Living with
Migraines

What is migraine? 

Migraine is a primary headache disorder characterised by recurrent attacks of intense pulsing or throbbing pain in one area of the head. Approximately one-third of migraine sufferers are able to predict the onset of a migraine attack because it is preceded by a so-called “aura” that consists of visual disturbances that present as flashing lights, zig-zag lines, or temporary loss of vision. 

In the United States of America, migraine headaches are the fourth most common reason for emergency department visits. It is estimated to affect more than 10 % of people globally, with women three times more likely to experience migraine than men. According to the National Health Services in the United Kingdom, 1 in every 5 women and around 1 in every 15 men are affected by this common health condition, which usually presents in early adulthood. 

How do you know you have migraine? 

A migraine usually presents as a moderate to severe headache characterised by a throbbing pain on one side of the head. 

Migraine headaches can be classified according to type as follows: 

• Migraine with aura – the headache is preceded by specific warning signs, such as flashing lights 

• Migraine without aura – there are no specific warning signs to herald the onset of a migraine (this is also the most common type of migraine) 

• Migraine aura without headache, the so-called “silent migraine” – warning signs (such as flashing lights) and other migraine symptoms are present, but a headache does not develop 

One of the distinguishing features of migraine headaches is their recurring nature. Some people experience migraines very frequently, up to several times a week, while others develop migraines only occasionally. 

When to see a doctor 

Anyone who experiences a sudden, agonising headache unlike anything experienced before should seek immediate medical attention. In addition, if you experience a headache accompanied by any of the following, you will also require emergency medical care: 

• Paralysis or weakness in one or both arms, or one side of the face 

• Slurred or garbled speech 

A fever, stiff neck, confusion, seizures (or epileptic fits), double vision 

In the above instances, urgent medical evaluation is called for to rule out serious underlying medical conditions, such as stroke or meningitis. 

It is also advisable to consult your GP (general practitioner) if you experience frequent migraine attacks, especially if you have one on more than 5 days per month, or if you have severe symptoms. 

What causes migraine? 

It is not yet clear what causes migraine. These headaches have been linked to changes in the blood vessels, nerves, and chemicals in the brain. Genes are also thought to contribute since approximately 50 % of people who experience migraines, have a close relative also suffering from the condition. 

Trigger factors 

In some people, migraines are associated with certain triggers and many such possible triggers have been documented. These include hormonal, emotional, physical, dietary, environmental, and medicinal factors. Herewith some examples of such factors: 

• Emotional factors, such as stress, anxiety, tension, shock, depression, and excitement. 

• Physical factors, such as tiredness, poor-quality sleep, shift work, poor posture, neck or shoulder tension, jet lag, low blood sugar, or strenuous exercise in those not used to it. 

• Hormonal changes, such as with the onset of menstruation or menopause (although many women find that their migraines improve after the menopause). 

• Dietary triggers, such as missed, delayed or irregular meals, dehydration, or the consumption of alcohol, caffeine-containing products, chocolate, citrus fruit, or foods containing tyramine (e.g., certain cheeses or cured meats and yeasts extracts). 

• Environmental factors, such as bright lights, flickering screens, smoking, loud noises, change in humidity or very cold temperatures, strong smells, or a stuffy atmosphere. 

• Certain medicines, such as specific types of sleeping tablets, the combined oral contraceptive pill or hormone replacement therapy. 

How is the diagnosis made? 

According to the International Headache Society, a migraine is diagnosed by its typical pain characteristics coupled with the number of attacks (at least 5, lasting 4 to 72 hours if untreated), as well as additional symptoms including nausea and/or vomiting, or sensitivity to both light and sound. 

Although a number of conditions may present with headache, a medical history and physical examination will go a long way to correctly identify the cause or underlying condition. It may sometimes be necessary to perform scans or additional tests to rule out underlying conditions that may cause headaches or to identify comorbid conditions. Examples of such scans include magnetic resonance imaging (MRI) or computerised tomography (CT) scans. 

What treatment is available for migraine? 

Guidelines produced by healthcare experts in the United States, Canada and Europe concur that migraine management should include lifestyle modifications, avoidance of triggers, as well as healthy coping mechanisms. Apart from such general measures, the medical management of migraine rests on two pillars: symptom relief during the acute attack and prevention of future attacks. 

Symptom relief 

To relieve symptoms during an acute attack, several medicines may offer benefit. It is generally held that the sooner these medicines are administered, the more effective they are. Examples of medicines that have been shown to provide relief for acute migraine include: 

• Analgesics, which may include over-the-counter medicines such as ibuprofen, aspirin, or paracetamol and which are usually indicated for the treatment of mild to moderate headaches. 

• Rizatriptan or sumatriptan, which may help to reverse certain changes in the brain that contribute to the development of migraine and which are usually reserved for more severe headaches. Triptans should be administered early to allow for the best possible effects. 

• Ergotamine, which is usually reserved as a second-line therapy when the above medications have failed to provide adequate pain relief. 

• Medicines to treat nausea and vomiting. These medicines are often given by injection. 

General measures, such as lying in a darkened room or sleeping, may also be of benefit. 

While there is moderate evidence to support the effectiveness of opioids such as codeine and tramadol for relief from migraine, routine use of these medicines is not recommended. This is due to their high abuse potential as well as the receptor changes they induce that might decrease response to further therapy. 

Prevention 

Avoidance of trigger factors (such as certain foods) may help to reduce your risk of developing migraines. 

If your migraines are severe, if you are still experiencing frequent attacks despite the avoidance of trigger factors, and if you require the use of acute medications more than two to three times per week, your doctor may opt to prescribe any of the following medicines to prevent further attacks: 

• Anti-epilepsy medicines such as topiramate 

• Blood-pressure-lowering medicines including beta-blockers such as propranolol 

• Antidepressants such as the tricyclic antidepressant amitriptyline 

• Botox injection 

All of the above medications have side effects, and not all options may be suitable for every patient. Your doctor will determine the best option for you. 

Apart from the above, patients may also benefit from some alternative therapies, notably acupuncture, biofeedback, cognitive behavioural therapy, meditation and yoga, or the use of certain herbs such as feverfew and butterbur. 

Living and managing 

It is generally recommended that you maintain a healthy lifestyle which should include regular exercise, getting enough sleep and eating healthy, well-balanced meals. It is also important to ensure that you stay well hydrated and that you limit your consumption of caffeine and alcohol. 

Conclusion 

Migraine is a common condition that affects a large number of people across the world. It occurs more frequently in women and many trigger factors have been described. For sufferers across the globe, help is available in the form of medicines to provide pain relief, but also in the form of preventative medicines to reduce the risk of future attacks. 

References

1. Mayans L, Walling A; Acute Migraine Headache: Treatment strategies; American Family Physician; 2018; 97(4): 243 – 251 

2. National institute of Neurological Disorders and Stroke; Migraine Information Page; National Institute of Health; dated 31 Dec 2019; accessed on 24 February 2022; available from https://www.ninds.nih.gov/Disorders/All-Disorders/Migraine-Information-Page#disorders-r2 NIH 

3. National Health Service; Migraine – Overview; NHS; dated 10 May 2019; accessed on 24 February 2022; available from https://www.nhs.uk/conditions/migraine/ NHS 

4. National Health Service; Migraine – Causes; NHS; dated 10 May 2019; accessed on 24 February 2022; available from https://www.nhs.uk/conditions/migraine/causes/ NHSA 

5. Mayo Clinic Staff; Migraine – Diagnosis and Treatment; Mayo Foundation for Medical Education and Research; not dated; accessed on 24 February 2022; available from https://www.mayoclinic.org/diseases-conditions/migraine-headache/diagnosis-treatment/drc-20360207?p=1 MAY 

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References

1. Mayans L, Walling A; Acute Migraine Headache: Treatment strategies; American Family Physician; 2018; 97(4): 243 – 251 

2. National institute of Neurological Disorders and Stroke; Migraine Information Page; National Institute of Health; dated 31 Dec 2019; accessed on 24 February 2022; available from https://www.ninds.nih.gov/Disorders/All-Disorders/Migraine-Information-Page#disorders-r2 NIH 

3. National Health Service; Migraine – Overview; NHS; dated 10 May 2019; accessed on 24 February 2022; available from https://www.nhs.uk/conditions/migraine/ NHS 

4. National Health Service; Migraine – Causes; NHS; dated 10 May 2019; accessed on 24 February 2022; available from https://www.nhs.uk/conditions/migraine/causes/ NHSA 

5. Mayo Clinic Staff; Migraine – Diagnosis and Treatment; Mayo Foundation for Medical Education and Research; not dated; accessed on 24 February 2022; available from https://www.mayoclinic.org/diseases-conditions/migraine-headache/diagnosis-treatment/drc-20360207?p=1 MAY 

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