Migraine Management

Migraine Management

by Dr. John Rees

Neurologist Dr John Rees joins us for a new monthly health feature. In this issue he explores migraines that affect approximately 14% of the adult population and some possible remedies.

We are beginning to understand the mechanism of migraine, which is an effect of serotonin, a chemical messenger in the brain on blood vessels in the meninges (the lining around the brain), and the scalp. There is also a major temporary effect on the electrical activity of the surface of the brain especially the part that deals with vision, causing the common visual symptoms.

Many factors may trigger a migraine, these include stress, severe exertion, chocolate, cheese, alcohol, striplights, hormonal change and some smells such as mown grass, tarmac and perfumes.

The four phases of a migraine attack are:

  1. A prodrome, which often includes mood changes that patients often do not recognise but a partner or family member will.
  2. Aura, often with visual symptoms of flashing or zig-zag lights, disturbance of sensation or motor function on one side of the body and occasionally with speech disturbance lasting 5 to 60 minutes.
  3. Headache, usually one-sided lasting 4 to 72 hours associated with nausea, occasional vomiting, sensitivity to light and noise. It is not just a bad headache but at least 10 times worse than the worst headache a non migraine sufferer has experienced.
  4. A post drome or hangover-like feeling.

There are different types of migraine; sufferers of migraines with aura comprise of about 20%, whilst those who have migraines without aura who are the majority, perhaps 75%.

There are also the unusual forms of migraine, including the aura without the headache, hemiplegic migraine when one side of the body may be paralysed, basilar migraine when visual symptoms and vertigo predominate, cyclical vomiting in children and finally chronic migraine when the headache becomes constant.

Surprisingly, taking large amounts of frequent painkillers for headache can actually promote constant headache and the treatment here is to recognise this and stop the analgesics.

There is no cure for migraine. Occasional attacks can be managed with simple painkillers and/or anti nausea pills but if the attacks are severe or are interfering with home or work life, then see your doctor. The key to good treatment is to identify in each patient what trigger factors if any are relevant. It is often useful to ask a relative or close friend, since mood change can herald an attack and treatment at that time can prevent one occurring. Clearly, if there are trigger factors and the migraines are frequent and/or disabling, it makes sense to avoid them.

Many people find that lying down in a quiet, dark room is helpful. Sleeping may also be advantageous. Some find that their symptoms die down after they have been sick. If ordinary painkillers are not relieving your symptoms, your GP might prescribe you a triptan to be taken in addition to over the counter painkillers.

Triptans were designed with detailed knowledge of the mechanism of migraine and have transformed the treatment of an acute attack often relieving symptoms in 30 minutes.

If a migraine occurs more than three to four times per month, you may well need to go on preventative treatments, which may include beta blockers, some anti epileptic drugs, tricyclics and calcium channel blockers. Newer treatments, still requiring more research and evaluation include: Botox, transcranial magnetic stimulation and external nerve stimulation and recently, the use of specific antibodies against calcitonin gene related peptide (CRGP), given as an injection.

If your situation does not improve after treatment, you may be referred to a specialist migraine clinic.