Migraine: not just a headache

Migraine is humanity’s headache. If you suffer from headaches bad enough to stop you doing what you want to do, you’re getting migraines. If you suffer from headaches that make you feel sick, you’re getting migraines. If you suffer from headaches that are made worse by light, or noise, or movement, they’re migraines. If you get headaches with your periods, or when you eat a Chinese takeaway, or when you overindulge, or when you sleep in, these are migraines. Top neurologist and headache expert Dr Mark Weatherall explains:

Migraines make it difficult for people to concentrate, to attend to work, to meet friends, to carry on the normal activities of daily life. Migraine affects 25% of women, and 10-15% of men. As for what causes migraine, the tendency to suffer from it has a genetic basis, but individual attacks may be triggered by internal or external influences, or simply come by themselves for no apparent reason.

The name ‘migraine’ originally comes from the Greek word hemicrania, meaning ‘half of the head’. It is true that migraines sometimes affect only one side of the head, but often the pain is bilateral, at the front or the back of the head; more rarely in the face, and rarer still in the body. It is generally throbbing in nature, and made worse by any movement or even modest exertion. Most migraine attacks are severe.

Migraine symptoms

The pain of migraine is typically accompanied by other features such as nausea; dizziness; sensitivity to light, noises, and smells; lack of appetite; and disturbances of bowel function.

Many people experience premonitory (warning) symptoms up to 48 hours before their migraines. These may include fatigue or abnormal bursts of energy, neck stiffness, yawning, and frequent urination.

About 20% of migraine sufferers experience aura, usually before the headache starts. Most aura is visual, consisting of a combination of moving or expanding zig-zag lines that cross the vision over 20-30 minutes, often accompanied by blind spots. Some sufferers also experience sensory aura, consisting of tingling and numbness that spreads down one side of the body.

Should I have a brain scan?

Most patients with headaches do not need a brain scan, or indeed any other investigations. Demand for scans is driven by two influential cultural myths: that headaches are commonly due to brain tumours; and that in modern medicine diagnoses can only be made by abnormal scans or blood test results. Neither are true.

Migraine treatment

There are three approaches to treating migraine: lifestyle and trigger management, acute treatments (painkillers taken during attacks), and preventive treatments (medication or other interventions that reduce the tendency to have attacks).

• Lifestyle and trigger management - migraine likes people to be a bit boring! A regular regimen of meals, hydration, sleep, and stress is always helpful in reducing the tendency to migraines; recognizing this is straightforward, but making changes like this in a modern busy life may be tricky.
• Acute treatments – some form of painkiller is usually needed. If simple painkillers such as paracetamol, aspirin, or ibuprofen are not effective, then specific migraine drugs (triptans) should be tried. Opiates (codeine, tramadol, and the like), benzodiazepines and barbiturates must be avoided.
• Preventive treatment is prescribed when headaches significantly interfere with work, school, or social life. Typical preventives include old-fashioned tricyclic antidepressants taken in low doses; medications that reduce blood pressure, such as beta-blockers or angiotensin blockers; or some of the drugs originally used to treat epilepsy. If drugs fail, interventions such as greater occipital nerve blocks or Botox can be tried. New non-invasive neurostimulation techniques, such as transcranial magnetic stimulationTMS) and vagal nerve stimulation (VNS) may also be helpful.

These are exciting times for the treatment of migraine. New options will become available over the next 1-2 years, most notably the CGRP antibodies. In the meantime, however, our existing armamentarium holds plenty of possibilities for clinicians and patients to work together to improve the lives of people with migraine.