For Patients & The Public

Learn more about your headaches


 

Learning About Headaches

Headache is an almost universal experience. Most of us have some kind of headache at some time in our lives. There are many types and causes of headaches.


Types of headache

The International Headache Society (IHS) has 2 broad categories for headache disorders:

  • The first is based on symptoms (called primary headache disorders) and includes migraine, tension-type headache and cluster headaches.
  • The second is based on their causes (called secondary headache disorders). This would include headaches associated with a head injury, stroke, infection, disorders of the neck, eyes, nose, sinuses or teeth.

If you experience regular headaches it is helpful to understand the type of headache which you have in order to manage your condition effectively.

How is a headache different from a migraine?

There is a difference between a headache and a migraine headache. Headaches are not usually accompanied by other symptoms that are associated with migraine. However, it is quite likely that if you have migraine you will also experience other headaches.

Headache

Headaches can vary greatly in their duration, cause and severity. For example headaches associated with an infectious illness improve when the illness is over. It is especially important to identify the type of headache you have so you can get the right treatment. A headache can be the result of a whole variety of factors such as head injuries, infections and other medical conditions.

Migraine

Migraine attacks are experienced as a headache of at least moderate severity usually on one side of the head and occurring with other symptoms such as nausea, vomiting, sensitivity to light and noise. The headache is usually worsened by physical activity. Migraine attacks usually last from 4 to 72 hours and in most cases there is complete freedom from symptoms between attacks. Certain factors are involved in triggering an attack. These are called trigger factors and can include lifestyle, and hormonal changes.

The importance of a diagnosis

If you get regular headaches, it is important to see your doctor and get a proper diagnosis. Diagnosis will depend upon your doctor taking a detailed medical history, and some may need further investigations. The correct diagnosis of a headache can help you to manage your headaches.

By being able to distinguish between the types of headaches the right treatment can be selected.

The importance of an accurate diagnosis

Before you start any form of treatment you need to be sure that you are being treated for the right condition.  If you are getting regular headaches or other symptoms that you suspect could be migraine, it is important to see a doctor and get a proper diagnosis.

 Proper diagnosis of your symptoms can:

  • Give reassurance that the headaches or other symptoms are not a sign of a very serious illness.
  • Allow you to get advice on stopping, managing and treating your symptoms.
  • If other medical conditions co-exist alongside your migraine this is important in terms of treatment.
  • A confirmed diagnosis of migraine and appropriate treatment can help prevent some attacks from occurring and help you to control the remaining attacks more effectively.

How is a diagnosis made?

There is no confirmatory test to diagnose migraine. The diagnosis will depend upon your doctor taking your medical history in detail and excluding other causes for the attacks.

To make a firm diagnosis, information from two sources will be used:

A detailed history of the headaches and/or other symptoms is taken.

This history includes analyzing:

  • The features of the headaches (for example, how often they happen, how severe the pain is, what symptoms go with them).
  • The effect the headaches have on your everyday activities.
  • The family history of headaches.

A thorough neurological assessment.

When you visit your doctor, you should expect to give quite detailed information about your attacks. Keeping a simple headache diary can be very helpful. Details of previous treatment that you have tried in the past will be useful.

You may have had brain scans (CT or MRI) in the past for your headaches. Although these tests will help exclude other causes of headache, they cannot be used to diagnose migraine.

Similarly, an EEG (electroencephalograph) will not help the doctor to make a correct diagnosis of migraine; nor do routine blood tests help.

Changing symptoms

A change in the pattern of your headaches or other symptoms might be the result of the naturally changing course of migraine. Symptoms can vary at each stage of a migraineur’s life, especially in women where hormonal changes can influence attacks. Migraine mainly affects younger people, and the condition often improves with age. However, any change in the pattern of your headaches should be checked with your doctor. This can help rule out any other causes, especially if your migraine attacks get worse or develop unusual symptoms.

Mixed headaches

Many migraine sufferers also experience other types of headache, such as tension-type headache. These other headaches need to be identified so they can be treated appropriately. Tell your doctor if you suspect that you are experiencing more than one type of headache Bringing other headaches under control can also lead to a drop in the number of migraine attacks you suffer.

As well as treating your headache symptoms with medication it is also important to think about aspects of your lifestyle that may be affecting your headaches.


Diet

  • Eat a cereal / oat based breakfast to give a slow release of sugar.
  • Do not go for long periods without food – to avoid low blood sugar levels.
  • Limit intake of caffeine – tea, coffee, fizzy drinks including cola.
  • Eat balanced meals including five portions of fruit and vegetables a day.

Alcohol

  • Keep alcohol intake to recommended weekly levels:
  • Men 21 units
  • Women 14 units

One unit = half pint of beer, one glass of wine / spirits

Smoking
Speak to your doctor regarding advice on how to get help for smoking cessation. Nicotine replacement therapy (such as gum, patches, lozenges etc) is available on prescription.

Water

  • It is recommended that we drink two litres (eight large glasses) of water a day.
  • Drinking too little water can lead to tiredness, lethargy, headaches, inability to concentrate, dry / cracked skin and low blood pressure.
  • Coffee, tea, alcohol and related products can cause headaches.
  • Coffee, tea and alcohol are diuretics and therefore cause more water loss from your body.
  • Take a bottle of water to work / school / university. Keep drinking throughout the day.

Sleep

  • Try to maintain a regular time of going to bed.
  • Ensure you have a period of wind down before going to bed.
  • Avoid working at a computer close to bedtime.
  • Think about your routine just before you go to bed.
  • Try to have the same amount of sleep – do not under or over sleep.

Posture and eyesight

  • Avoid slouching in front of the TV.
  • Check your position in front of the computer. The VDU should be at eye level.
  • Do not sleep with too many pillows.
  • If you have problems with your eyesight see an optician for a check up.
  • If you already have a visual condition make sure you have regular check ups.
  • Check your driving position.

Exercise

  • It is recommended that we try and exercise five times a week for thirty minutes.
  • Walking is an ideal and cheap way of exercising.
  • Think what you like doing and how you may build it into your life.

Stress / relaxation

  • Avoid negative ways of coping (such as alcohol, smoking).
  • Prioritise problems / tasks, recognise signs of stress.
  • Try and include exercise in your routine to aid relaxation.
  • Consider alternative therapies (such as reflexology, acupuncture).

Migraine

What is migraine?

It is a condition with a wide array of symptoms. For many the main feature is a painful headache. Other symptoms include disturbed vision, sensitivity to light, sound and smells, feeling sick and vomiting. Migraine attacks can be very disabling and may result in one having to lie still for several hours.

Symptoms will vary from person to person. Individuals may have different symptoms during different attacks. Your attacks may differ in length and frequency. Migraine attacks usually last from 4 to 72 hours and most people are well in between attacks. Migraine can have a significant impact on your work, family and social lives.

Are there different types of migraine?

There are different types of migraine. The International Classification of Headache Disorders system gives different names to the different types of migraine and headache that involve different symptoms.  This helps doctors to diagnose and treat them.

The most common types of migraine fall into 2 categories:

  • Migraine with aura
  • Migraine without aura

Under ‘migraine with aura’ some other rarer forms of migraine have been described. These include migraine with brainstem aura, where symptoms such as loss of balance, double vision, or fainting can occur. Familial hemiplegic migraine, where reversible weakness occurs, is also classed as ‘migraine with aura’. There are other rare forms of migraine, which are classified separately.

Headache or migraine?

Distinguishing between different types of headache can be difficult. You can experience different types of headaches at different times of your life for varying reasons. For example, if you have migraine you may also experience other types of headache. Keeping a migraine or headache diary is really useful and can be invaluable in trying to identify a specific headache type.

What is the treatment?

The complex nature of migraine means that the treatments available are varied and differ from person to person. There is currently no cure for migraine. The management is individualized.

What causes migraine?

There is no known cause for migraine, although most people with it are genetically predisposed to migraine. If you are susceptible to migraine there are certain triggers which commonly occur. These include stress, lack of food, alcohol, hormonal changes in women, lack of sleep and the environment.

Prevalence

Migraine is the third most common disease in the world with an estimated global prevalence of 14.7% (around 1 in 7 people).

In Singapore, the prevalence of migraine is 9.3%.

Chronic migraine affects approximately 2% of the world population.

Migraine affects three-times as many women as men, with this higher rate being most likely hormonally-driven.

More than three quarters of migraineurs experience at least one attack each month, and more than half experience severe impairment during attacks.

Migraine often starts at puberty and most affects those aged between 35 and 45 years, but it can trouble much younger people including children.

Burden – impact and disability

Migraine is ranked globally as the 7th most disabling disease among all diseases (responsible for 2.9% of all years of life lost to disability/YLDs) and the leading cause of disability among all neurological disorders.

The estimated proportion of time spent with migraine (i.e. experiencing an attack) during an average person’s life is 5.3%.

Severe migraine attacks are classified by the World Health Organization as among the most disabling illnesses, comparable to dementia, quadriplegia and active psychosis.

Cause

Migraine is a disorder that almost certainly has a genetic basis.

An older theory on the causation of migraine included that migraine is primarily a disease of the blood vessels. It is now accepted that migraine is not related to any vascular pathology and brain mechanisms are more likely involved in the development of migraine attacks.

Diagnosis and management

Migraine remains undiagnosed and undertreated in at least 50% of patients, and less than 50% of migraine patients consult a physician.

The greatest single advance in migraine management in the last half of the 20th century was the triptan class of drugs, which emerged in the 1990s. The first drug under this class to be developed was sumatriptan.

Less than 50% of migraine patients are satisfied with their current treatment. The majority self-medicate using non-prescription (over-the-counter) medication and do not seek medical help.

Historical aspects

The word migraine derives from the Greek word ‘hemicrania’ (imikrania; ημικρανία) which means ‘half the skull’. In 400 BC Hippocrates described in detail the occurrence of migraine attacks, including the visual disturbances during migraine aura and the relief from vomiting.

70-90% of people with migraine experience this type


Common symptoms of ‘migraine without aura’

Attacks of ‘migraine without aura’ last between 4 and 72 hours when untreated or unsuccessfully treated.

The headache is usually on one side of the head (in 2/3 of individuals) but can also be both sides (1/3 or individuals) with a throbbing or pulsating pain. The headache affects your normal daily life and may worsen when you engage in physical activity.

During this type of migraine you will be likely to feel sick and may vomit.

You may also become sensitive to light (photophobia), sound (photophobia) or smell (osmophobia).

Likely frequency of attacks

May occur anything from once a year to several times per week.

A common type of migraine featuring additional neurological symptoms


What is aura?

Aura is a term used to describe a focal neurological disturbance(s) that can occur in migraine.

Common symptoms of ‘migraine with aura’

People who this type of migraine will have many or all the symptoms of a ‘migraine without aura‘ and additional neurological symptoms which develop over a 5 to 20 minute period and last less than 60 minutes.

 Visual disturbances (most common) can include:

  • blind spots in the field of vision
  • coloured spots
  • shimmering/ flashing lights
  • tunnel vision
  • zig zag-lines
  • temporary blindness

 Other aura symptoms can include:

  • numbness or tingling
  • pins-and-needles in the limbs
  • weakness on one side of the body
  • dizziness or a feeling of spinning (vertigo)

Speech and hearing can be affected and some people have reported memory changes, feelings of fear and confusion and, more rarely, partial paralysis or fainting.

These neurological symptoms usually happen before a headache. At times no headache may follow.

Prevalence

10-30% of people with migraine experience this type.

Subtypes of migraine with aura

Other uncommon subtypes of migraine with aura include migraine with brainstem aura, hemiplegic migraine and retinal migraine.

What causes aura?

It’s believed that the various aura symptoms are due to an electrical or chemical wave that moves across the part of your brain that processes different signals.

Potential complications

People who have migraine with aura are at a slightly higher risk of stroke. Women who have migraine with aura appear to have an even higher risk of stroke if they smoke or take birth control pills

If you experience headache on more than 15 days per month you may have chronic migraine


The International Headache Society (IHS) defines chronic migraine as more than 15 headache days per month over a 3 month period of which more than eight are migrainous, in the absence of medication over use. Episodic migraine is the other migraine sub-type, which is defined as less than 15 headache days per month.

Impact of chronic migraine

It is estimated that this condition affects less than 1% of the population. Due to the nature and length of time that the sufferer is affected, people with chronic migraine experience significantly more time absent from work, school, leisure, housework and social activities than that of episodic migraine patients.  Their productivity in these areas may also be decreased.

The impact of chronic migraine can be very disabling. Some people are unable to work at all. This can lead to sufferers frequently becoming depressed and unable to cope.

Just like episodic migraine there is no single cause for chronic migraine. Some people have noticed that there is a steady progression in headache frequency, especially in long term sufferers. This can lead to the migraines becoming so frequent that they cross the threshold of more than 15 days per month and become defined as chronic migraine. It is estimated that every year between 2.5 and 4.6% of people with episodic migraine experience progression to chronic migraine. The good news is that approximately the same proportion regress from chronic to episodic migraine spontaneously.

Treatment for chronic migraine

Many therapies prescribed for chronic migraine are the same as those prescribed for episodic migraine. Apart from medication, a combination of lifestyle changes and understanding migraine triggers is important.

Medication overuse

It has been shown that approximately 70% of chronic migraine patients overuse pain-killers. This may result in further complications, so it is important that if you use these medications daily, help should be sought early.

Currently there is no known cure for chronic migraine.

Specialist migraine/headache clinics

People with chronic migraine are three times more likely to consult their GPs compared to episodic migraine. Furthermore patients with chronic migraine are nearly four times more likely to end up visiting the accident and emergency department in any three month period, than those with episodic migraine. Further investigations into chronic migraine may be required as well as an individualized treatment plan to try to minimise the frequency and severity of attacks.

Taking control

Chronic migraine is a distinct type of migraine that is sometimes progressive. It is therefore important to recognise how often everyday life is disrupted by migraine and keep a record of how many days per month you have a headache. If this is more than half the month, you may well have chronic migraine and should see a neurologist for help.

Migraine attacks linked to the menstrual cycle


 When it occurs?

This type of migraine is thought to affect fewer than 10% of women. Menstrual migraine has been found to correlate with falling levels of oestrogen. Studies show that migraine is most likely to occur in the 2 days leading up to a period and the first 3 days of a period. There is no aura with this type of migraine and it can often last longer than other types.

Why it occurs?

The 2 most accepted theories on the cause for menstrual migraine at the moment are:

  • the withdrawal of oestrogen as part of the normal menstrual cycle
  • the normal release of prostaglandin during the first 48 hours of menstruation

No tests are available to confirm the diagnosis. The only accurate way to tell if you have menstrual migraine is to keep a diary for at least 3 months recording both your migraine attacks and the days you menstruate. This will also help you to identify non-hormonal triggers that you can try to avoid during the most vulnerable times of your menstrual cycle.

Treating menstrual migraine

There are several treatment options depending on the regularity of your menstrual cycle, whether or not you have painful or heavy periods, menopausal symptoms or you also need contraception.

If you have migraine and heavy periods, taking a non-steroidal anti-inflammatory drug (NSAID) could help. Naproxen can be started 2 to 3 days before the expected start of your period.  If your periods are not regular, it is often effective when started on the first day.  It is usually only needed for the first two to three days of your period.

Another strategy includes the use of oestrogen supplementation. Topping up your naturally falling oestrogen levels just before and during your period might help if your migraine occurs regularly before your period. Oestrogen can be taken in several forms such as skin patches or gel. The patch can be applied for 7 days starting from 3 days before the expected first day of your period. Similarly, you rub the gel onto your skin for 7 days. In this way the oestrogen from the patch or gel is absorbed directly into your blood stream. Oestrogen supplements should not be used if you think you are pregnant or you are trying to get pregnant. Keeping a diary of your migraines will help you to decide when best to start the treatment.

Will having a hysterectomy help menstrual migraine?

Thee female reproductive system consists of the uterus (womb) and the two ovaries. The ovaries contain the eggs and also produce the sex hormones oestrogen and progesterone. At the beginning of each menstrual cycle, some of the eggs will start to mature under the influence of hormones produced by the ovaries. In the middle of the cycle, usually one egg will ovulate. If the egg is not fertilised it will get absorbed by the body but more importantly the level of hormones fall. This fall of hormones triggers the lining of the womb to break down and be shed through the vagina. This is called menstruation. It is this withdrawal of hormones that acts as a trigger in women with menstrual migraine or menstrual-related migraine. So, if someone is considering a hysterectomy to treat menstrual migraine, it would not help as the ovaries would need to be removed.

A rare condition involving temporary weakness on one side of the body


What is hemiplegic migraine?

The word ‘hemiplegic’ simply means paralysis on one side of the body. More often, patients with this form of migraine will experience a temporary weakness on one side of their body as part of their migraine attack. This can involve the face, arm or leg and be accompanied by numbness, or pins-and-needles. The person may experience speech difficulties, visual problems or confusion. This can be a terrifying experience as these symptoms are similar to those of a stroke. This weakness may last from one hour to several days, but usually it goes within 24 hours. The head pain associated with migraine typically follows the weakness, but the headache may precede it or be absent.

What causes the symptoms of hemiplegic migraine?

The brain and nervous system depend on electrical and chemical signals to function. Electrical signals passing through nerves opens ‘channels’ which acts like a ‘gate’. This process leads to the release of neurotransmitters (or chemical messengers) which affect neighbouring nerve cells and tell them how to respond. If a channel in the brain is not working properly, neurotransmitters may be released in an abnormal way. In hemiplegic migraine, channel dysfunction is known to play a role.

Types of hemiplegic migraine

There are 2 types of hemiplegic migraine: familial hemiplegic migraine (FHM) and sporadic hemiplegic migraine (SHM).

Familial hemiplegic migraine

Familial hemiplegic migraine (FHM) is defined as migraine attacks occurring in two or more people in the same family who experience weakness on one side of the body as a symptom with their migraines. Approximately 50% of children who have a parent with hemiplegic migraine will develop this disorder. At least 3 different genes have been implicated in FHM. In half of the families where FHM occurs, a gene with a defect on chromosome 19 has been identified. This causes the related calcium channel to work incorrectly from time to time, and when it does a series of biochemical changes result in a migraine attack. For other families, chromosome 1 is implicated which alters the behaviour of a channel involved in cell energy and in still others a sodium channel gene on chromosome 2 is altered.

 Sporadic hemiplegic migraine

If someone has all the features of FHM but does not have a family history of a similar condition, they are diagnosed as having sporadic hemiplegic migraine. The cause of SHM is unknown. Some may be due to new or ‘sporadic’ gene mutations.

 Getting a diagnosis and treatment

When symptoms of either type of hemiplegic migraine occur it is important that a firm diagnosis be made and that you seek medical advice to evaluate the sudden onset of one sided weakness or numbness. The diagnosis of these migraine variants must always be based on a thorough evaluation of the symptoms as experienced by the individual and includes a full family history.

Specialist advice will also ensure that you avoid embarking on the wrong treatment regimen. Despite often being prescribed for the more common types of migraine, the triptans are best avoided during the aura phase of sporadic of familial hemiplegic migraine.

Introduction

Migraine with brainstem aura is an relatively rare variant of migraine with aura.  It is characterised by neurological symptoms that typically include at least 2 of the following symptoms:

  • Slurring of speech (dysarthria)
  • Vertigo (an illusion of movement)
  • Ringing in the ears (tinnitus)
  • Double vision (diplopia)
  • Unsteadiness of gait as if drunk (ataxia)
  • Transient impairment of consciousness (syncope)
  • Simultaneous bilateral sensory symptoms eg. pins-and-needles and /or numbness affecting both upper or lower limbs
  • Simultaneous bilateral visual aura

Symptoms often develop gradually and typically precede or accompany typical migraine headache in those who experience it.

In general, most individuals first experience symptoms associated with their migraine headache in early adult life. However, the occurrence of these attacks can potentially occur at any age.  Individuals experiencing their first attack especially if it occurs later in life (after age 50 years) often need further investigations such as brain imaging to ensure that other neurological conditions are not responsible.

Whilst three genes have so far been identified as being responsible for familial hemiplegic migraine by contrast genetic studies looking at individuals who experience attacks of pure migraine with brainstem aura without weakness have not shown that the same genes are commonly implicated. Thus routine genetic testing is not indicated.

Migraine with brainstem aura like other forms of migraine with aura can be triggered by all the usually recognised migraine triggers.  If migraine with brainstem aura attacks occur in the context of hemiplegic migraine then head trauma however minor is also a well recognised triggering factor.

As migraine with brainstem aura is simply a more unusual variant of migraine with aura it is considered to have the same associations as typical migraine with aura.  It is therefore not thought to have an excess ischaemic stroke risk over and above what is considered for migraine with typical visual aura.

A trigger is any change which seems to result in migraine


The identification of triggers is not always easy. Almost any factor can trigger an attack in a person predisposed to migraine, and the list of possible suspects can be long and confusing.

How to identify triggers

It may not be easy to identify what is triggering your migraine if your attacks are linked to a number of different things. A trigger may not cause an attack every time, which may confuse the situation even more.

Imagine you are a young woman and your triggers are skipping a meal, stress and a change in hormonal levels. If you come home late from a very stressful meeting at work, your period is just about to start, and you go straight to bed without eating a proper meal, you may almost certainly have an attack. If you skipped dinner another time, when the other triggers were not present, you will probably not get a migraine. Many people find that they have long periods of time without a migraine between attacks. During this time, the body seems to be in a less sensitive state, and you may find that even a combination of triggers does not start a migraine.

Sometimes triggers can be wrongly identified. For example, at the beginning of an attack, you may experience a craving for sweet things. If you eat some chocolate to satisfy this craving, and then get a headache, you may identify chocolate as one of your triggers. In fact, you were starting to get a migraine before you ate the chocolate.

Keeping a diary

One of the best ways of identifying triggers is to keep a detailed diary. Trigger factors can influence an attack up to 48 hours before the headache comes on. A migraine diary can help you to look at this period before each attack. You may notice a pattern of possible triggers which are occurring together during this time.

You should try to keep a record of:

  • what time you get up and then what time you go to sleep
  • where you are (your environment can contain triggers)
  • what food and drink you consume
  • when you eat and drink
  • when you have bowel movements
  • exercise or travel
  • your mood
  • what the weather is like
  • (for women) your menstrual cycle
  • if you have a migraine or other headache, its severity and symptoms
  • the medications you take and the dosage
  • anything you can think of that is a changing part of your lifestyle

The timing of your attacks may also help you to identify your triggers. For example, if you suffer at weekends, your headache may be triggered by caffeine withdrawal due to drinking fewer cups of tea or coffee at home than at work. Winding down at the weekend after a stressful week at work can also bring on attacks. Some sufferers find that too much sleep at the weekends can trigger an attack.

Avoiding triggers

If your migraine attacks are triggered by a single thing that is easy to avoid, you may be able to stop most of your attacks from happening. It may be harder to avoid attacks that are triggered by a combination of factors.

It is important to be clear about what you expect to achieve from a routine for managing migraine, and that what you expect is realistic. For example, aiming to reduce how often the headaches happen may be realistic, but wishing for a life without headaches may not be. A realistic goal will give you something to aim for. You should not feel bad, or guilty, if you cannot control all your attacks by avoiding triggers. Many sufferers require other management methods to bring their condition under control.

Lifestyle changes

Changing your lifestyle can be difficult. However, if you are able to make these changes, you may find they lead to major improvements in your quality of life.

You should aim exercise regularly, and eat a well-balanced diet. If you are fit and in good health, you will be able to better cope with migraine attacks when they do occur.

You may continue to have disabling headaches even after addressing all the issues discussed here. If this is the case, you need to talk to a doctor regarding the possibility of using preventative treatment.

Commonly reported migraine trigger factors include hunger, dehydration, stress and changes in routine


Common triggers

Changes in routine

Some people find that changes in their routine can trigger a migraine e.g. changing sleep patterns. Even pleasant changes in routine such as a holiday can be implicated.

 Weekend headaches

Many people complain that they suffer migraines during the weekend. At the weekend you may have a change in many of your daily routines such as meal times, reduced caffeine consumption which is particularly noticeable if you have a sleep in after a busy week.

Stress

Migraine and stress are strongly linked. Indeed, anxiety, excitement and any form of tension may all lead to a migraine attack. However, some people report that their migraine attacks start when the stress reduces. This is sometimes experienced as “weekend headaches” when, after a busy and stressful week at work, an individual might experience a migraine at the weekend when they are more relaxed.

Sleep

The complex nature of trigger factors is illustrated by sleep. Too much and too little sleep can be implicated in a migraine. Some people find that sleepless nights, a number of late nights and being over tired can trigger a migraine. Other people find that over-sleeping has the same effect.

Caffeine

Excessive consumption of caffeine may contribute to the onset of a migraine attack. Try not to have more than 4 or 5 cups of tea, coffee or cola in a day. Some people find that suddenly stopping caffeine altogether can also be a trigger. If you suspect this, you may wish to cut down on caffeine more gradually. Some people find that consuming less caffeine at the weekend can have an impact on migraine attacks, but you should also note that caffeine can be found in many products including chocolate and over the counter painkillers.

Hormonal changes in women

Migraine is closely associated with female hormones. Some women find their migraines start at puberty, and are linked to their menstrual cycle. The additional hormonal trigger for women may explain why more women than men experience migraine during their reproductive years. The menopause is often the most difficult time for women with migraine.

The environment

There are certain trigger factors which can be related to environmental issues such as high altitude, weather changes, high humidity, loud noises, exposure to glare or flickering lights.

Computer screens

Sitting in front of a computer at home or work for long periods of time can cause problems if you experience migraine. Taking regular breaks, using anti-glare screens and good lighting can help prevent this. Good workplace sitting ergonomics is very important when you use a computer to avoid muscle tension building up in the head, neck and shoulders. This muscle tension is implicated in the onset of migraine.

Food

Food related triggers occur in about 10% of people with migraine. Many people will crave sweet food such as chocolate before the pain of the migraine is experienced which leads them to conclude that eating sweet food is a cause. However, sometimes the craving for particular food is a symptom of the beginning of the migraine (during the premonitory phase).

Did you know?  The widespread belief that chocolate should be avoided by migraine patients lacks scientific evidence. Chocolate is more likely to be a dietary symptom of a migraine attack (people can experience food cravings before the onset of an attack), rather than a dietary cause.

(Lippi G et al. Chocolate and migraine: the history of an ambiguous association. Acta Biomed. 2014 Dec 17;85(3):216-21.)

Although some people may be sensitive or intolerant to certain foods, research has not demonstrated a consistent link with tyramine, nitrites or any other food component. A true sensitivity to a food as a migraine trigger usually causes attacks repeatedly rather than occasionally.

(Frith A. Coping with Headaches and Migraine. Sheldon Press 2009.)

Lack of food

Missing meals or eating sugary snacks instead of a balanced meal can all contribute to a migraine attack. Insufficient food is probably one of the most important dietary triggers. You may find that eating small snacks at regular intervals can help to control your attacks.

Additives

Some food products contain chemicals or additives which may also be implicated in an attack. Ones which are frequently mentioned by people with migraine are monosodium glutamate, nitrates and aspartame.

Alcohol and cheese

There is some evidence that red wine may trigger a migraine because it contains tyramine which has been linked to migraine. Certainly many people with migraine avoid red wine. Tyramine is also found in other food products such as soft cheeses like camembert and brie.

Mild dehydration

Mild dehydration can have an impact on people who have migraine. It is recommended that you should drink at least 8 glasses of water per day. This is in addition to any other drinks you may have. Fizzy drinks can contain the sweetener aspartame which some people link to their migraine.

Exercise

Like sleep, exercise can both help to prevent migraine and conversely can be a trigger factor for some people. Regular exercise which is built up gently can help to prevent migraine. It also stimulates the body to release its own natural painkillers, as well as increasing the individual’s sense of well-being and general health. Sudden vigorous exercise, particularly for people who do not usually take exercise, can be a trigger factor.

Oral contraceptives

The use of contraceptives which contain hormones such as the contraceptive pill can trigger migraine for some women. Medical advice should always be sought if this occurs. If you already experience migraine you should tell your doctor this before you start taking hormonal contraceptives.

Teeth grinding

Some people grind their teeth during the night and find they awake with head pain. If this is the case it is worthwhile seeing a dentist as there are special mouth plates (splints) which can reduce the teeth grinding.

Physical conditions

Head injury – Specific head injuries can result in headaches and migraine.

Muscle tension – Tense muscles in the neck and shoulder areas can cause headaches and may be a premonitory symptom of the migraine starting.

 Coughing – Repeated coughing can lead to a migraine for some people.

A guide to recording your migraine attacks


Why keep a migraine diary?

 Recording details of your migraine attacks can be useful in:

  • helping the doctor make a diagnosis
  • helping you recognise trigger factors
  • assessing if your acute or preventative medication is working

 The records may include information on:

  • when the symptoms such as headache started
  • how frequently they occur
  • where the pain is located
  • the type of pain (e.g. throbbing, stabbing, piercing, etc)
  • if there are other symptoms (e.g. being sick or having visual problems)
  • the duration of attacks
  • treatment(s) that you have taken
  • effectiveness of the treatment(s)

It is helpful to record as many aspects of daily life as possible, such as:

  • what and when you eat (e.g. meal skipping)
  • medication you take for other conditions
  • vitamins or any health products you take
  • how much sleep you have
  • exercise you take
  • social and work activities
  • the effect of weather on your headaches
  • for females, details of their menstrual cycle.

In particular, the 6-8 hours before the migraine attack are particularly important to record.

Diary and records to keep

 Monthly diary

By keeping this diary over a period of 2 or 3 months you may see a pattern to your migraine attacks. The effect of different aspects of your lifestyle on your headaches may become clearer, and you may identify your trigger factors so you can try to avoid or minimise them.

 Migraine attack record

This is useful if you want to keep more detailed information about each attack you have. You can use this together with the monthly record to give more detailed information about each migraine attack.

An introduction to the use of medicines in treating migraine


Introduction

There are many medications available to treat migraine. It is useful to have some background information to help you make informed choices about which drug may be best for you. There is no standard treatment for migraine, so the choice of medication should always be made individualised. Whilst drugs may be necessary to treat your attack, an important factor in the overall management of migraine is finding out what may be causing it and exploring other non-medication strategies that can help you can manage it.

How do migraine drugs work?

Most migraine drugs act in changing the way cells function.

Understanding how drugs are classified

Drugs are classified in the following way:

  • the group name: according to their chemical similarity, their use or the way they work
  • the generic name: the name of the basic active ingredient
  • the brand name: the name chosen by the manufacturer

It is useful to be able to identify drugs by their generic names, especially with Over-The-Counter (OTC) preparations. This will give you a clearer idea of what you are choosing.

Different drug companies produce aspirin (for example) under different brand names. By knowing the generic name you may be able to stop you duplicating and taking more than one preparation with the same active ingredient.

Finding the right migraine drug for you

There are two groups of drugs for treating migraine:

  • acute medicines– treatment taken when the migraine starts
  • preventive medicines– treatment to prevent an attack.

Before taking any drug treatment

It is always important to read the patient information sheet supplied with the drug. This is important for a number of reasons:

  • some drugs cannot be taken if you have other medical conditions or are taking certain medications
  • some drugs can cause side effects which, although mild, are worth knowing about so you can inform your doctor if you experience them
  • some drugs interact with other drugs, food, or alcohol. This interaction may increase the drug’s effectiveness. Caffeine for example is sometimes added to improve the effectiveness of pain relief. On the contrary, some interactions can be harmful and can reduce the efficiency of the drug. Some herbal remedies can also interact in this way so it is important to inform your doctor of everything you are taking to help your migraine.

The combination of drugs

To get the best out of your medication you should always aim to take the right drug, at the right amount, and at the right time.

Take your medicine at the first sign of an attack, as soon as you start having symptoms.

The combination and method by which drugs are taken can make a difference to the time it takes for them to be absorbed into your system and to produce an effect. This can be a crucial factor in migraine, because when an attack takes hold the digestive system slows down. This could mean that drugs taken at the wrong time may not be properly absorbed and so will not be as effective.

Taking medications

Some people with migraine experience vomiting and find it difficult to take medication by mouth. There are various ways that drugs can be taken, including:

  • being swallowed
  • held under the tongue
  • by injection

Taking control

By keeping a record about all aspects of your migraine you be able to find out what works best for you. This may be a change in your lifestyle and / or the use of drugs. It is helpful to keep a record on as many aspects of your daily life as possible to see what may be a factor in triggering a migraine attack. This could include what and when you eat, exercise and patterns of sleep. Using this information combined with a record of the severity of the migraines you should be able to understand what may cause your migraine, the signals to look out for, what drugs work for you and when is the best time to take them.

Keeping a record of the drugs you are taking

With any drug treatment you should keep a record of the drugs you are taking. This will give you an idea about the type of drugs that work best for you. You should keep a record of the following:

  • generic name
  • date started
  • date finished
  • daily dosage taken
  • effectiveness
  • side effects (if any)

You should also include any vitamins, herbal products, tonics or supplements, inhalers, creams or ointments that you are using.

Medication-overuse headache

For many people, painkillers are a safe and effective way of treating headache or other pain.

If you have regular migraine you will most likely experience an attack once or twice a month. Sometimes an additional less severe headache may develop or the migraine attacks may become more frequent.

The pain and discomfort you are feeling every day means that you will be increasing your dosage of painkilling medications due to the development of tolerance (when your body becomes used to the drug so it stops being as effective.) This can then lead you into a process where the drugs are actually making your headaches worse and more frequent. This process is called ‘rebound phenomenon’.

It is vital that you seek medical advice when changing your medication in any way.

And you should only withdraw acute medications under medical supervision. This can help exclude any other underlying causes of the headache and help if you need to start taking a headache preventative medication as soon as you have withdrawn from your acute medication.

Drugs and pregnancy

You should be very cautious about taking drugs while pregnant or breast-feeding. Fortunately, many women’s migraine attacks improve in pregnancy, especially after the first three months. You should seek medical advice if you are pregnant whilst taking any medication.

Taken when an attack occurs to treat the symptoms


Introduction

These treatments can’t stop you from getting migraine but they can reduce your pain and other symptoms. Drugs called triptans have been designed especially for migraine attacks. Their main effect is to reduce the pain information coming to the brain. For a small percentage of people with headache, frequent use of drugs particularly ergotamine, triptans, codeine, paracetamol, NSAIDs and caffeine have been implicated in chronic daily headache and medication-overuse headache.  If you are experiencing four or more migraine attacks per month you should consider the use of preventive treatment to avoid attacks.

Analgesics (painkillers)

 Action

Analgesic drugs relieve pain and reduce stiffness associated with migraine.  The non-steroidal anti-inflammatory drugs (NSAIDs) also reduce inflammation by inhibiting the production of certain chemicals in the body. Analgesics tend to be more effective when taken as soluble, effervescent or liquid formulations because they are absorbed quicker (not all drugs are available in these forms). Enteric coated preparations are less suitable for treating migraine attacks because they are absorbed more slowly and therefore may take longer to work.

Codeine is an analgesic which blocks pain signals in the spinal cord and brain.

Caffeine is a weak stimulant that is often combined in small amounts with analgesics to enhance their effect.  However, there is evidence that caffeine can provoke headache and may result in headaches following its withdrawal after long term treatment.

Brand names

There are many different preparations of analgesics so the brand names are too numerous to mention. Several combination preparations are available.  The most commonly used contain aspirin or paracetamol combined with codeine, caffeine and/or an anti-emetic.

 

Non-steroidal anti-inflammatory drugs (NSAIDs)

Aspirin, Ibuprofen, Naproxen, Diclofenac, Mefenamic acid

 

Other painkillers’

Paracetamol, codeine phosphate

 

Anti-emetics (anti-sickness)

Domperidone, Metoclopramide, Prochlorperazine

Action:  Anti-emetics relieve the nausea associated with migraine attacks.

Metoclopramide and domperidone also promote normal activity of the gut and can accelerate the absorption of analgesics. They should be taken before or at the same time as analgesics.

 

Specific anti-migraine drugs

Serotonin (5-HT1) agonists or ‘Triptans’ (group name):

Sumatriptan, Rizatriptan, Zolmitriptan, Almotriptan, Eletriptan, Frovatriptan, Naratriptan

(availability depends on hospital formulary)

 Action

Selective 5-HT1 agonists relieve pain by blocking the transmission of pain in sensory nerves supplying the skin and structures of the face.

Sumatriptan has been available for the longest period of time.  If one triptan doesn’t work for you then it is worth trying a different one.

 

Ergot Alkaloids:

Ergotamine tartrate

 Action

The value of ergotamine for migraine is limited by difficulties in absorption and by its side effects particularly nausea, vomiting, abdominal pain and muscle cramps.  It is best avoided.

Recommended doses of ergotamine preparations should NOT be exceeded and treatment should not be repeated at intervals of less than four days.  To avoid tolerance, the frequency should be limited to no more than twice a month.  Patients should be warned to stop treatment if numbness or tingling of the extremities develops.  It is most effective if taken at the onset of a migraine attack.

 These are taken to prevent attacks


Introduction

If you are having at least four migraine attacks per month you may wish to discuss preventive options with your doctor.

It could take up to three months for the preventative effect of the drug to be felt. Therefore, if the drug did not relieve your migraine attack it does not mean that the drug itself did not work but that you need to give it some time. You must avoid overusing painkillers as this can make the headaches harder to treat.

It is important to note that some preventative drugs prescribed for your migraine may be licensed for other conditions such as high blood pressure, depression or epilepsy.

Migraine is a complicated condition which varies widely between individuals. What may work for one person may not for another and your migraine management plan will be individualised..

Doctors are unable to predict how an individual will respond to a particular treatment so this means you may need to try several different treatments until one is found that is the best at controlling your condition. Migraine is a condition for which, unfortunately, there is currently no cure.

 

Beta-blockers

Propranolol, Metoprolol, Atenolol, Nadolol, Timolol 

 Action

These drugs have several actions and are used to treat people with high blood pressure, but are also effective in treating migraine. They should be avoided by people with asthma. They reduce the activity of the brain cells involved in migraine.

 

Anti-serotonergic (Anti 5-HT) drugs

Pizotifen

Action

Serotonin (5-HT) is a chemical occurring in the body, which is thought to play a key role in migraine.  These drugs block 5-HT2 receptors to stop the effects of 5-HT. Pizotifen also has anti-histamine properties and is related to the tricyclic antidepressants.

 

Tricyclic antidepressants (TCAs)

Amitriptyline, Dosulepin, Nortriptylin

 Action

These drugs were previously used for depression, however, they are also effective at preventing migraine. They can be helpful in people with migraine who also have difficulty sleeping.

Tricyclic antidepressants are thought to:

Block the re-uptake of 5-HT and norepinephrine

Block 5-HT2 receptors.

 

Anti-convulsants

Sodium valproate, Topiramate, Gabapentin

 Action

Mode of action in migraine is unclear.  They may reduce the capacity of the nerves to transmit pain signals in the brain.

 

Non-steroidal anti-inflammatory drug (NSAID)

Naproxen sodium

Action

NSAIDs reduce inflammation by inhibiting the production of certain chemicals in the body.

They should not be used as long-term preventatives.

 

Calcium channel blockers (calcium channel antagonists)

Flunarizine

Action

Reduces calcium entry into neurons making them less ‘excitable’.  Blocks dopamine receptors in the brain.

 

Angiotensin II blockers

Candesartan

Action

Mode of action in migraine is unclear. They block the hormone angiotensin II. They are used in the treatment of hypertension.

Hormonal changes in women is a common trigger for those prone to migraine. This is often shown in pregnancy when the sex hormone levels show profound changes which have an impact on whether your migraine get better or worse. Oestrogen sometimes reaches one hundred times the normal level, whilst progesterone levels decrease, rising again towards the end of the pregnancy.

However, the fluctuation of levels is not as pronounced as during the non-pregnant state, which may be why migraine often improves during pregnancy. This improvement may also be due to the increased levels of natural pain-killing hormones (endorphins). These are several times higher during pregnancy, and though the relief from migraines they provide might last the whole pregnancy, the levels settle back down after delivery, normally allowing migraine attacks to recur.

However, it is not always the case that your migraine will improve, especially in the early weeks of pregnancy. For some women, migraine can go on unchanged, or more rarely even get worse. During breastfeeding, stable oestrogen levels may be protective against having headache again after pregnancy.

Planning a pregnancy

If you are taking regular medication for your migraine and are planning a pregnancy, you should see your doctor for advice on the management of your migraine before and during pregnancy, after the birth and while you breast feed.

Migraine without aura in pregnancy

Studies show that migraine without aura improves after the first three months of pregnancy for about 60-70% of women. This is the case especially if your migraine has been linked to your menstrual cycle.

Migraine with aura in pregnancy

If you experience migraine with aura you are more likely to continue to have attacks during your pregnancy. Also if you experience migraine for the first time while you are pregnant it is likely to be with aura.

If you do think you are experiencing migraine for the first time whilst you are pregnant it is important to visit your doctor so the causes for your head pain can be found and treated if necessary. Pre-eclampsia and other more serious causes of headache can have symptoms similar to migraine.

Conventional medication and pregnancy

If you are taking any preventive treatments you should discuss stopping these or switching to a safer alternative with your doctor. It is advisable to take as few drugs as possible in the lowest effective dose and ideally all drug treatments should usually be avoided whilst you are pregnant.

Most of the evidence for the safety of drugs in pregnancy is circumstantial as drugs cannot usually be tested on pregnant or breast feeding women for ethical reasons. This means the advice regarding drug treatments for migraine in pregnancy will usually err on the side of caution.

Ideally, all drug treatments should be avoided, as many are either considered unsafe or their safety has not been tested in pregnancy or breast feeding. The use of any drugs during pregnancy or while breast feeding needs to be discussed with your doctor, so that you can weigh up the relative risks and benefits of any treatment.

For treating a migraine attack as it begins, paracetamol is the drug considered safe during pregnancy and breast feeding. This should be taken in soluble form at the earliest signs of an attack, preferably together with something to eat. Aspirin has been used by many pregnant women in the first and second terms of pregnancy. Aspirin should be avoided nearer to the expected time of the birth as it can increase bleeding. Ibruprofen should not be taken in doses over 600mg per day.

Continued use of triptans is not recommended during pregnancy. Although the evidence from instances when pregnant women have taken triptans is reassuring, there is not yet enough evidence to recommend the use of triptans during pregnancy.

If you need anti-sickness drugs for your migraine, prochlorperazine has been widely used in pregnancy without evidence of harm. Domperidone and metoclopramide are safe in pregnancy, but they are probably best avoided in the first three months. Again, you will need advice from your doctor on what is best for you.

If none of these approaches work, it would be worth speaking to your doctor about a greater occipital nerve injection, which is a small injection of a local anaesthetic and steroid which is injected into the back of the skull, underneath the skin into the muscle around a large nerve which is involved in headache disorders. This is a quick procedure which can provide short to medium term relief, and can be organised through a headache neurologist. It is safe in pregnancy.

For preventive treatment, the lowest effective dose of propranolol is considered to present the lowest risk in pregnancy and breast feeding. Prolonged use may have adverse effects on the baby. Amitryptiline is a safe alternative, and there are no reports of adverse outcomes using pizotifen in pregnancy and breast feeding.

The first three months of pregnancy

During the first three months the symptoms of pregnancy can make your migraine worse. Morning sickness can mean that you feel like eating and drinking less which can cause low blood sugar and dehydration. If you are not careful this can make your migraines worse. You should try to eat small frequent meals and drink frequent small amounts of water to prevent this. You will also be helping reduce any pregnancy sickness.

After birth

For some women migraine returns with the return of their periods. Some mothers find they have a bad attack within a couple of days of giving birth. This may be due to the sudden drop in oestrogen levels after the birth. Exhaustion, dehydration, erratic sleep and low blood sugar after giving birth may all play a part.

Migraine and your baby

There is no evidence that migraine (with or without aura) has an effect on the outcome of the pregnancy. Migraine in a mother does not harm or endanger her baby.

Breastfeeding

If you breast feed your baby it is still best to avoid medication as far as possible because the baby will be taking whatever you take through the milk. The same drugs used in pregnancy can be taken whilst breastfeeding with the exception of aspirin. The aspirin which enters the breast milk could impair blood clotting in susceptible babies and so is best avoided.

If you need to take aspirin or other non-recommended medication, such as the anti-sickness drug metoclopramide, whilst you are breastfeeding it is best to not to breastfeed for 24 hours after the last dose. Ideally, keep some expressed milk in the freezer for such occasions; otherwise you will need to give formula milk. Although you may feel too unwell to do so, it is best to express milk at the usual feeding times but this will need to be thrown away. This can help ease discomfort as the breasts become engorged with milk and will help to prevent milk production diminishing.

The triptans almotriptan, eletriptan, frovatriptan, rizatriptan and sumatriptan are licensed for use during breastfeeding as long as you do not breastfeed your baby within 24 hours of the last dose so again you may need to express your milk and throw it away in this situation.

Complementary and alternative medicine

Many women prefer to take complementary and alternative medicines whilst they are pregnant. It is important to remember some complementary treatments can have an unwanted effect on your pregnancy just as conventional medicines can. For instance, some women find aromatherapy massage very helpful, and may be unaware that some essential oils (rosemary for example) need to be avoided. Reflexology treatment is not always advisable during pregnancy, and all complementary medicines should be taken under supervision of a qualified practitioner. Feverfew should not be used during pregnancy. Non-drug treatments certainly can be helpful, and massage, acupuncture, relaxation and biofeedback have been found to be useful by some. Some women also find applications of heat or cold to the head can be useful.

Conclusion

The best advice is to take as few drugs as is practically and realistically possible for you, and at the lowest effective dose. The use of any drugs or herbal remedy to treat your migraines during pregnancy and whilst breast feeding is a balance of risk and benefits. Always remember that if you are getting more than 2 or 3 headaches a week you should discuss this with your doctor rather than take over the counter painkiller as it is possible to develop a condition known as ‘medication overuse headache’. Any medication you do take should be recorded in your pregnancy notes. As far as you can: rest and that way avoid becoming over-tired. Not everyone is able to stop and go to bed, but planning ahead, setting a regular routine and delegating work or household tasks whenever possible can often help.

Botox is a treatment option for adults with chronic migraine


Introduction

Botox® (onabotulinum toxin A) was licensed specifically for the treatment of chronic migraine. Botox® has not been shown to be effective for any other headache type (e.g. episodic migraine, tension-type headache, cluster headache) as yet.

What is botulinum toxin?

Botulism – paralysis of muscles caused by high doses of botulinum toxin – was first described in 1817. The responsible bacterium, Clostridium botulinum, was not isolated until 1895. Seven different subtypes of botulinum toxin (A-G) are known. A highly dilute preparation of botulinum toxin type A (Botox®) was introduced in clinical practice in the 1970s and 1980s to treat squint and blepharospasm. Since then it has found uses in other areas of medicine including dystonia (including writer’s cramp), post-stroke spasticity, and hyperhidrosis.

Botulinum toxin and headache

In the mid-1990s a number of people reported improvement in headaches in patients receiving botulinum toxin for other reasons. Well-conducted clinical trials of botulinum toxin in various types of headache followed, but the results were disappointing, with no difference over placebo being found in tension-type headache, episodic migraine, and undifferentiated chronic headache. Detailed analysis of the results suggested, however, that there might be a subgroup of patients with chronic migraine who could benefit, and further trials were undertaken.

Botox® in chronic migraine: the PREEMPT trials

Two Phase 3 Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) trials recruited 1384 patients with chronic migraine, and randomised them to treatment with Botox® or placebo. These patients were suffering on average 20 days of headache each month, of which 18 were moderate or severe. Those randomised to Botox® received fixed-site, fixed dose injections every 12 weeks over 56 weeks. These injections covered seven specific areas of the head and neck, with a total dose of between 155-195 units. At six months, after two cycles of treatment, those treated with Botox® had on average eight less days of headache each month. After 12 months, 70% of those treated had ≤50% the number of headaches that they had done originally. Botox® was well-tolerated, the commonest side effects being neck pain (6.7%), muscular weakness (5.5%), and drooping of the eyelid (3.3%). No serious irreversible side effects have ever been reported in trials of Botox® in headache.

How does botulinum toxin work in chronic migraine?

Botulinum toxin inhibits pain in chronic migraine by reducing the expression of certain pain pathways involving nerve cells in the trigeminovascular system. The trigeminovascular system is a sensory pathway thought to play a key role in the headache phase of a migraine attack.

Unlike many of the other conditions in which it is used, it is not thought to work by relaxing overactive muscles. Botulinum toxin has been shown to reduce pain in a number of disease states, including cervical dystonia, neuropathic pain, lower back pain, spasticity, myofascial pain, and bladder pain.

Is Botox® right for me?

Only patients with chronic migraine are eligible for treatment with Botox®. Chronic migraine is defined as headaches occurring on 15 or more days each month, at least half of which have migrainous features. There are, however, other treatments available to patients with chronic migraine, and it is important that patients have an informed discussion of their headaches and the options for treatment with a practitioner experienced in the diagnosis and management of headaches before a decision to use Botox® is taken.

What is the treatment schedule like? How regularly are the injections administered?

In general, the current standard of care for the treatment of chronic migraine with Onabotulinum toxin type A (Botox®) is injections every 12 weeks. It is generally worthwhile having at least two treatment sessions to assess treatment response. If individuals have not responded by two to three treatment sessions it is generally considered that the individual is a non-responder. As experience increases with the use of Botox® as a preventative treatment for chronic migraine some clinicians are identifying that longer periods between injections may sometimes be acceptable.

The choice of 12 weeks between treatments with Botox® for chronic migraine is largely based on the pivotal research studies that were used to gain its treatment approval. In day-to-day clinical headache practice it is not unusual to vary the duration between Botox® treatments in some patients. Experience has shown that some individuals not only gain benefit over the 12 weeks following their last Botox® injection, but also sometimes for further weeks afterwards. In such scenarios doctors who administer Botox® may suggest increasing the time intervals between injections. However, it is difficult to generalise about such decisions as they are often made on an individualised basis.

In general terms cranial Botox® is usually administered approximately every 12 weeks due to the treatment response being considered more reliable over this time period. It is unfortunate when patients experience a wearing off effect of any preventative treatment effect 10 to 12 weeks after the last injection, but the logistics of care delivery i.e. clinic capacity, staff availability or other factors are sometimes responsible for extending the time between injections.

There is no good evidence to suggest that cranial Botox® is less likely to work if delayed more than 12 weeks. In fact, in patients who may be considered equivocal or borderline Botox® treatment responders, some headache clinics choose to wait a further month or two beyond 12 weeks to assess whether any relapse to more frequent migraine occurs compared to the immediate few months post treatment. This sometimes allows an assessment about whether further Botox® is actually needed.

The role of hormones and migraine

Migraines are more common in women than in men and the difference is more common in the reproductive years. The main reason for this is the role of the female sex hormone which implicates the menstrual cycle as a significant migraine trigger for women.

Sex hormones, oestrogen and progesterone, and the physical and chemical processes that go towards producing them, all have a widespread effect on your body. The contraceptive pill is made up of similar hormones there will be an effect on your migraines.

Some women are more sensitive to the fluctuations within the menstrual cycle. Migraine can be triggered by a drop in your oestrogen levels such as those which naturally occur in the time just before your period and the result of falling oestrogen levels in the later phase of the menstrual cycle.

Hormones and the contraceptive pill

Headaches are a common side-effect of taking oral contraceptives and this usually improves over time. They can be affected by the dose and type of hormone in the pill. Some women find that their headaches and migraines improve when they start the pill. Others notice that their headaches and migraine get worse. Studies suggest that headaches are less likely to occur with the lowest dose pills (20 micrograms of oestrogen) containing newer types of progestogens but this is not the same for everyone. It is important to find the pill that suits you best.

Types of oral contraceptives

It is important to understand the combinations of oral contraceptives available, to establish which is the best for you and the type of migraine you have.

There are two types of oral contraceptives:

Combined oral contraceptives

Progestogen-only pills.

 

Combined oral contraceptives

This type of contraceptive pill is made up of a combination of oestrogen, called ethinyloestradiol, and a progesterone, called progestogen. The pill was introduced over 40 years ago, and the amount of hormones is now much lower than in the past. This has meant that unwanted effects like headaches and migraines, are much less likely to occur. However, for many women their migraine attacks become more severe or frequent during the week they do not take the Pill. This is because the hormone levels drop at this time. The drop in oestrogen can trigger the migraine.

What to do

There are several ways to prevent headache or migraine that occurs only during the week that you don’t take the pill

Consider changing to a different type of pill with a different dose of ethinyloestradiol and/or a different type of progestogen.

You may find that by taking the pill continuously for at least 3 cycles followed by a 4 to 7 day break may help. This keeps the levels of oestrogen constant whilst you are taking the 3 packets. You should have less withdrawal bleeds per year and therefore fewer migraines.

You may wish to consider taking the pill continuously and never take a break.

Taking the pill continuously

Taking the pill continuously can stop migraines. However, because there is no controlled withdrawal bleed, unpredictable breakthrough bleeding may occur.

There is little evidence that the monthly breaks from the pill are associated with any added health benefits and that the benefits of reduced menstrual problems and increased efficacy are clear.

The combined contraceptive pill and the risk of stroke

If you suffer from migraine with aura you should not take the combined oral contraceptive pill. This is because the combined pill is associated with a very small increased risk of ischaemic stroke. This risk increases when the pill is taken by women who have additional risks for stroke, such as smoking and migraine with aura. Statistics show that the risk is extremely small but nevertheless, it is still a risk, which can be avoided. The risk from the pill is due to ethinyloestradiol, and not progestogen. So progestogen-only contraceptives are a safer alternative. Some of these are more effective contraceptives than the combined pill.

Progestogen–only pill

You may consider taking this form of contraception if you are unable to take the combined pill. Although this method suits many women, others find that erratic bleeding is a problem. This can, in turn, lead to more headaches.

Taking the pill and the risk of stroke

For most women the pill is a safe form of contraception. However, women who have high blood pressure or smoke cigarettes heavily are not advised to take the pill as they are at risk of developing a stroke and this is increased further by taking the pill. If you normally have migraine without aura and then you start to experience aura after starting the pill you should stop taking the pill and change to another form of contraception.

Migraine with aura and the pill

Studies have shown that there is an association with migraine with aura and ischaemic stroke. An ischaemic stroke occurs as a result of a reduction or loss of blood supply to part of the brain. As was stated earlier, this means that if you have migraine with aura you are at more risk of experiencing a stroke if you take the combined oral contraceptive pill. The risks are extremely small but nevertheless the risk is there and cannot be ignored. You can still use progestogen-only methods.

Other methods of contraception

No oestrogen

There are a range of progestogen-only methods of contraception around that are a safer alternative for women who cannot take combined hormonal contraceptives. Some of these, such as implants, injectable progestogens and one type of progestogen-only pill containing the progestogen desogestrel, act in the same way as the combined hormonal contraceptives in that they inhibit ovulation. You should discuss this with your family doctor. The list includes:

Implants – lasts for three years

Injection – lasts for three months

Progestogen – only pill – taken daily without a break

Intrauterine system – inserted into the womb and last for five years

 Non-hormonal methods of contraception

If you decide to switch to a non hormonal form of contraception there is a range of methods to choose from. You should consult your family doctor. You may choose the coil (copper intrauterine device), however this may make migraines worse as periods become heavier. Condoms and diaphragms have no effect on the hormonal pattern.

Taking oral contraception to control migraine

If your migraine is associated with premenstrual syndrome you may find that the combined oral contraceptive pill or the injectable contraceptive can help reduce migraine at this time in your cycle. As these hormones switch off the normal menstrual cycle the natural fall in oestrogen does not occur so premenstrual migraine should be alleviated or reduced.

We look at the evidence for supplements and herbs used in the management of migraine


Introduction

A variety of natural supplements, vitamins and herbal preparations have been promoted as having efficacy (being helpful) for migraine prophylaxis (prevention). Among the most commonly recommended vitamins and supplements are magnesium, riboflavin, and coenzyme Q10 (CoQ10). The most common herbal preparations are feverfew and butterbur.

Each of these compounds has a theoretical mechanism or reason for the effect on migraine, and has had at least one placebo-controlled trial that has demonstrated efficacy.

Magnesium

Adult human bodies contain about 24 grams of magnesium. Magnesium plays a vital role in multiple physiologic processes and therefore it is a vital component in a healthy diet. It is absorbed through the gastrointestinal tract (gut), with more absorbed when the internal content is lower. Magnesium also appears to facilitate calcium absorption. Spices, nuts, cereals, coffee, cocoa, tea, and vegetables are rich sources of magnesium. Leafy vegetables, as well as grains and nuts, generally have higher magnesium content than meats and dairy products.

No adverse effects have been associated with taking magnesium as a naturally occurring substance in foods. However, adverse effects have been seen with excessive magnesium intake as a consequence of the use of various magnesium salts for pharmacological/medicinal purposes. The primary manifestation of excessive ingestion of magnesium from non-food sources is diarrhoea, which is reversible and thus stops when you stop taking the magnesium.

Side effects from increased magnesium intake are not common because the body removes excess amounts.

 Interaction with other drugs

Some antibiotics, called aminoglycosides, can affect the muscles. Magnesium can also affect the muscles, so taking these antibiotics and magnesium might cause muscle problems. Magnesium might decrease how much antibiotic the body absorbs. Taking magnesium along with some antibiotics might decrease the effectiveness of some antibiotics. To avoid this interaction these antibiotics should be taken at least 2 hours before, or 4 to 6 hours after, magnesium supplements. Magnesium might decrease blood pressure. Taking magnesium with medication for high blood pressure might cause your blood pressure to go too low, also known as hypotension. Magnesium seems to help relax muscles. Taking magnesium along with muscle relaxants can increase the risk of side effects of muscle relaxants.

 Use for migraine

Studies have shown that migraineurs have low brain magnesium during migraine attacks and may also suffer from magnesium deficiency. Furthermore, magnesium deficiency may play a particularly important role in menstrual migraine. Two controlled trials have shown that oral magnesium supplementation (taking in by mouth) is effective in headache prevention. A third study was negative, but this result has been attributed to the use of a poorly absorbed magnesium salt, as diarrhoea occurred in almost half of patients in the treatment group. In general, the published trials yielded mixed results, with favourable effects reported for acute treatment of patients with aura and possibly also menstrual migraine prevention. Magnesium’s efficacy may depend on a “high dose” supplementation (over 600mg) for a minimum of 3 to 4 months to achieve any benefit from preventative therapy.

Feverfew

Feverfew (Tanacetum parthenium) is an herb that is available as an off-the-shelf remedy. Its yellow-green leaves and yellow flowers resemble those of chamomile (Matricaria chamomilla), with which it is sometimes confused. The herb feverfew has had a long history of use in traditional and folk medicine. Recently it has become a popular prophylactic treatment for migraine headaches and its extracts have been claimed to relieve menstrual pain, asthma, dermatitis, and arthritis. Traditionally, the herb has been used as an antipyretic (fever reducer), from which its common name is derived.

 Human safety data

If you have any health problems that may be treated with feverfew, consult your doctor before use. Caution is advised if you have diabetes, alcohol dependence or liver disease. Liquid preparations of this product may contain sugar and/or alcohol, and feverfew is not recommended for use in children under 2 years of age. Because of the potential risk to the infant, breast-feeding while using this product is not recommended, and feverfew is contraindicated during pregnancy.

 Potential side effects

Most adverse effects of treatment with feverfew are mild, although some patients have experienced increased heart rate. Feverfew possibly may interact with anticoagulants. A small percentage of people may experience mild stomach upset from feverfew, although this is rare. Chewing fresh feverfew leaves may lead to minor mouth ulcerations occasionally, an effect not observed with capsule users.

 Interaction with other drugs

It is advised to avoid use of feverfew when taking anticoagulant drugs. Feverfew is contraindicated to those allergic to other members of the family Compositae (Asteraceae) such as chamomile, ragweed, or yarrow.

Use for migraine

Seventeen migraine patients who already used feverfew daily as migraine prophylaxis enrolled in a controlled trial in which 8 patients continued to receive feverfew while  stopped taking their feverfew and received placebo treatment instead (i.e. untreated patients). Those who received placebo had a significant increase in the frequency and severity of headache (an average of 3.13 headaches every 6 months when taking placebo vs. only 1.69 headaches every 6 months when taking feverfew), nausea, and vomiting, whereas there was no change in the group receiving feverfew. In a larger study of 72 patients, feverfew was associated with a 24% reduction in the mean number and severity of attacks although the duration of the individual attacks was unaltered.

 Coenzyme Q10 (CoQ10)

Coenzyme Q10 (CoQ10) is often described as a vitamin, or a vitamin-like substance. CoQ10 is involved in the creation of the important substance in the body known as adenosine triphosphate (ATP). ATP serves as the cell’s major energy source and drives a number of biological processes including muscle contraction and the production of protein. CoQ10 also works as an antioxidant.

Some food sources, such as meat and fish, contain CoQ10 but the amounts in food are naturally less than can be obtained from supplements. Primary dietary sources of CoQ10 include oily fish (such as salmon and tuna), organ meats (such as liver), and whole grains. Most individuals obtain sufficient amounts of CoQ10 through a balanced diet, but supplementation may be useful for individuals with particular health conditions.

If you use or are planning to use CoQ10 for any specific health condition, you may want to let your doctor know. It appears to be safe, and when taken by healthy volunteers in a trial at different doses over 4 weeks did not cause safety concerns or adverse events. Other safety assessments have been favourable, but it seems sensible to avoid supplementation in pregnancy.

No toxicity has been reported with supplements up to 600 mg for every kg of body weight. Minor side effects that may occur with supplementation (but are unusual) include a burning sensation in the mouth, loss of appetite, nausea and diarrhoea. In large studies the incidence of gastrointestinal side-effects is less than 1%.

 Interaction with other drugs

Cholesterol-lowering drugs such as lovastatin block the natural synthesis of CoQ10, so supplementation of 100 mg/day is recommended while taking these drugs.

 Use for migraine

Thirty-two patients diagnosed as having migraine with or without aura were treated with CoQ10 at a dose of 150 mg per day in a controlled experiment. No adverse events were associated with CoQ10 therapy in any of the trial participants. As a result of the treatment, 61.3% of the patients treated had a greater than 50% reduction in number of days with migraine headache. Only two participants showed no improvement with CoQ10 therapy in their migraine headache intensity compared with baseline (ie when the trial started). The average number of days with migraine headache during the baseline non-treatment phase was 7.34 and this decreased to 2.95 days by the end of the trial. The reduction in migraine frequency after 1 month of treatment was 13% and this improved to 55% by the end of 3 months of therapy. From this open-label (called “open” as participants were aware of whether they were taking CoQ10 or not) investigation, CoQ10 appears to be a good migraine preventive. The data presented in this trial suggest that CoQ10 starts to work within 4 weeks but usually takes 5 to 12 weeks to yield a significant reduction in days with migraine. An important finding from this study is that taking CoQ10 appears to be associated with no significant adverse events and is extremely well-tolerated. In another study migraine attack frequency after 4 months of treatment was reduced at least 50% in 48% of patients as compared to 14% for placebo. CoQ10 supplementation may be particularly effective in the treatment of childhood migraine.

 Coenzyme Q10 (CoQ10)

Coenzyme Q10 (CoQ10) is often described as a vitamin, or a vitamin-like substance. CoQ10 is involved in the creation of the important substance in the body known as adenosine triphosphate (ATP). ATP serves as the cell’s major energy source and drives a number of biological processes including muscle contraction and the production of protein. CoQ10 also works as an antioxidant.

Some food sources, such as meat and fish, contain CoQ10 but the amounts in food are naturally less than can be obtained from supplements. Primary dietary sources of CoQ10 include oily fish (such as salmon and tuna), organ meats (such as liver), and whole grains. Most individuals obtain sufficient amounts of CoQ10 through a balanced diet, but supplementation may be useful for individuals with particular health conditions.

If you use or are planning to use CoQ10 for any specific health condition, you may want to let your doctor know. It appears to be safe, and when taken by healthy volunteers in a trial at different doses over 4 weeks did not cause safety concerns or adverse events. Other safety assessments have been favourable, but it seems sensible to avoid supplementation in pregnancy.

No toxicity has been reported with supplements up to 600 mg for every kg of body weight. Minor side effects that may occur with supplementation (but are unusual) include a burning sensation in the mouth, loss of appetite, nausea and diarrhoea. In large studies the incidence of gastrointestinal side-effects is less than 1%.

 Interaction with other drugs

Cholesterol-lowering drugs such as lovastatin block the natural synthesis of CoQ10, so supplementation of 100 mg/day is recommended while taking these drugs.

 Use for migraine


Thirty-two patients diagnosed as having migraine with or without aura were treated with CoQ10 at a dose of 150 mg per day in a controlled experiment. No adverse events were associated with CoQ10 therapy in any of the trial participants. As a result of the treatment, 61.3% of the patients treated had a greater than 50% reduction in number of days with migraine headache. Only two participants showed no improvement with CoQ10 therapy in their migraine headache intensity compared with baseline (ie when the trial started). The average number of days with migraine headache during the baseline non-treatment phase was 7.34 and this decreased to 2.95 days by the end of the trial. The reduction in migraine frequency after 1 month of treatment was 13% and this improved to 55% by the end of 3 months of therapy. From this open-label (called “open” as participants were aware of whether they were taking CoQ10 or not) investigation, CoQ10 appears to be a good migraine preventive. The data presented in this trial suggest that CoQ10 starts to work within 4 weeks but usually takes 5 to 12 weeks to yield a significant reduction in days with migraine. An important finding from this study is that taking CoQ10 appears to be associated with no significant adverse events and is extremely well-tolerated. In another study migraine attack frequency after 4 months of treatment was reduced at least 50% in 48% of patients as compared to 14% for placebo. CoQ10 supplementation may be particularly effective in the treatment of childhood migraine.

Riboflavin

Riboflavin, also known as vitamin B2, is found in small amounts in many foods. It is needed for converting food to energy, and like CoQ10 also works as an antioxidant by mopping up the damaging free radicals.

Lean meats, eggs, legumes, nuts, green leafy vegetables, dairy products, and milk provide riboflavin in the diet. Breads and cereals are often fortified with riboflavin. Because riboflavin is destroyed by light, foods with riboflavin should not be stored in exposed glass containers. Riboflavin is stable when heated but will leach into cooking water, and the pasteurisation process causes milk to lose about 20% of its riboflavin content. Alkalis, such as baking soda, also destroy riboflavin.

 Human safety data

No toxic symptoms have been reported at doses of up to 400 mg per day for at least 3 months, other than occasional minor side effects that were not clearly attributable to the compound. Because riboflavin is a water-soluble vitamin, excess amounts are excreted, and harmless yellow discoloration of urine occurs at high doses. While apparently non-toxic at any dose in adults, and while foetal toxicity is unproven, riboflavin supplementation in pregnancy is not always recommended so please check with your health visitor.

 Potential side effects

In general the limited capacity of adults to absorb riboflavin taken by mouth limits its potential for harm. Possible reactions to very high doses (over 400 mg) include itching, numbness (insensitivity), burning/prickling sensations, and yellow discolouration of the urine. Individuals who have inadequate food intake are at risk of deficiency, particularly children in developing countries. It is thought that riboflavin also aids the body in absorbing iron, since it is common for iron deficiency to accompany a deficiency in riboflavin.

Interaction with other drugs

Riboflavin is necessary for the activation of vitamin B6. Sulfa drugs, anti-malarial drugs, oestrogen and alcohol may interfere with riboflavin metabolism. High doses of riboflavin can reduce the effectiveness of the anticancer drug methotrexate, whilst some antibiotics and phenothiazine drugs may increase riboflavin excretion. Riboflavin must be activated in the liver which may be inhibited by major tranquilizers and some antidepressants.

 Use for migraine

In the only study involving riboflavin alone, Schoenen and others studied 55 migraine patients and reported that 59% of the participants who took 400 mg/day riboflavin for 3 months experienced at least 50% reduction in migraine attacks compared with 15% for placebo13. Statistically significant reductions in both migraine frequency and number of headache days were reported. Adverse events reported from studies investigating riboflavin have been limited to diarrhoea and polyuria (passing of large volumes of urine), both occurring in extremely low numbers.

Butterbur (Petasites hybridus)

Butterbur products are linked with liver toxicity and should not be used.


I  am pregnant / breastfeeding and experiencing migraine; I feel that it would be better for me and my baby to use a ‘natural’ remedy, is there any scientific data to help me decide?

Pregnancy and lactation are situations that warrant special consideration in the treatment of the migraine. Although migraines generally improve during pregnancy, headaches may worsen or remain the same in some women. An increase in headaches during the first trimester is not uncommon, due to wide fluctuations in oestrogen levels.

Women of reproductive age should be counselled about the risks of acute and preventative migraine medications. Owing to the limitations on pharmacologic treatment of migraine during pregnancy and lactation non-drug approaches such as regular exercise and lifestyle changes are the first issues to consider. Maintaining hydration is also crucial, especially for those in whom nausea and vomiting are prominent. These women should avoid herbal remedies, including feverfew and butterbur as there may be unidentified risks for the unborn baby.

For women who continue to have frequent headaches during pregnancy and lactation, magnesium supplementation is an option, both in acute and preventative treatment. For acute migraine treatment, the dose is much lower than with some other health conditions. Supplementation is unlikely to be associated with adverse effects.

We look at the key issues for women who experience migraine during the onset of their menopause


Midlife

At least 90% of people with migraine start having attacks before the age of 40. Most people have their first attack during their teens or early twenties. It is rare for migraine to start later in life. Typically, migraine becomes less severe and frequent, and may even disappear, by around the age of 50. For some women this is associated with their menopause, for others it may be retirement or reduced stress.

The impact of the menstrual cycle

Around 50% of women with migraine say their menstrual cycle directly affects this. The whole menstrual cycle, not just your period, is associated with biological changes in your body, both physical and psychological. Sex hormones, oestrogen and progesterone, and the physical and chemical processes that go towards producing them, all have a widespread effect on your body.

It has long been recognised that there is a close relationship between female sex hormones and migraine, and that some women are more sensitive to the fluctuations within the menstrual cycle such as the time just before your period when, studies suggest, migraine attacks can be the result of falling oestrogen levels in the later phase of the menstrual cycle. Factors such as prostaglandin (a naturally occurring fatty acid that acts in a similar way to a hormone) release may also be implicated at this time.

The onset of the menopause

From about the age of 40 onwards, you become less fertile as your ovaries gradually stop producing eggs each month. The time from when your periods become irregular until they stop is called the peri-menopause. The menopause marks the time when your periods stop completely. This process can last as long as twenty years. The average age for the menopause is between 51 and 52 years with a range of 40 to 60 years.

You may find that your migraine attacks are linked to your periods during the peri-menopause. The ovaries produce less oestrogen and changes in your hormone levels can make your migraine attacks become more severe or happen more often.

Menopause makes migraine worse for up to 45% of women, 30-45% do not notice a difference and 15% notice an improvement. Some women find their attacks continue to follow a cyclical pattern years after the menopause and the reason for this is unclear.

It is recognised that the hormonal cycle can continue for some years after the last menstrual period, although the hormone changes are not sufficient to result in menstruation but could still provoke migraine. In these cases, hormones as a trigger factor for migraine should settle within 2 to 5 years after the menopause.

Other non-hormonal triggers may become more obvious after your menopause, as well as additional ones that develop such as neck tension. These may provoke attacks in a cyclical pattern. This works on the pattern of an individual having a “threshold” to migraine and different factors building up over time to cross the threshold and trigger migraine.

The menopause can be a difficult time for women with migraine. The irregularity of your periods can make it harder to cope with your migraine as they may be more difficult to predict. Typically the problems that can be experienced at the menopause (hot flushes and night sweats) result in disturbed sleep, adding to your stress levels and therefore increasing the likelihood of you experiencing a migraine.

Keeping a diary

Keeping a diary for three months is a helpful way to see if there is any link between your migraine, your periods and your menopausal symptoms. After three months you can review your diary and see if your migraine can be managed better. It is helpful to take your diary to show your GP so that you can discuss the best course of action to manage your migraine and your menopause.

Hormone replacement therapy (HRT)

HRT is given to women to treat symptoms of the menopause such as hot flushes and night sweats. There is little research evidence to be found on the effects of HRT on migraine in women. It can help some women but may aggravate it for others. HRT is not suitable or necessary for every woman, nor is it a problem free treatment. If you decided to try HRT it is important to try it for three months to give your body the time to find its balance. Being a woman with migraine is not in itself a reason to avoid HRT although other health issues may need to be considered such as the incidence of breast cancer in your family.

HRT if taken in a way that suits you with the right dose can often help peri-menopausal migraine. If you need HRT for menopausal symptoms but develop headaches as a result of the treatment managing your headaches can be difficult. It is not, however, impossible. You will need to work with your medical practitioner to find the right dose and the right hormone balance. Also, by trying different methods of taking HRT you can help to find the best course of treatment for you.

There are many different types of HRT available and the effect on migraine can vary depending on the type used. So, for example, you may find that switching from pills to patches improves your headaches. Non-oral forms of HRT provide the most stable levels of hormone and are usually better for women with migraine. These can be in the form of a skin patch or gel which you rub on your skin.

If one type does not suit you, it is well worth trying another. HRT containing the lowest dose of oestrogen that will effectively control your menopausal symptoms and produce the most stable levels of oestrogen should be used if your migraine becomes worse following HRT.

What are the risks of HRT for women with migraine?

There is no current evidence to suggest that women who have migraine and are using HRT have an increased risk of having a stroke. Most doctors recommend that you start HRT around the time of the menopause and take it only for a few years. It can have the benefit of reducing the risk of osteoporosis and bone fractures.

Non drug treatments

 Lifestyle

If you are experiencing menopausal symptoms which are distressing it is worth remembering that these and your migraine can be helped by regular gentle exercise and a healthy diet. This can also help protect you against other diseases such as heart disease and osteoporosis.

Surgical menopause

Menopause brought on by surgery does not usually improve migraine and it may even make it worse, especially if the ovaries are removed as well as the womb (hysterectomy). If a hysterectomy is required for other medical reasons, the effects may sometimes be reduced by oestrogen replacement therapy.

Try and keep drug treatments to a minimum as your body may not tolerate drugs as well as you get older, especially if you are taking drugs for other medical conditions. In addition, any other co-existing medical condition can become another trigger for migraine. Although a few women continue to have regular attacks after their menopause, for most women the end of a natural menopause can be a time of significant improvement in migraine.

Migraine can improve with age, but unfortunately this is not the case for everyone


We often hear from migraine sufferers that they expected their migraine attacks to get better as they got older. Unfortunately this is not the case for everyone and there are many people with migraine in their 60s, 70s, and 80s. Here we look at the key questions about migraine in older age.

Migraine and age

Migraine often occurs for the first time in your teens or early 20s. It is most common in the 30 to 40 age group. At least 90% of people with migraine experience a first attack before the age of 40.

Generally it is true that migraine improves as we get into our 50s and 60s. Studies show 40% of people with migraine no longer have attacks by the age of 65. Before the menopause, three times as many women as men have migraine. After 60, when hormonal factors are less likely to play a role, twice as many women as men have migraine.

It is therefore reasonable to expect your migraines to get better as you get older, however, the total number of people with migraine in later life is considerable in many populations worldwide.

Can migraine occur for the first time in later life?

It is rare, but not impossible, for migraine to occur for the first time later in life. If new migraine-like symptoms develop for people over 60, underlying disease may be responsible. In a study of older patients with new migraine-like headaches, five out of 69 patients had an abnormality which showed on a scan. Doctors will be cautious when considering a new diagnosis of migraine for a person over 60.

Can migraine symptoms change over time?

Migraine symptoms can change throughout a person’s lifetime. Attacks of migraine aura without development of headache are relatively common as migraine sufferers get older. Pain may not be as severe, symptoms may be less intense, or attacks may reduce in frequency. It is possible to have attacks in your teens or twenties, which return after years of being migraine free. This is less likely to be of concern than headaches starting for the first time, or if symptoms begin to change a great deal.

What if you have more than one health condition?

As we age, the likelihood of developing medical conditions increases, sometimes with implications for migraine treatment. Conditions such as hardening of the arteries (atherosclerosis), high blood pressure, diabetes, heart disease or stroke, may have implications for the management of migraine. In addition, having another health condition can be an additional trigger for migraine, whilst treating the co-existing health condition may help reduce migraine attacks. Some frequently asked questions are about migraine and stroke, depression, cognition, vertigo or epilepsy.

Migraine and other conditions

Migraine and stroke

Migraine, especially with aura, has been found to be a small risk for ischaemic stroke (that is, stroke due to a reduced blood supply sometimes due to a clot) in women under 35 though not haemorrhagic stroke (where a damaged or weakened artery bleeds into nearby tissue). However, migraine is not more common in older people who have had an ischaemic stroke. One study has suggested a higher cardiovascular risk profile in people with migraine, particularly with aura, than those without migraine. The risk is thought to be relevant only to women with migraine with aura and the majority of people with migraine have migraine without aura. However, although these data provide support, as do previous studies, for an association between migraine aura and ischaemic stroke, it is not possible to make any strong inference in the absence of more detailed research.

Migraine is considered to be insignificant as a risk for stroke over the age of 50, compared to more important age-related factors. It is important that everyone over 45 remembers that a sensible diet, good blood pressure control and not smoking are worth the effort as they are all risk factors that can be controlled for heart disease and stroke.

Migraine and depression

People with migraine are more likely to have depression. People who have had depression at any time in their lives are more likely to continue to have migraine attacks in older age.

 Migraine and cognition

Migraine causes significant and often frequent disruptions of the physiology of the brain and there is a higher incidence of brain lesions in people with migraine with aura (though this does not seem to have a clinical consequence). Some people worry that this will eventually cause cognitive decline (meaning decline in reasoning or problem solving). However studies have failed to find a relationship between migraine and cognitive decline. Even a long history of severe migraine does not seem to impair cognition. It is very unlikely that migraine and cognitive impairment in older people are related.

 Migraine and vertigo

There is evidence to suggest a condition related to migraine called ‘migraine–related vertigo’ or ‘migrainous vertigo’. In this condition, a person with migraine experiences a sensation of spinning or turning that interferes with daily life. Usually, the onset of this type of vertigo is delayed beyond the start of migraine symptoms, by months or years. Dizziness is a common complaint and seems to increase with age. However the occurrence of migraine-related vertigo is most common in the 40s in men and between the 30s and 40s in women.

People with Meniere’s disease more often have migraine than people without Meniere’s disease. About half of people with Meniere’s disease experience attacks of dizziness with migraine-like symptoms. Often, migraine symptoms will have been experienced for some time – sometimes up to 30 years or more – before the onset of Meniere’s disease.

 Migraine and epilepsy

There has been little research carried out so far concerning older people who have both migraine and epilepsy. For those who have both conditions, it may influence the choice of preventative migraine treatment, as some medicines can treat both conditions.

Managing your migraine

As with migraine experienced at any age, it is always worth being aware of what may be triggering your migraines and taking steps to reduce your exposure to these triggers where possible. Trigger factors can change over time and new triggers may be discovered if your circumstances change. Stress and red wine may be implicated at times whereas neck and back problems, and other health conditions, may be more significant at other times.

If you visit a health professional for advice in managing your migraine, it is very useful to keep a migraine diary before the appointment and take this along. You can simply block out days in different colours to distinguish migraine days, other headache days and headache-free days. This helps to show the pattern of symptoms and is useful for your doctor. You can also use migraine diaries to identify trigger factors although this is not always easy. It is thought that people with migraine have a more than usually sensitive nervous system that reacts to factors to which you are sensitive. Frequently mentioned migraine trigger factors include: hunger, bright or flickering light, stress and changes of routine. Almost any factor can trigger an attack in a person predisposed to migraine and the list of possible suspects can be long and confusing. However it is worth persevering as reducing your exposure to your personal trigger factors can mean you are less vulnerable to a migraine attack.

Treatment for migraine in later life

Treatment of migraine may not be straightforward in older age. That may be due to taking a number of different medications or having more than one health condition.

Health professionals have less information to rely on when prescribing medication for migraine in older people. Drug trials are usually carried out on healthy young adults so often less is known about how a drug may work or react in a child or an older person. This can reduce the number of treatment options available. Your doctor will need to take into consideration any other health conditions you may have and medications you might already be taking.

Make sure that your doctor knows what medication you are currently taking, including over the counter treatments and herbal remedies, especially if you are starting new medication.

The likelihood of side effects from medication can increase during older age. Getting older involves several changes that together alter the responses to medicines. These include changes to the digestion, liver, kidneys and vascular system. As we get older we are more likely to experience side effects from drugs. The significance of a particular side effect can change. For example if a drug has a side effect of dizziness, this could be of more concern to a person who may also be at risk of falling, than another younger person for whom the same side effect may not be as serious.

Medication taken for other health problems can cause headaches as a side effect, and this is often an unrecognised cause of headaches in older people. Drugs with the potential to trigger headaches include those used to treat certain heart conditions. Some drugs used for high blood pressure can worsen headaches, but others, such as beta blockers, can treat both. Be aware also that drugs may interact causing unwanted side effects or reduced efficacy. If you find your headaches increasing and you take several different drugs for medical conditions other than headache, it is worth checking with your doctor or pharmacist whether these medicines are a possible cause of some of your headaches.

Managing your migraine

As with migraine experienced at any age, it is always worth being aware of what may be triggering your migraines and taking steps to reduce your exposure to these triggers where possible. Trigger factors can change over time and new triggers may be discovered if your circumstances change. Stress and red wine may be implicated at times whereas neck and back problems, and other health conditions, may be more significant at other times.

If you visit a health professional for advice in managing your migraine, it is very useful to keep a migraine diary before the appointment and take this along. You can simply block out days in different colours to distinguish migraine days, other headache days and headache-free days. This helps to show the pattern of symptoms and is useful for your doctor. You can also use migraine diaries to identify trigger factors although this is not always easy. It is thought that people with migraine have a more than usually sensitive nervous system that reacts to factors to which you are sensitive. Frequently mentioned migraine trigger factors include: hunger, bright or flickering light, stress and changes of routine. Almost any factor can trigger an attack in a person predisposed to migraine and the list of possible suspects can be long and confusing. However it is worth persevering as reducing your exposure to your personal trigger factors can mean you are less vulnerable to a migraine attack.

Treatment for migraine in later life

Treatment of migraine may not be straightforward in older age. That may be due to taking a number of different medications or having more than one health condition.

Health professionals have less information to rely on when prescribing medication for migraine in older people. Drug trials are usually carried out on healthy young adults so often less is known about how a drug may work or react in a child or an older person. This can reduce the number of treatment options available. Your doctor will need to take into consideration any other health conditions you may have and medications you might already be taking.

Make sure that your doctor knows what medication you are currently taking, including over the counter treatments and herbal remedies, especially if you are starting new medication.

The likelihood of side effects from medication can increase during older age. Getting older involves several changes that together alter the responses to medicines. These include changes to the digestion, liver, kidneys and vascular system. As we get older we are more likely to experience side effects from drugs. The significance of a particular side effect can change. For example if a drug has a side effect of dizziness, this could be of more concern to a person who may also be at risk of falling, than another younger person for whom the same side effect may not be as serious.

Medication taken for other health problems can cause headaches as a side effect, and this is often an unrecognised cause of headaches in older people. Drugs with the potential to trigger headaches include those used to treat certain heart conditions. Some drugs used for high blood pressure can worsen headaches, but others, such as beta blockers, can treat both. Be aware also that drugs may interact causing unwanted side effects or reduced efficacy. If you find your headaches increasing and you take several different drugs for medical conditions other than headache, it is worth checking with your doctor or pharmacist whether these medicines are a possible cause of some of your headaches.

Migraine medicines for older people

Acute migraine drugs

Paracetamol can be used by older people with migraine, but your doctor may monitor liver function if you are taking it regularly in doses over 3 grams a day. If there are concerns about liver or kidney function, the dose may be reduced by 50 – 75%. Aspirin should be used with caution due to the risk of gastric ulcer or bleeding. Sometimes a painkilling drug will have caffeine added to increase effectiveness, this does not lead to increased side effects.

Non-steroidal anti-inflammatory drugs, such as ibuprofen and diclofenac, should be used with caution, if at all, by older people. Codeine, and other opioids, should be used with caution as they cause drowsiness and other side effects. If you use these medicines, your doctor will start with a low dose and increase the dose slowly until the lowest effective dose is found.

Medicines for sickness during migraine attacks such as metoclopramide can increase the possibility of side effects, called extrapyramidal side effects, such as involuntary movements or tremor.

Ergotamine should be avoided or used with caution because of its side effects.

 Can I take triptans after 65?

One action of triptans is to constrict blood vessels so there is a concern that any diseased blood vessels may also be constricted, such as those in the heart. As we age, blood vessels become narrower, and drugs that further narrow blood vessels should be avoided. Some people are more at risk than others, but it is not always easy to identify who may be affected. There is a general recommendation that those over 65 avoid taking triptans and this is largely based on a lack of systematic studies. It does not necessarily mean that you cannot take triptans. An older person should receive an evaluation for risk before triptans are prescribed.

Preventive drugs for migraine

These are some of the drugs you may be prescribed:

  • Tricyclic antidepressants, such as amitriptyline and nortriptyline, should be used with caution. The doses used for migraine are lower than for treating depression so there is less likelihood of side effects. Nortriptyline is associated with fewer side effects
  • Beta-blockers – use may be limited as they influence other medical problems and the dosage of propranolol needs to be altered from that taken by a younger person
  • Sodium valproate– side effects are more common in older age
  • Topiramate– risk of side effects in all ages
  • Lisinopril and candesartan– sometimes prescribed for high blood pressure, should be used with caution as they can cause kidney problems
  • Calcium channel blockers– dosage needs to be adjusted for older people as side effects are more common.

Sometimes a doctor will prescribe a course of preventative migraine drugs for people who have frequent attacks of migraine aura symptoms without subsequent development of headache.

Can migraine cause any long-term damage?

There is no firm evidence at present that having migraine will cause any permanent damage to your brain.

Headaches specific to later life

Headache is a common symptom and can occur at different times for many reasons. Headaches such as migraine and tension-type headache remain common at all ages. Some headaches are specific to older age.

Some severe and incapacitating headaches can mimic migraine but may be due to another health condition. If you have a new kind of headache occurring for the first time, always see your doctor, even if you have had migraine in the past.

 The types of unusual headache include:

 Hypnic headache

This is a rare type of headache, which usually affects people over 50, called hypnic headache syndrome. Hypnic headaches occur exclusively at night, waking you from your sleep. The pain can be either on one or both sides of the head. The pain (sometimes described as throbbing) begins abruptly and typically lasts about 30-60 minutes.

It is more common amongst women than men. The pain is not associated with autonomic features (such as a blocked nose or watering eyes) like cluster headache, nor are nausea, and sensitivity to light and noise, usually associated with hypnic headache as they are with migraine.

Temporal arteritis

This condition is rare in young people, usually affecting those over the age of 50, particularly women. Its cause is unknown. In this condition, the arteries in the temples and elsewhere become inflamed and swollen. The arteries beneath the skin of the temples become painful, particularly when touched, and the skin over the artery becomes red. A headache is a symptom of temporal arteritis, the pain is on one or both sides of the head and is worse over the affected blood vessels. In some cases, chewing causes pain in the muscles of the jaw.

If you suspect that you may have temporal arteritis it is really important that you seek medical advice as an emergency. The disorder may affect blood vessels inside the head such as the temporal artery, which supplies the eye, and permanent blindness may result. Your doctor can do a simple blood test to help confirm the diagnosis. Occasionally it is necessary to take a small sample of the affected blood vessel. Steroids ease the pain rapidly and prevent blindness developing. This treatment needs to be continued for some time.

Trigeminal neuralgia

Trigeminal neuralgia is more common in older people, affecting slightly more women than men. The pain is restricted to a nerve in the face, which causes sudden spasms of severe shooting pain in the cheek and jaw which last for only a few seconds. This spasm of pain is often described as being like an electric shock, and occurs in bouts every day for several weeks or months.

Triggers for this pain include chewing, cleaning your teeth, shaving and cold wind on your face. The condition is usually controlled with a drug called carbamazepine. A few people with trigeminal neuralgia do not get relief from the pain and may need surgical treatment.

Conclusion

Many people continue to have migraine attacks in older age. Special attention should be paid to the diagnosis of new migraine-like symptoms, especially visual migraine symptoms without headache. Any other co-existing health conditions have an important role not only in diagnosis but also in treatment choices. Acute and preventative medication should be chosen carefully. Effective treatment is available and, as for all age groups, careful management improves the quality of life.

Exercise and its effects on the management of migraine


Although some patients’ experience is that exercise triggers a migraine attack, increasing data from the research suggests that moderate regular exercise can be an effective way to reduce the frequency of attacks.

Introduction

The therapeutic effects of exercise are well documented. Regular physical activity will improve your overall health and reduce the risk of developing diseases like high blood pressure, diabetes, depression and obesity. Benefits also include reducing stress, reducing cholesterol levels, improving the quality of sleep patterns and producing a feeling of wellbeing.

If you are prone to migraine you may have found that strenuous exercise can provoke an attack. This may have led you to avoid exercise as you have identified it as a trigger. If this is the case then you are missing out on the benefits that exercise can bring to your overall wellbeing.

Moderate exercise can reduce the frequency and severity of migraine attacks in some people. Regular  exercise can be effective in preventing migraine.

Studies have shown that exercise changes the levels of a wide range of body chemicals. Exercise stimulates your body to release natural pain controlling chemicals called endorphins and natural anti-depressant chemicals called enkephalins. This could mean that embarking on a well planned exercise program could enable you to reduce your drug intake, particularly drugs taken daily to prevent migraine (prophylactic medicine).

Exercise as a trigger

You may well feel that all this talk about exercise and its benefits are wasted on you as you are one of those people who find that exercise gives you migraine.

If you have found that exercise has triggered an attack it could be due to the following reasons:

  • You start exercising suddenly with no prior planning which means that your body has a sudden demand for oxygen.
  • You have not eaten properly before exercising so that your blood sugar level falls as you become very hungry.
  • You have not taken sufficient fluids before and during exercising so your body becomes dehydrated.
  • You start a strenuous ‘keep fit‘ programme at the same time as ‘healthy’ new diet . If not managed properly, these changes to your lifestyle can act as an additional trigger.
  • You undertake strenuous infrequent exercise which causes stiff, aching muscles which can then act as a trigger.
  • You experience a minor blow to your head during sport, for example you may be hit by or head a football. This can trigger an instantaneous migraine aura.
  • A headache can be brought on by and occur only during or after strenuous exercise.  This is called exercise headache (previously referred to as exertional headache) and may last from 5 minutes to 48 hours after the exercise. It tends to occur in hot weather or at high altitude.

Choosing the right type of exercise

Mild regular aerobic exercise offers the most benefits to those with migraine. Remember, it is important to choose an exercise activity that you enjoy. It could be:

  • Jogging
  • Swimming
  • Dancing
  • Cycling
  • Brisk walking

At the start of your new exercise regimen it is best to avoid activities which are too strenuous or competitive until you are fitter, but moderate intensity (equivalent to brisk walking) is fine.

You should try to exercise for at least 30 minutes of moderate intensity, 3 times a week. Give yourself at least 6 weeks to see if there is any beneficial effect.

Keeping a diary

It is worth keeping a migraine and exercise diary, recording both your migraine attacks and exercise you have undertaken. This will give you an idea of the affect aerobic exercise has had on your migraine and any steps to take to help ensure that exercise is not a trigger for you. It will also act as a record of whether you are decreasing or increasing migraine medication. Details to record include the date and time of your exercise, how you prepared, and the type and duration of exercise.

Preparing to exercise

Preparing for exercise is as important as the exercise itself.

If you have any concerns about your health, or if you have not exercised for a long period of time you should inform your doctor who can give you a basic health check prior to starting your program.

You should begin your exercise program gradually, building up the momentum over several weeks. It is best to do short, frequent sessions.

You should always:

Eat – at least an hour and a half before exercising, leaving time for your body to digest the food – this will avoid a low blood sugar level which can trigger a migraine. You could also take glucose sweets to maintain blood glucose levels prior to exercising.

Drink – fluids before, during and after exercise. You not only lose fluid through sweating but also as water vapor in the air that you breathe out. If fluid is not replaced quickly you will become dehydrated – and this is a major migraine trigger. You should always have a bottle of water available. You may also find isotonic drinks help. Isotonic drinks are widely available in health shops. They are drinks in which the mineral salts and glucose are equal to those in the blood. Therefore they will help keep your body in balance.

Warm up – this is really important and should be done before and after exercise.

You should never stop or start your session suddenly. Stretching exercises for at least 5 – 10 minutes at the beginning and end of the session will prevent muscle tension which may then act as trigger.

Wear the correct clothing – the right footwear is also important so it is worth a visit to a sports shop for some basic trainers. Other clothing depends on the sport you are doing, but the main thing is that you feel comfortable in the clothing you wear.

Remember – if at any stage during your exercise program you feel uncomfortable – stop. There is always another day. Note it in your diary so you can see the triggers.

Plan ahead – set a regular routine so that you can ensure that exercise is built in to your lifestyle along with regular meals and regular bedtimes. In this way you will also be able to monitor the affect it is having on your migraines.

Introduction

There is an inseparable relationship between sleep and headache. Migraine may be both caused and relieved by sleep, as well as being a cause of too much or too little sleep.

Sleep: the basics

Sleep is largely governed by two conditions. First, the brain’s biological clock determines the correct time during the 24-hour light-dark cycle in which sleep should occur which, in health at least, corresponds to darkness. At dusk, specialised cells in the retina of the eye begin to sense a drop in light levels, and signal to the brain to start producing the melatonin, a sleep-promoting hormone. The levels of melatonin peak and trough over a 24-hour period, which is timed to the light-dark cycle. This 24-hourly, or circadian, rhythm of melatonin secretion is complemented by a separate cycle of sleep pressure, which increases steadily during wakefulness, and dissipates rapidly during sleep. At the point where these two conditions intersect, the correct chemical and physiological environment within particular areas of the brain (particularly the hypothalamus and brainstem) is generated which allows the balance between wakefulness and sleep to tip in favour of one state or the other.

Even within the states of sleep and wakefulness, there are faster, shorter cycles of brain activity. In sleep, the brain successively ascends and descends through various depths of sleep in a regular pattern, alternating between rapid eye movement (REM) sleep and nonrapid eye movement (NREM) sleep. During REM sleep the body is paralysed, except for the eyes, which dart about rapidly. It is during this phase that most dreaming occurs. During NREM sleep, the brain enters a deeper state of sleep known as slow wave sleep, which is thought to be very important in many processes including memory processing and regulation of the immune system and metabolism. These stages of sleep also exert regulatory effects on the autonomic nervous system, which is the part of the nervous system responsible for controlling bodily function such as blood pressure and blood flow through the arteries and veins, including those within the brain.

Sleep and headache: the evidence

It is clear that some headache disorders are profoundly influenced by sleep, and some seem to occur exclusively in relation to sleep. Conversely, both of these groups of headache disorders can affect sleep, giving rise to a causality dilemma (or a “chicken and egg” scenario).

Migraine attacks are said to be more likely to occur between 04:00 and 09:00 am, which might suggest a timing mechanism that relates to sleep or circadian rhythms, or both. Lack of sleep is a well-known trigger, as is too much sleep (such as lying in at the weekend). Similarly, shift-work and jet lag have been reported to be triggers in some individuals, suggesting an influence of both sleep and the circadian timing system. Excessive sleepiness may be part of the premonitory phase before a migraine attack, or a symptom following the attack. Sleep can also be very therapeutic during a migraine attack, and may often help terminate the attack if achievable, particularly in children.

Cluster headache attacks show a striking relationship to sleep. Attacks arise mainly, although not exclusively, during sleep, and often occur at similar times each day and night. This again points towards disruptions in the biology of sleep and/or circadian rhythms in sufferers.

Hypnic headache is thought to be a rare form of headache disorder, mainly affecting women of older age, whereby attacks seem to wake sufferers from nocturnal sleep with a dull, featureless headache, often occurring several times a night. The integrity of sleep stages alters with age, with older populations having less slow wave sleep than younger people, so it may be reasonable to assume that hypnic headache might result from a reduction in slow wave sleep in susceptible individuals. Interestingly the stimulant caffeine is reported to be an effective treatment in some cases.

Insomnia and migraine may co-exist, especially in chronic sufferers. Both insomnia and migraine are more likely in people who sustain often quite mild head injuries, as part of a post-concussion syndrome. Excessive sleepiness, particularly during the daytime, can be associated with headache. Dull morning headaches are often a symptom of obstructive sleep apnoea, a condition of disordered breathing during sleep, which causes such significant sleep disruption at night that sufferers find it very hard to stay awake during the day. In addition, people with narcolepsy, who have sudden, uncontrollable sleep attacks, are said to have a higher proportion of headaches than the general population.

The parasomnias are a group of sleep disorders, which represent abnormal behaviour during sleep. Sleep walking and night terrors are said to be more common amongst migraine sufferers, especially children. Restless legs syndrome is associated with an uncomfortable urge to want to move one’s legs, particularly in the evening hours and at night, causing sleep disruption. This condition has recently been shown to have a higher incidence amongst migraine sufferers.

Finally, several of the drugs known to be helpful as headache preventatives have notable effects on the sensation of sleepiness during the day, sleep stages, dream experiences and circadian rhythms.

Why such a close relationship?

The balance of sleep and wakefulness, and its correct timing, relies on a finely tuned system, which in nature is referred to as homeostasis. If too much overloads this system in favour of one state (sleep or wakefulness) versus the other, such as staying up late, having fragmented sleep, sleeping in at the weekends, or sleeping at inappropriate times relative to your body clock (as happens in jet lag), the system will try and compensate to redress the balance.

One idea might be that a migraine attack may actually represent one of these regulatory mechanisms, albeit an extreme and abnormally over-compensating one. For instance if you are sleep deprived, suffering a migraine may actually force you to keep still and lie down in the dark, in the hope of trying to sleep as a way of ridding yourself of the migraine. Having too much sleep may also have the opposite effect and keep you awake with a migraine on subsequent nights. Both scenarios may be a way of trying to redress both sleep pressure and circadian alignment, and keep the system in equilibrium.

How can we use this to our advantage?

Clearly these homeostatic mechanisms aren’t the only basis for migraine, but it is logical to think that trying to maintain a well-balanced sleep-wake cycle may make triggering a migraine attack less likely. It is therefore perhaps important for migraine sufferers to observe good sleep hygiene, which is a set of suggestions designed to keep the sleep-wake cycle, and the quality of sleep, as even as possible.

Despite some rather compelling evidence of a close interaction between sleep and headache, there is clearly much to still be learnt and therapeutically exploited. Assessing both brain states in tandem, both scientifically and clinically, is likely to yield a much clearer view of this complex relationship in future.

Sleep hygiene

  • Try to go to bed and get up at the same time each day, as sleeping during the correct phase of your circadian cycle is important.
  • Understand your sleep need, including both the timing of sleep (when feels right for you to go to bed), and the duration of sleep (most adults need about 8 hours a night).
  • Do try and spend some time outdoors or in natural light during the daytime, as this provides an important cue to your brain for fine-tuning timing of the body clock.
  • Try and make your sleeping environment as restful as possible, including sufficient darkness and quiet, comfortable bedding and few devices around the bed, particularly those with lights.
  • Exercise, preferably before dinner rather than before bed, can be helpful as can stopping smoking as nicotine has a stimulant effect and suppresses melatonin.
  • It would be sensible to recommend that you don’t use your bed for activities that could be done elsewhere (such as watching TV, studying), and try to avoid staying in bed if you are wide-awake.
  • Avoiding caffeine before bed is recommended, as is avoiding alcohol, as this actually reduces the overall quality of your sleep rather than improving your sleep as is commonly assumed.

Learn more about the common symptoms of migraine and the different stages of attacks


Introduction

Not everyone will have a ‘typical’ migraine. There are different types of migraine that involve different symptoms.

The most common symptoms of a migraine attack include a throbbing or pulsatile headache, sensitivity to light and noise, nausea (feeling sick), vomiting (being sick) and lethargy.

Migraine attack stages or phases

It is often difficult to predict when a migraine attack is going to happen. However, you can often predict the pattern of each attack as there are well defined stages.  It is these stages and their symptoms which distinguish a migraine from a headache.

In adults, we can divide a migraine attack into four or five phases that progress on from one stage to another:

  • Premonitory phase
  • Aura (not always present)
  • The headache or main attack phase
  • Postdromal phase (resolution)

Learning to recognise the different phases of a migraine attack can be very useful. You might suffer from a combination of these phases, and this may may vary from attack to attack. Each phase can vary in length and severity.

Recognising different symptoms at different times during your headache attack can give your doctor information which may help diagnosis. In addition, taking medication before the symptoms have fully developed may reduce the effect of an attack.

Premonitory phase

This describes certain physical and mental changes such as tiredness, food cravings or aversions, mood changes, feeling thirsty, a stiff neck, and increased urination. These can last from 1 to 24 hours.

 Aura

The aura of migraine includes a wide range of neurological symptoms. This stage usually lasts from 5 to 60 minutes, and usually happens before the headache. Migraine without aura does not include this stage. In some people, changes in the brain cause changes in their sight, such as dark spots, coloured spots, shimmering lights, or zig-zag lines. Numbness or tingling, weakness, and dizziness or vertigo (the feeling of everything spinning) can also happen. Speech and hearing can also be disturbed, and sufferers have reported memory changes, feelings of fear and confusion, and more rarely, partial paralysis or fainting. These neurological symptoms are called the ‘aura’ of migraine. They usually happen before the headache itself. In addition, it is possible to have the aura symptoms without the headache.

 The headache or main attack stage

This stage involves head pain which can be severe. The headache is typically throbbing, and is worsened by physical activity. Some sufferers describe a pressing or tightening pain. The headache is usually on one side of the head, especially at the start of an attack. Some sufferers get pain on both sides of the head, or over the forehead. Nausea (sickness) and vomiting (being sick) can happen at this stage, and the sufferer may feel sensitive to light or sound, or both.

 Resolution

Most attacks slowly fade away, but some stop suddenly after the sufferer is sick. Sleep seems to help many sufferers, who find that even an hour or two can be enough to end an attack.

 Postdrome

This is the final stage of an attack. Often one feels ‘washed-out’ and this can last hours or days before resolution. Symptoms can be similar to those of the premonitory phase, and often they are mirrored symptoms e.g. if you lost your appetite at the beginning of the attack, you might be very hungry now. If you were tired at the beginning, now you might feel energetic.

Tension-type Headache

Tension-type headache (TTH) is usually described as a pain that feels like a tight band round your head or a weight on top of it. Your neck or shoulder muscles may also hurt along with the headache. The pain can last from 30 minutes to several days, or may be continuous. Tension-type headache can develop into chronic tension-type headache when it becomes more disabling.

If you have TTH, it will produce a mild to moderate pain whereas the pain of migraine can reach disabling severity. Normal movement during everyday activities shouldn’t make TTH worse, unlike a migraine, which can be aggravated by movement.

There is an overlap in the triggers of migraine and TTH, as both may be brought on by stress or tiredness. Head and neck movements are important triggers in patients with TTH whereas hunger and odour were significantly common triggers in migraine.

The most common causes of TTH reported are anxiety, emotional stress, depression, poor posture, and lack of sleep, although the evidence for each of these (except stress) is poor.

Physical exhaustion is also a common cause of TTH, so make sure you are getting enough sleep.

Obviously removing the cause of headaches would be the best treatment. Over-the-counter painkillers such as ibuprofen, aspirin, paracetamol and naproxen are commonly used to treat TTH and remain the mainstay of treatment for TTH. It shouldn’t be necessary to take stronger medications. Using painkillers more than twice a week, however, can increase the risk of TTH developing into chronic daily headache. This occurs when ‘rebound headaches’ form as each dose of medication wears off, and is especially common if the painkillers contain caffeine or codeine.

Psychological factors affecting your headaches are hard to tackle. You may find it helpful to learn relaxation techniques, and avoid stressful situations as much as possible. If you find you can’t reduce, or even identify the causes of stress in your life, that may be triggering your headaches, you may find it beneficial to seek help from a psychotherapist or counsellor.

Different treatments for TTH work for different people, so if one thing doesn’t help try another. Discovering what works for you is the key.

If you are pregnant you should discuss use of any drugs (both prescribed and over the counter) with your doctor. Not all drugs are safe to use in pregnancy.

Overusing painkillers to treat TTH can cause chronic daily headaches to develop. These headaches usually occur early in the morning, and their symptoms include: poor appetite, nausea, restlessness, irritability, memory or concentration problems, and depression. Chronic daily headache is usually resistant to painkillers, and most sufferers experience migraines as well as an almost permanent TTH. The headache can vary in intensity, duration, and location, and the symptoms can be more severe than in people who have occasional TTH.

If you suffer chronic tension-type headache you are advised to see a neurologist or headache specialist. Also, although it is hard to do, if painkiller overuse has caused you to develop chronic daily headache, you should try to withdraw from the painkillers slowly. The headaches will initially get worse, and can cause problems such as nausea, but the headache intensity and frequency will begin to reduce within two weeks after you finish the withdrawal.

Cluster Headache

A rare type of headache that affects about 1 to 2 people in every 1,000

Cluster headache is one of the most painful conditions known to mankind and women suffering from cluster headache describe the pain as worse than childbirth.

What are the symptoms?

The symptoms of cluster headache are characterised by unilateral (one sided) pain, although for some people the side can vary from time to time. The pain is usually centred over one eye, one temple or the forehead. It can spread to a larger area making diagnosis harder.

During a bout of cluster headache the pain is often experienced at a similar time each day. The headache often starts at night waking people one to two hours after they have gone to sleep. The pain usually reaches its full intensity within 5 to 10 minutes and lasts at this agonising level for between 30 and 60 minutes. For some people the pain can last for 15 minutes, for others 3 hours has been known. It then stops, usually fairly abruptly.

You may experience the head pain every other day during a bout, or up to 8 times per day during a bad cluster.

In about 80% of people with cluster headache the bouts (or “clusters”) of head pain last for 4 to 12 weeks once a year often at the same time and often in the spring or autumn. It may then disappear for several months or even years. This is known as episodic cluster headache. The reason for this seasonal timing is not completely known, although it is one of the key aspects of diagnosis and may involve a brain area called the hypothalamus. The remaining 20% of people do not have these pain free intervals and are said to have “chronic cluster headache.”

People with cluster headache are usually unable to keep still during an attack and often try to relieve the agonising pain by pacing the room or walking outside, sometimes even banging their heads against a wall until the pain subsides.

Other symptoms which are characteristic of cluster headache are a blocked or runny nose, and on the same side of the head as the pain, a drooping eyelid and watering and redness of one eye. Many people also experience a flushed or sweating face.

Who can get cluster headache?

Cluster headache can start at any age but most commonly starts in your 20’s or older. You are not likely to grow out of cluster headache, although as you get older it is likely that the pain free periods between bouts of cluster headache will get longer.

Approximately 1 in 20 people with cluster headache have a family member who also has the condition. Unlike migraine, it is more common in men than women (by five to six times). It is also more common in heavy smokers.

As with all forms of headache, cluster headache occurs in children but it is less common than in adults.

Obtaining a diagnosis

There is no special test to diagnose cluster headache and so your doctor will need to take a very detailed history of all your symptoms in order to make the correct diagnosis. You may be referred for an MRI scan to rule out other causes for the pain starting suddenly.

What triggers cluster headache?

Alcohol is one well known trigger of cluster headache, often bringing on the pain within an hour of drinking. If you have cluster headache you should not drink any alcohol during a cluster period. Once the bout is over you will be to drink alcohol again. A significant number of people find that strong smelling substances such as petrol, paint fumes, perfume, bleach or solvents can trigger an attack. During an episode of cluster headaches you should try to avoid these things. Some people find exercise or becoming over heated will bring on an attack, so again avoiding these is the best advice during a bout. Research has showed that heavy smokers are at an increased risk of developing chronic cluster headache so giving up smoking or cutting down is worth considering.

Treatment

Whilst there is currently no cure for cluster headache, the treatment has become much more effective in the last 10 years.

Acute treatment

Acute treatment is used to stop the pain once it has started. Treating cluster headache can be tricky because the pain becomes extremely severe very quickly – usually within 10 minutes. Thus the key to treating cluster headache during an attack is speed to reduce the excruciating pain as fast as possible. Ordinary painkillers that you can buy over the counter are not usually effective, as the pain of cluster headache is too intense and they take too long to work.

Oxygen is one of the safest ways to treat cluster headache. You need to breathe the oxygen in at a rate of between 7 and 12 litres per minute. The treatment usually starts to work within 15 to 20 minute. For some people the attack is delayed rather than stopped altogether.

Sumatriptan injections have been found to reduce the pain within 10 minutes during an attack. In general tablets are less effective if you have cluster headache because of the time they take to work. Sumatriptan and zolmitriptan nasal sprays do help some people although the onset of action maybe slower than the injection.

Preventive treatment

Preventative treatment is used to try and stop the attack from starting in the first place. There is a far wider range of preventative treatments available now than in the recent past. You will need to take the preventative treatment when the cluster period starts and continue for about two weeks after the bout has ended. You will need to stop the drugs gradually and restart them if a new bout begins.

The most common preventative treatments are:

Verapamil prescribed for cluster headache as research has shown that a daily dose can be effective in both episodic and chronic cluster headache. You will probably need to see a specialist in a hospital or clinic if you are prescribed this drug, because your heart will need to be monitored regularly using an ECG machine whilst the correct dose for you is established.

Lithium at a low dose can be effective although again this will need careful monitoring. It is more effective in treating chronic cluster headache than episodic.

Corticosteroids are given because they are fast acting. They can be used in a short burst for 2 to 3 weeks in decreasing amounts as a first step to break the cycle. They are often used alongside other treatments which take longer to work. Corticosteroids are more effective for chronic cluster headache to break the cycle. If used for episodic cluster headache, when the medication is reduced the headaches come back.

Topiramate has been reported to be useful in cluster headache.

As with any drug treatment you may need to work with your doctor to determine what works best for you. You may need to try several treatment regimes before you discover the best one for you.