Migraine

Frequently asked questions

Information for patients and carers

Department of Neurology Aberdeen Royal Infirmary

What is migraine?
Migraine is a disabling headache disorder that affects 12 to 15% of the population. It affects people of all ages but is most common in the 20 to 50 age group. Around two thirds of sufferers are women. Migraine can be episodic if it occurs on fewer than 15 days a month or it can be chronic if it occurs 15 or more days a month. About 20% of migraine sufferers will get aura symptoms with some or all of their migraine. This is e plained below.

What causes migraine?

The cause of migraine is not !nown but it is recognised that migraine is a brain disorder. Migraine not only results in a disabling headache but also a number of other symptoms such as nausea and sensiti"ity to noise and light. It is thought that the migraine brain is more sensiti"e to the en"ironment around it and that any change in this en"ironment can stimulate the brain and trigger a migraine. #ommon triggers include hormonal changes$ tiredness and missing meals.

What is aura?
Aura is a temporary disturbance of brain function before or during the headache. %ccasionally it can happen without headache. These disturbances &!nown as the 'aura() usually occur 15 to *0 minutes before the headache.

Aura is thought to be due to a temporary change in electrical acti"ity in the brain. Aura symptoms can be frightening but are harmless and usually settle in 15 to *0 minutes &see below for symptoms).

What are the symptoms of migraine?

There are said to be fi"e stages of a migraine. +ot e"eryone will ha"e all of the following features. ,"eryone-s symptoms are uni.ue to them. Stage 1: Prodrome These are symptoms that occur in about /0% of migraineurs &people who get migraine) up to 20 hours before their headache starts. 1ymptoms include mood changes such as irritability$ depression$ elation or a feeling of wellbeing. It is possible to feel drowsy$ fatigued$ to yawn or to be e cited. There can be changes to your senses including a disli!e of light$ sound and strong smells. Stage 2: Aura This produces a "ariety of "isual and sensory disturbances before or into the headache stage. 2isual disturbances are the commonest form of aura. They can include3 blind spots flashing lights 4ig 4ag shimmering lines areas of the "ision may be missing and replaced by a blac! area.

%ther aura symptoms include3 di44iness$ "ertigo and balance problems pins and needles in the hand$ arm or face difficulty with speech rarely$ confusion.

Stage 3: eadache The headache stage is usually the most significant feature of migraine. Many people describe it as throbbing$ and it may be one sided and moderate to se"ere in intensity. It may be se"ere enough to interfere with your ability to function normally. Any part of the head can be affected. 1ometimes$ pain can be felt in the nec!$ shoulders and the face. 5uring the headache phase people commonly report a disli!e of light$ sound or strong smells. 6ou may not feel li!e eating or drin!ing due to nausea$ "omiting$ abdominal pains or diarrhoea. %ther symptoms include blurry "ision$ watering of the eye or nose$ sensations of heat or cold and sweating. Many people report an increased sensiti"ity to touch and can find wearing glasses$ hats or clothes painful. This phenomenon is called allodynia. Stage !: Resolution This often in"ol"es you needing to sleep deeply to get rid of the headache.

Stage ": Reco#ery 6ou may ha"e symptoms similar to those in the first prodrome phase and feel generally washed out or hung o"er. This can last a couple of days.

What are the potential triggers for migraine?

The brain of a migraine sufferer is belie"ed to ha"e a lower sensiti"ity to stimuli. 1ome e amples of stimuli 7 also !nown as triggers 7 are gi"en in the list below. This stimulation of the brain results in a migraine. 8eople with migraine can trigger an attac! from their day7to7day acti"ities. It is not always easy to recognise triggers$ as on their own they often do not cause a migraine attac!. There seems to be a threshold effect so that se"eral together may trigger an attac! but these need not be the same for each attac!. 1ome common triggers are3 missing meals such as brea!fast tiredness or o"ersleeping changes in routine &such as shift wor!$ tra"el and 9et lag) stress or being "ery busy$ or when stress stops &such as the wee!end or the first day of a holiday) either too much or too little sleep hormonal changes &such as menstruation or when periods are irregular before the menopause) physical stimuli &such as bight light$ heat$ smell$ noise or changes in atmospheric pressure). 0

How is migraine diagnosed?

5iagnosis is made from ta!ing a thorough history of your condition. 6our story gi"es the clues to what your headache is. %ften$ in"estigations are not necessary and are usually unhelpful.

What is the treatment for migraine?

This includes assessment of diet and lifestyle and drug treatment. 5rug treatments can either be acute medication which you ta!e when you get an attac! or pre"entati"e medication which you ta!e e"ery day to try and reduce how often you ha"e your attac!s.

Why is it important to look at diet and lifestyle issues?

The cause of migraine is un!nown so it is not possible to cure it. :owe"er the se"erity and fre.uency of attac!s can be reduced by minimising your e posure to potential triggers. A stable lifestyle pattern is less li!ely to trigger a migraine. ;or e ample some migraineurs who miss brea!fast find they get a migraine starting later in the morning. %thers find they can pre"ent a headache by ta!ing regular e ercise as a way to combat stress. The '<ifestyle( section towards the bac! of this leaflet e plains the sorts of diet and lifestyle changes that can help reduce the ris!s of an attac! occurring.

Chronic migraine and medication overuse headache

This is migraine that occurs more than 15 days a month. 2ery often episodic migraine transforms o"er time into chronic migraine. =hen migraine becomes chronic some of the headache days may not be as bad as a day of se"ere migraine and often can 9ust feel li!e a tension headache. :owe"er there will still be usually more than eight days a month that are migraine days. The commonest reason for migraine becoming chronic is ta!ing acute treatment for migraine more than twice a wee!. The tablets most li!ely to do this contain codeine or similar medicines &such as co7codamol$ co7dydramol$ Migrale"e >$ 1olpadeine >$ 1yndol >$ dihydrocodeine$ tramadol). ;or this reason people with migraine should a"oid these tablets where possible.

What type of medication might I have?

Acute medication This is ta!en to put the headache away. ?enerally the sooner the medication is ta!en after the headache starts the more chance it has to wor!. 8eople who get allodynia find medication wor!s better if ta!en before they get allodynia. 1. Aspirin 7 three tablets &@00 milligrams) or paracetamol 7 three tablets &1.5 grams) 2. Ibuprofen A00 milligrams or diclofenac 100 milligrams or diclofenac suppository 100 milligrams. /. Medication for sic!ness &such as domperidone tablets or suppositories) can help nausea and also ma!e the pain!illers wor! better. 0. Triptans &such as almotriptan$ eletriptan$ fro"atriptan$ naratriptan$ ri4atriptan$ sumatriptan$ 4olmitriptan). These medications are not pain!illers but are specific anti migraine drugs. Triptans can be ta!en as tablets$ nasal sprays and sumatriptan can be used as an in9ection. +ine out of ten patients find that these help but the response to each triptan is "ariable. 6ou may ha"e to try all se"en to find the one that wor!s best. A triptan should be tried for three separate migraine headaches before it is deemed as not wor!ing. If a triptan helps your migraine$ it can be ta!en again after two hours if your headache becomes bad again. If the first dose does not help$ a second dose should not be ta!en. Two doses is the ma imum daily dose. B

Pre#entati#e medication $pre#enters% These are ta!en e"ery day to help reduce the number of migraine headaches. These medications are used if you get fre.uent migraines or migraines that cause disability and ha"e an impact on your life. ,ach medication will usually wor! in fi"e out of ten patients they are gi"en to$ so sometimes more than one needs to be tried to find one that wor!s best. These medicines will not stop all migraine headaches but can reduce the number of headaches by half. 2ery often these medications are used in combination with one another for better effect. <i!e all medications they ha"e the potential to cause side effects. 1ide effects are reduced by starting at a low dose that is built up o"er a few wee!s. Thus some of these medications may ta!e a few wee!s to start to wor!. Many people who find that these treatments do not wor! for them ha"e not ta!en the drugs for long enough at high enough doses and ha"e not gi"en the drugs the best chance to wor!. 8re"enter medication is usually ta!en for si to twel"e months and then reduced gradually. 1ome people will need to use these medications longer if they still get disabling migraine when the treatment is stopped.

There are many different classes of drugs used as pre"enter treatments. These medications are listed below and a separate leaflet has more information about them. Clood pressure medication beta7bloc!ers &usually propranolol) ADCs &candesartan)

Anti7depressant medication tricyclic &amitriptyline$ nortriptyline$ dosulepin) 1+DI &"enlafa ine)

Anti7epileptic medication &topiramate$ sodium "alproate$ gabapentin) 8i4otifen &wor!s better in children).

Non drug treatments

Many migraine sufferers try alternati"e treatments. The e"idence for these is limited$ with acupuncture ha"ing the best e"idence.

ifestyle
As well as treating your headache symptoms with medication it is also important to thin! about aspects of your lifestyle that may be affecting your headaches. Diet ,at a cereal E oat based brea!fast to gi"e a slow release of sugar. 5o not go for long periods without food F to a"oid low blood sugar le"els. <imit inta!e of caffeine F tea$ coffee$ fi44y drin!s including cola. ,at balanced meals including fi"e portions of fruit and "egetables a day. Alcohol Geep alcohol inta!e to recommended wee!ly le"els3 Men 21 units =omen 10 units %ne unit H half pint of beer$ one glass of wine E spirits

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Smo&ing Ise your local +:1 1mo!ing Ad"ice 1er"ice to help you stop. +icotine replacement therapy &such as gum$ patches$ lo4enges etc) is a"ailable on prescription. Most pharmacists can ad"ise and supply appropriate treatment. 'ater It is recommended that we drin! two litres &eight large glasses) of water a day. 5rin!ing too little water can lead to tiredness$ lethargy$ headaches$ inability to concentrate$ dry E crac!ed s!in and low blood pressure. #offee$ tea$ alcohol and related products can cause headaches. #offee$ tea and alcohol are diuretics and therefore cause more water loss from your body. Ta!e a bottle of water to wor! E school E uni"ersity. Geep drin!ing throughout the day.

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Sleep Try to maintain a regular time of going to bed. ,nsure you ha"e a period of wind down before going to bed. A"oid wor!ing at a computer close to bedtime. Thin! about your routine 9ust before you go to bed. Try to ha"e the same amount of sleep F do not under or o"er sleep. Posture and eyesight A"oid slouching in front of the T2. #hec! your position in front of the computer. The 25I should be at eye le"el. 5o not sleep with too many pillows. If you ha"e problems with your eyesight see an optician for a chec! up. If you already ha"e a "isual condition ma!e sure you ha"e regular chec! ups. #hec! your dri"ing position.

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()ercise It is recommended that we try and e ercise fi"e times a wee! for thirty minutes. =al!ing is an ideal and cheap way of e ercising. Thin! what you li!e doing and how you may build it into your life. Stress * rela)ation A"oid negati"e ways of coping &such as alcohol$ smo!ing). 8rioritise problems E tas!s$ recognise signs of stress. Try and include e ercise in your routine to aid rela ation. #onsider alternati"e therapies &such as refle ology$ Cowen techni.ue$ acupuncture). Ma!e sure you include time in your life for youJ

!seful contact details

If you want more information about healthy lifestyles$ please call3

N S +rampian healthline ,",, 2, 2, 3,

Monday to ;riday @am to 5pm #alls to the healthline are free

1/

What other support is availa"le?

The organisations below pro"ide information and support3 The Migraine Trust 2nd ;loor$ 5575* Dussell 1.uare <ondon =#1C 0:8

,2, -!3. 133.

www.migrainetrust.org

The Migraine Action Association Init *$ %a!ley :ay <odge Cusiness 8ar! ?reat ;olds Doad ?reat %a!ley +orthamptonshire ++1A @A1

,1"3. !.1333
www.migraine.org.u! 8lease note that +:1 ?rampian is not responsible or liable for the .uality of the information$ resources or maintenance of e ternal websites. Any ad"ice on e ternal websites is not intended to replace a consultation with an appropriately .ualified medical practitioner.

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/his leaflet is also a#ailable in large print and on computer dis&0 1ther formats and languages can be supplied on re2uest0 Please call 3uality De#elopment on $,122!% ""!1!4 for a copy0 As& for leaflet ,"310

;eedbac! from patients and carers helped us to de"elop this leaflet. If you ha"e any comments or suggestions about how we can impro"e this leaflet$ please let us !now.

5epartment of +eurology Aberdeen Doyal Infirmary <eaflet supplied by3

De"ised Kune 2011 L +:1 ?rampian Muality 5e"elopment$ ;oresterhill