Richard Wood [00:50:34]  I think that’s very true. And I think it’s probably the right time, isn’t it, to talk about medication overuse headache. And earlier in the podcast, we mentioned how men might prefer to just self treat than seek medical advice. But there’s a bear trap out there if you do that. And that’s medication overuse headache. So medication overuse headache, the way I explain it, is that if a migraneur takes a pain reliever, actually for any condition, whether it be their head or gammy knee, they take a pain reliever for any condition for more than 10, depending on the painkiller 15 days a month, for more than three months, they can lock their migraine centres into the on position. And actually presents as more and more frequent migraine, which is harder to treat. And often it’s got a grumbling headache in between, which never really seems to go away. And  the classic story, the classic presentation is someone who may be going through some work, stress or relationship stress or something just triggered off their migraine so they logically are taking more and more pain relief for it. And before they know they’re taking it on most of the days of the week, they’ve been doing that for three months and then they’re coming to you and nothing’s working anymore and they’ve got a headache almost every day. And that’s medication overuse headache and that’s a real problem.


Prof Paul Booton [00:51:52] And it can be quite spectacular medication overuse headache, sometimes it’s just a dull headache but sometimes it’s really quite frightening symptoms. And I can remember one particular patient who ended up having a scan and casualty for what it was and after he stopped his codeine tablets, miraculously, the headache just melted away.


Dr Richard Wood [00:52:13] Yes, that’s right. And codeine is the worst offender, really, or tramadol, all those opioids if you like. The least offensive is probably the nonsteroidals like ibuprofen, followed by aspirin and then even triptans can do it as well. I tend to say of any pain reliever, no more than 10 days a month and that’s the max. If you’re using that, then you need to get onto preventive therapy, which will probably talk about in the second. But just to finish off the medication overuse headache it’s definitely worth listening to the podcast on that. But in short, the only way you can really treat medication overuse headache is to go cold turkey off all your pain relief for eight weeks, during which time you’re pretty miserable, especially the first two weeks. It’s very difficult to work during that time. So it’s best of all actually to avoid taking it that much. And if you find yourself needing a pain reliever for more than two days a week, then you should be thinking about migraine preventer.


Dr Katy Munro [00:53:04] I always think we should be talking about it when we are first seeing people who are asking our opinion about what rescue treatment they should take. I mean, I always try and say to them, you know, just be aware of that because you’re right, people can do that, quite understandably, treating their bad headaches, treating them early. And then if you don’t explain it carefully, they get into the worry because they vaguely heard about medication overuse headache so they don’t want to take too much so they wait too late and then they don’t treat their episode effectively. And so it’s knowing about, I think, quoting a number of days, I normally say eight days a month for triptans and 14 days for other painkillers. And I think this is typical of doctors that we have slightly different messages, but we’re roughly on the same thing. It’s around 10, isn’t it? You just need to be really counting and careful. And if you’re getting more than about five migraine attacks a month, we need to be thinking about preventer’s. And there are lots of different ways of preventing. I normally talk about medications, injection therapies and neuromodulation devices under this heading, but we’ve got more options in the injections now and fewer in the neuromodulation devices. But medication is normally the next step isn’t it. The number of medications that were always used for other things that were then discovered can actually help improve migraines.


Prof Paul Booton [00:54:34] Yeah, there’s a whole bunch of things which don’t bear any obvious relation to each other, which have been noticed over the years quite by chance to help preventing migraines. And there’s a friend of mine who’s a GP in Devon who said ‘I was struck by the number of patients who I took off these blood pressure pills called beta blockers and suddenly all these headaches started appearing because they silently had been preventing their headaches over the years’. He had taken them off them because they turned out not to be such a good drug for blood pressure. That’s a different story. But so we could start with that one. It’s one of the drugs that I’d most commonly use if somebody needed a preventer. They’re things called beta blockers. They were actually invented by a guy who used to work just down the corridor from me when I was at King’s College Medical School. He got the Nobel prize for it. I’m still waiting for mine and i may wait for quite a while longer, so i’m lead to believe. So it started life as a blood pressure pill. It’s also used to sort of slow your heart rate in a number of different conditions. It’s also used for anxiety as it happens but the reason it works in migraine has nothing to do with anxiety, just like the antidepressants that we can use in migraine are nothing to do with being depressed. It’s not a psychological problem that we’re treating. And with all these preventers, the trick is you start on a small dose and you gradually build it up to what should be an effective working dose. And the best thing to do is to keep a diary during that time so you can see exactly what’s happened to your migraine. Preventers aren’t magical, they’re not going to suddenly switch the migraine off altogether. You can still expect to get headaches. In fact, you probably only get about a 50 percent reduction in headaches with a preventer which is working well. But that said, the drugs you then take to treat the rest of your headaches do tend to work much more effectively. And so it works well all around.


Dr Richard Wood [00:56:50] I think it’s worth saying that even if there’s a 50 percent reduction in your headache severity and how bad they are and how often you get them, that’s still a massive improvement in quality of life for people who have regular headaches, I mean, just half how many headaches you get is a big improvement.


Prof Paul Booton [00:57:06] It’s a big improvement. But just to say to be realistic, these things don’t sort of turn a switch. They more turn down the volume.


Dr Katy Munro [00:57:14] We don’t want to hear that people are hoping for a cure, do we? Because that’s unrealistic. There’s nothing we can do that will cure their migraine. We can’t make them a promise that it will be 100 percent effective forever more.


Dr Richard Wood [00:57:27] It’s a genetic disorder, it’s part of them, it’s part of who they are. It’s what they’ve inheirited from their parents and what they may well pass on to their children. But it doesn’t mean that they have to suffer as much as they are if they’re really suffering, because we can still do things that improve quality of life.


Dr Katy Munro [00:57:46] Going on to another preventer sort of group with the antiepileptics, which seeme to be useful. But a lot of these preventers, the problem is that they have side effects and it’s the maximum tolerated dose that people can get to isn’t necessarily the maximum dose that they would potentially achieve if they have no side effects at all. So getting to a dose that they’re not having side effects, that they’re beginning to have some benefit and then hanging on in there, I think people have to be patient. They have to keep going for I usually say about three months.


Prof Paul Booton [00:58:21] Yeah. And it’s pretty important to say that there’s a good chance you’re going to have side effects. There’s a good chance those side effect will be worse when you first started off so if you can grit your teeth and just get on with it unless they’re awful and the chances are it’ll settle down and become tolerable over time. For that reason we start a very tiny dose and build it up slowly. And there’s some evidence, or at least there’s the feeling amongst neurologists that migraine as part of the migraine brain, they may suffer worse from side effects than in other people. So one of the drugs we use is amitriptyline, which is an old fashioned antidepressant, we often start with migraine we start them on 10 milligrams of that. Whereas if you were using it for depression, you usually start four times that dose. But migraine people seem to need to start that low to avoid those side effects.


Dr Richard Wood [00:59:16] Yes. And the advice I often give is if you’re going up the doses of your preventer to try and get to the maximum tolerated dose, if you hit a side effect you don’t like or you’re not tolerating it very well, it’s okay to drop down a dose for a week or two and then back up again and then you may find that you tolerate it better the second time.


Dr Katy Munro [00:59:33] The other thing people ask me is, do I have to be on this forever now? And so I want to say to them, well, no, actually what we’re aiming for is to control the migraine as well as we can with this and once that control of the irritability of the brain has happened then the preventer isn’t needed anymore. So it might take six months, possibly a year, and then you can start to wean gently down because migraine is a fluctuating thing. So it will come in peaks and troughs throughout a period of time. And it may well be that your brain is settled down and you don’t need to take that preventer. And certainly I had a friend who was on the preventer for 15 years, and I said, when did you last have a migraine? And she said, oh, about 14 years ago. And she came off it and she was fine. So I think we forget to stop things sometimes.


Prof Paul Booton [01:00:28] I think the another thing, which is very important to say as well, is make sure that you build up the dose of the drug to an effective level. Again, I can’t tell you how many patients I’ve seen who’ve been on something or another in a tiny dose, which you couldn’t treat anything with. And you say, ‘well, has that worked?’ And they say, ‘Oh, no, no’. But they’ve taken it for all those years. And it’s important with your GP, you build the dose up to something which is a there’s often not a rule about exactly how much it should be, but to a sensible amount, should we say, and hold it on that for a couple of months and see if that’s working and if that is working all well and good. If it’s not working, then you can stop it and move on to the next one. But being on drips and drabs of stuff for years and years is not really a good plan.


Dr Katy Munro [01:01:19] There are some injection therapies now available and some that we’ve been using for years. So Botox therapy, greater occipital nerve blocks and the new CGRP, anti-CGRP I should say, monoclonal antibody injections. And we’ve done podcast episodes on all of those topics. So I don’t think we need to go into great detail. But just for people to be aware that those are now options that you can get on the NHS, two of them of the CGRP drugs are now approved on the NHS, but I hesitate to push people towards them because the overloading of the NHS, particularly with covid-19 and the waiting list backlogs and the reality of life in terms of cost and funding and things mean that you can’t just pitch up and say, ‘please, can I have this’ and expect to get it. So there will be options available, but it may well be that people have to try medications first or possibly Botox therapy first before they would get one of these very new innovative therapies.


Prof Paul Booton [01:02:25] Yes, and that’s partly because they’re really very expensive and indeed, Botox is very expensive. And so it’s perfectly reasonable to say to people to let’s try the ordinary stuff first, see how you get on with that. Actually, with most people that will sort out their migraines, but for those it doesn’t, there are these newer and in some cases rather high-tech alternatives which are having an effect on people’s migraine, we’re jolly glad we’ve got them to offer patients in that difficult situation.


Dr Katy Munro [01:02:54] Yeah, yeah. I wanted to just speak a bit now about mental health and migraine, because we are in Movember and raising awareness of all sorts of aspects of men’s health is part of the theme of this month. But in particular, I think mental health and migraine, because there was a study about the risk of suicide in men who have migraine, and they found that it was much more increased in men who had migraine with aura or who had chronic migraine. And I think, the message needs to be very strongly ‘seek help’, seek help for your migraine, seek help if you’re feeling, you know, the mental health impacts of everything that’s going on around us. And there are some really excellent resources out there to help people with that.


Prof Paul Booton [01:03:50] Migraine or bad migraine is a little bit like your own personal lockdown. It so limits the number of things you can do and people do just get weary of it. They just get tired of it. And that can lead to depressive illness. So if that’s you, we would really encourage you to get help with that because there’s stuff you can do about it.


Dr Richard Wood [01:04:12] It’s interesting, I mean, there are some studies that say that people who get frequent migraines, 75 percent of them may suffer from anxiety or depression at some point in their life. And it may not just be a causal thing that migraines make you depressed. There may actually be a common genetic underlying vulnerabilities which both migraine and mental health problems share together. You are more likely to get one when you have the other because of your genetics, not just because of your experiences. I mean, this research is still in development, but it’s definitely worth being aware of. It’s also worth being aware, of course, that the risk of suicide, as Katy’s  mentioned is many fold over in migraine but also men are more vulnerable to suicide as well. And it’s really, really important that a doctor addresses the mental health around the migraine experience, but also that the patient who’s suffering a migraine, is able to verbalise ‘actually, my mental health is also suffering’.


Dr Katy Munro [01:05:11] Yes, I think the other thing, anxiety is huge around migraine, isn’t it, that sort of anticipatory anxiety, that worry that you’re going to get an attack. And I’ve had many of my patients say to me, ‘you know, I’ve just stopped arranging things. I’ve stopped planning things with friends. I’ve stopped pushing myself to do that study course I wanted to do because I’m just so worried that I won’t be able to do it’. And then the anxiety, of course, increases the stress and that increases the likelihood of having a migraine.


Dr Richard Wood [01:05:47] Of course it does.


Dr Katy Munro [01:05:49] It’s a kind of vicious circle, really.


Dr Richard Wood [01:05:52] And interestingly, I’ve had patients who’ve had both active migraine and active mental health problems, depression and anxiety. And sometimes we’ve just we haven’t been able to make much headway on the migraine- to treating the migraine. It just troublesome. And then we’ve taken a different tack, we said, you know what, let’s work on the mental health and we’ve taken a change of tack. And sometimes treating one actually ends up improving the other. So actually, treating the mental health can improve the migraine and then or for other patients, treating the migraine actually improves the mental health. So if you’re not winning with one, try the other.


Dr Katy Munro [01:06:28] And it can affect the choice of preventer, can’t it, because there’s one of the preventer’s, topiramate, which I would really avoid if people are feeling very depressed or low because it can aggravate that. And then some of the antidepressant medications, some of them have been useful in preventing migraine as well. So if you’re feeling that you’ve got bad anxiety or bad depression and you want a migraine preventer as well, it makes sense to talk that through with the headache specialist who’s giving you advice as to whether that might be a nice option to choose one of them. So the final thing I just wanted to talk about was a little bit more about driving just because we’ve never really mentioned much about driving in the podcast. And I sometimes get asked that. We talked a little bit about how aura prevents people driving, but it’s also about legal responsibility. So in the U.K., the DVLA, you do need to write to them and tell them if you feel your migraine is at such a level that it could impact on your driving and also if it changes after you’ve written to them. So just wanted to kind of put that in. So the migraine on its own isn’t a reason to stop you driving but it’s either the symptoms that you get, which might include aura or dizziness or hemiparesis, that weakness down one side of the body, if that comes on quickly, or it might be the side effects of the medication. Some of our medications that we’re using, even some of the triptans can make people feel quite drowsy. So sumatriptan in particular seems to make people feel quite groggy for several hours afterwards. And certainly some of the preventative medications can do so. So just really applying some common sense about safety and not driving.


Prof Paul Booton [01:08:26] I was just going to say that it is pretty rare, actually, for the DVLA to say someone can’t drive because of migraine. But it’s very, very important for all of us that if we’re at the wheel of a two tonne lump of metal, that we’re taking care to make sure that we’re in a good enough state to- that we’re safe to be driving, that we’re not testing our eyesight, for example. And also that’s a real thing for people. If you’re getting fortification spectra, if you’re getting this migraine aura, you may have to stop driving for 40 minutes until that settles down til you can drive again. We should be very careful to take responsibility. Otherwise, people like me on our bikes will come to a sticky end.


Dr Richard Wood [01:09:12] Yes. And that’s particularly I mean, not just the visual auras, but any aura, especially dizziness. Dizziness can be extremely disabling in the car because you can have a very- if you feel like your whole body is lurching to one side, you will have an involuntary reflex to pull the steering wheel the other way. And that can have catastrophic problems if you’re driving for you and those around you.


Dr Katy Munro [01:09:33] Well, I just like to summarise the messages, if you agree with me, that men are certainly going to be getting migraines, some men are getting it, because it is a very common condition. But there is a good amount of help out there for people with migraine and that it’s a good idea to go and ask for help or listen to all the episodes of this podcast, because we have tried to give easily accessible information in all of the episodes. The diagnosis, when you get to ask for help is usually quite straightforward. There are some other primary headache conditions that are really equally important to be diagnosed correctly, like cluster headache and tension type headache and some rarer secondary causes. So seeking help and getting that diagnosis is important. And then once you have found somebody who’s made a good diagnosis, they will hopefully help you to have a personalised treatment plan. And that’s certainly what we aim to do at the National Migraine Centre and people can refer themselves just by sending us an email or picking up the phone. So anything you two would like to add? Paul, what is your summary comment?


Prof Paul Booton [01:10:48] I just think the important thing is if you’re getting these symptoms and they’re getting in the way of your life, get help. In the first case from your GP. But if you need further help than that, there are various migraine specialist clinics up and down the country, which the NMC is a pre-eminent member, shall we say, but do get help because it can make a big difference to your life. And you may not realise how much it’s been affecting you until you see what you’re like without it, as it were.


Dr Katy Munro [01:11:19] And, Richard?


Dr Richard Wood [01:11:21] To be honest, I think that’s the key messages, isn’t it? I think I’d like to say to the men out there who suffer migraine is that if you’re really suffering, don’t do it yourself. If you’re going to, I should say, if you’re going to self-treat get some advice about how best to do it and know when you need to escalate your treatment with a medical professional. Because you don’t have to suffer as much as you may be.


Dr Katy Munro [01:11:46] Thank you very much for listening to this episode and thank you so much to Paul and Richard for those invaluable contributions.


Dr Richard Wood [01:11:55] Thanks, Katy.


Prof Paul Booton [01:11:56] It’s great to be here again.


[01:12:00] You’ve been listening to the Heads Up podcast. If you want more information or have any comments. Email us on info@NationalMigraineCentre.org.uk. Till next time.



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