Migraine

Introduction
A migraine is a severe headache that often has a number of associated symptoms, such as nausea, increased sensitivity, and visual problems.

Who is affected by migraines?
Migraines are common; affecting about 1 in 4 females and 1 in 12 men. It is thought that hormonal influences may be the reason why migraines affect more women than men. For example, some women find that migraine attacks are more frequent around the time of their period. However, this association has not been fully proven.

It is possible for migraines to begin later in life. However, it is more common for the condition to begin in childhood or as a young adult. About 90 per cent of people who experience migraines have their first one before they are 40 years old.

Types of migraine
There are two types of migraine - classical and common:

Classical migraine is when the headache follows a series of symptoms, known as aura (see the 'symptoms' section).
Common migraine is when a person does not experience aura symptoms.
Some people experience migraine attacks frequently, such as several times a week. Other people only experience a migraine occasionally. For example, it is possible for years to pass between migraine attacks.

Symptoms
The main symptom of a migraine is an intense headache. This usually occurs at the front, or on one side, of the head. However, during a migraine attack, the area of pain can sometimes change position. The pain can feel like a throbbing sensation and it can be moderate, or severe. The throbbing is usually made worse when you move.

Classical migraine symptoms (with aura)
Aura means a warning sign. It is the name that is used to describe the symptoms that you experience before the migraine begins. Around 1 in 4 people who experience migraines have additional aura symptoms. These can include:

Visual problems - you may experience visual disturbances, such as flashing lights, zigzag patterns, blind spots, and other visual distortions.
Stiffness - you may have stiffness, or a tingling sensation like pins and needles in your neck, shoulders, or limbs.
Problems with coordination - you may feel disorientated, or off-balance.
Difficulty speaking - you may find it difficult to express yourself properly using words.
Loss of consciousness - this only happens in very rare cases.
Aura symptoms typically start between 15 minutes and 1 hour before the headache begins. Some people may experience aura with only a very mild headache.

Common migraine symptoms
Symptoms associated with a common migraine include:

Nausea - you may feel queasy and sick. This may sometimes be followed by vomiting.
Increased sensitivity - you may experience photophobia (sensitivity to light), phonophobia (sensitivity to sound), and/or osmophobia (sensitivity to smells). This is why many people who have migraines want to rest in a quiet, dark room.
The symptoms of a common migraine often begin at the same time as the headache. However, these symptoms will usually disappear once the headache eases.

Other associated symptoms
During either a common or classical migraine, a number of associated symptoms can sometimes occur. These symptoms can include:

poor concentration
sweating
feeling very hot, or very cold
abdominal pain (which can sometimes cause diarrhoea), and
a frequent need to pass urine.
However, not everyone experiences associated symptoms, and they do not usually all occur at once.

The symptoms of a migraine can last anywhere between 4-72 hours (3 days). In between each migraine attack, all associated symptoms will usually disappear. You may feel very tired after a migraine attack, and this feeling can sometimes last for several days afterwards.

Causes
It is thought that migraines may be caused by changes in the chemicals of the brain. In particular, the level of the serotonin - the message-sending chemical - decreases during a migraine.

Low levels of serotonin can make the blood vessels in a part of your brain spasm (suddenly contract) which makes them narrower. This may cause the symptoms of aura. Soon after, the blood vessels then dilate (widen), which is thought to be the cause of the headache. However, the exact cause of the drop in serotonin levels is not yet fully understood.

Hormones
Some scientists believe that hormones are closely linked to the cause of migraines. Some women who experience migraines say that they are more likely to have an attack around the time of their period. This is known as a menstrual migraine. Fluctuating hormones are thought to be the reason why more females have migraines compared with males.

Just before women have their period, levels of the hormone, oestrogen, fall. It is not the low levels of oestrogen that cause a migraine, but it is linked to the changes from one level to another.

Women can experience menstrual migraines anytime between two days before to three days after the first day of their period. About one in seven women who experience migraines only have an attack around the time of their period. This is known as a pure menstrual migraine. However, it is possible to have migraine attacks around the time of your menstrual period and at other times as well. This happens to around 6 in 10 women who experience migraines.

Migraine triggers
Many factors have been identified as triggering the onset of a migraine. These triggers include emotional, physical, dietary, environmental, and medicinal factors.

Emotional
Emotional factors that can trigger a migraine can include:

stress,
anxiety,
tension,
shock,
depression, or
excitement.
Physical
Examples of physical factors that can trigger a migraine include:

tiredness,
poor sleep quality,
shift work,
poor posture,
neck, or shoulder, tension, and
travelling for a long periods of time.
The menopause can also trigger migraines.

Dietary
Dietary triggers of a migraine may include:

lack of food (dieting),
delayed or irregular meals,
dehydration,
alcohol,
food additives (specifically tyramine),
caffeine products, such as tea and coffee, and
specific foods like chocolate, citrus fruit, and cheese.
Environmental
Environmental factors that may cause migraines include:

bright lights,
flickering screens, such as a television or computer screen,
smoking (or smoky rooms),
loud noises,
changes in climate, such as changes in humidity or very cold temperatures,
strong smells, and
a stuffy atmosphere (a lack of fresh air).
Medicinal
Some medicines can trigger migraines, including some sleeping tablets, the contraceptive pill, and hormone replacement therapy (HRT), which is sometimes used to treat the menopause.

Diagnosis
When to visit your GP
Migraines can often be treated at home using over-the-counter (OTC) medication and self-help techniques. However, you should see your GP if you feel that painkillers, such as paracetamol, are not working, or you experience any of the things listed below.

You have aura symptoms that occur on the same side of your body with every attack.
Your first ever migraine occurs when you are over 50 years of age.
Your usual migraine symptoms have changed.
Your migraine attacks are becoming more frequent.
Diagnosing migraine
There is no specific test to diagnose migraine. On your first visit, your GP may give you a physical and neurological examination. This includes an examination of your mental functions by checking your vision, coordination, reflexes, and sensations. These checks will be carried out to make sure that there are no other underlying conditions that are causing your symptoms.

To give an accurate migraine diagnosis, your GP must identify a pattern of reoccurring headaches, alongside the associated symptoms. Migraines can be unpredictable, with differing periods of time where no symptoms are experienced. Therefore, obtaining an accurate diagnosis can sometimes be a lengthy process.

To help with the diagnosis, it can be useful to keep a diary of your migraine attacks. You should note down details including the date, time, and what you were doing when the migraine began. It is also helpful to make a note of the food you ate that day, as this can help your GP to identify any potential triggers.

Treatment
There is currently no cure for migraine. However, a number of treatment methods can be used to treat the symptoms of migraine. Treatments are mostly in the form of medicines. It may take time to work out which is the best method of treatment for you. For example, you may have to try different types of medicines, or different combinations, before you find the most effective ones.

Painkillers
Many people who experience migraine find that over-the-counter (OTC) remedies, such as painkillers, help to ease their symptoms. Paracetamol and aspirin are painkillers that are commonly used to treat a migraine.

When taking paracatemol, or aspirin, always make sure that you read the instructions on the packaging, and follow the dosage recommendations.

Children under 16 years of age should not take aspirin, unless it is under the specific guidance of a healthcare specialist.

Aspirin is also not recommended for adults who have (or have had in the past) stomach problems, such as a peptic ulcer, liver problems or kidney problems.

Painkillers are usually the first method of treatment for migraine, and they tend to be more effective if they are taken at the first signs of a migraine attack. This gives them time to absorb into your bloodstream and ease your symptoms.

Some people only take painkillers when their headache becomes very bad. However, this is not advisable because it is often too late for the painkiller to work. Soluble painkillers (tablets that dissolve in a glass of water) are a good choice because they are absorbed quickly by your body.

If you cannot swallow painkillers due of nausea, or vomiting, suppositories may be a better option. These are 'bullet-shaped' capsules that contain specific medicines. The suppository is inserted into the anus (back passage).

Stronger types of painkillers are also available, but they need to be prescribed either by your GP, or by a specialist.

Anti-inflammatory medicines
Due to their anti-inflammatory properties, you may find that anti-inflammatory medicines, such as ibuprofen, are more effective in treating your symptoms of migraine.

You can buy ibuprofen over-the-counter (OTC) at the pharmacists, and it is also available on prescription. However, as with aspirin, you should not take ibuprofen if you have (or have had in the past) stomach problems, such as a peptic ulcer, or if you have liver, or kidney problems.

Diclofenac, naproxen, and tolfenamic acid are other types of anti-inflammatory medicines that are only available on prescription

Anti-sickness medicines
If nausea is a symptom of your migraine, you can take anti-sickness medicines. These can be prescribed by your GP, and can be taken alongside painkillers. Ask your GP about anti-sickness medicines.

As with painkillers, anti-sickness medicines work better if taken as soon as your migraine symptoms begin. Anti-sickness medicines usually come in the form of a tablet, but they are also available in the form of a suppository.

Combination medicines
There are a number of combination medicines for migraine, which you can buy over-the-counter (OTC) at your local pharmacy. These medicines contain both painkillers and anti-sickness medicines. If you are not sure which medicine is best for you, ask your pharmacist for advice.

Many people who experience migraines find that combination medicines are convenient. However, you may find that either the doses of painkillers, or anti-sickness medicine, are not high enough to combat your symptoms. If this is the case, you may prefer to take painkillers and anti-sickness medicines separately. This will allow you to easily control the doses of each. Again, ask your GP or pharmacist if you are not sure about which medication is most suitable for you.

Triptan medicines
If ordinary painkillers are not helping to relieve your migraine symptoms, triptan medicines might be the next option. Triptan medicines are only prescribed by your GP, or by a specialist.

Triptan medicines are not the same as painkillers. They make the blood vessels around the brain contract. This combats the dilating (widening) blood vessels, which are believed to be part of the migraine process. Triptans are available in the form of tablets, injections, and nasal sprays.

Some triptan medicines work for some people but not for others. If one type of triptan medicine does not seem to be working, you should see your GP and ask them about other types.

Complementary medicines
Some people find that complementary therapies, such as acupuncture and homeopathy, help with migraines. However, there is a lack of scientific evidence as to the effectiveness of such treatment methods.

Complications
There are several complications that are linked to migraine:

Stroke
Migraine is associated with a small increased risk of ischaemic stroke. An ischaemic stroke occurs when the blood supply to the brain is blocked by a blood clot, or fatty material in the arteries.

Although it has been identified as a risk factor, the reasons why ischaemic stroke is linked to migraine are not entirely clear. However, an ischaemic stroke as a result of a migraine is very rare.

Another risk factor for ischaemic stroke is the use of the combined oral contraceptive pill. The general advice of medical professionals is that women who experience migraine with aura should avoid using the combined contraceptive pill.

Women who experience migraine without aura are able to take the combined contraceptive pill. However, if you take the combined contraceptive pill, and you experience aura symptoms, or if your migraines become more frequent, you should see your GP as soon as possible. They may advise you to stop taking the combined contraceptive pill.

Mental health problems
Migraine is associated with an increased risk of mental health problems including:

depression,
manic depression,
anxiety disorder, and
panic disorder.
Although migraine and mental health problems are linked, they are believed to have different causes.

Prevention
Although there is no cure for migraine, it is possible to bring the condition under control. This can be achieved through treatments and also by taking preventative measures.

Triggers
One of the best methods of preventing migraines is recognising the signs and the triggers of an attack. This is why keeping a migraine diary is helpful. For example, if you experience a migraine on several different occasions, after eating certain foods, you should avoid eating them. The same applies for avoiding other known triggers, such as avoiding stress, or anxiety.

Recognising the signs
Some people who experience migraines begin to feel unwell before a migraine attack. This can be up to a day, or so, before the more obvious symptoms, like a headache, begin.

The strange feelings that are sometimes experienced prior to having a migraine are known as the prodrome, and are often the first signs of a migraine attack. These can include:

a change in mood,
tiredness,
hyperactivity, or
food cravings.
However, as these feelings are not specific to migraine, it can be difficult to identify them as warning signs. Your relatives, or friends, might be first to notice these changes.

Medication
Medication is available to prevent a migraine attack. These medicines are usually given if you have tried other preventative measures and you are still experiencing migraines. Your GP may also prescribe these medicines if you experience very severe migraine attacks, or if your attacks happen frequently.

Medications used to prevent migraines include:

Beta-blockers
Beta-blockers include propranolol, metoprolol, and atenolol. They are traditionally used to treat angina and high blood pressure. It is not currently known how beta-blockers work to prevent migraine attacks. Beta-blockers are unsuitable for some people with asthma. Side effects of beta-blockers can include hallucinations, cold hands and feet, and tiredness.

Anti-depressants
Amitriptyline is a type of anti-depressant. However, it has been shown to work against migraines in a different way to how it treats depression. The medicine is usually started on a low dose which can be increased if necessary. Amitriptyline can be used together with beta-blockers.

Anticonvulsants
Topiramate is a type of anticonvulsant. Anticonvulsants are usually used to prevent seizures in people with epilepsy. However, they have also been found to help prevent migraines. Topiramate is currently the only anticonvulsant licensed for migraine prevention in the UK.

Serotonin agonists
Two serotonin agonists are pizotifen and methysergide. Some people who experience migraines find that these medicines can reduce the severity and frequency of their attacks. However, side effects can include drowsiness and weight gain.

Keep a migraine diary
You should be aware that these medicines may not stop your migraine attacks completely. Keeping a migraine diary will help you, and your GP, to monitor how well the medicine is working. As it can take up to three months for the medicine to take full effect, it is important to keep taking it for at least three months, even if you think that it is not working.