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Migraine - A Guide

A migraine is a severe headache usually felt as a throbbing pain at the front or on one side
of the head. Some people also have other symptoms, such as nausea and sensitivity to light.

Introduction
Symptoms of migraine
Causes of migraine
Treating migraine
Complications of migraine
Preventing migraine

Introduction

Migraine is a common health condition, affecting about 15% of adults in the UK.

There are two types of migraine:

  • Classical migraine is when you have a warning sign, known as aura, before the migraine begins. About a third of people with migraine have this. Warning signs may include visual problems (such as flashing lights) and stiffness in the neck, shoulders or limbs.
  • Common migraine is when there is no aura.

For more information, see Migraine - symptoms.

There are five stages to a migraine (see box, left), although not everyone will experience all of these.



Who is affected by migraines?

Migraines affect one in four women and one in 12 men in the UK.

Hormones may be the reason why migraines affect more women than men. For example, some women find that migraine attacks are more frequent around the time of their period. However, this association has not been fully proven.

Migraines usually begin in young adults. About 9 in 10 have their first migraine before they are 40 years old. However, it is possible for migraines to begin later in life.

How often do they occur?

Everyone will experience migraines differently. Some people have attacks frequently, up to several times a week. Other people only have a migraine occasionally. It is possible for years to pass between migraine attacks.

Outlook

A migraine can be very disabling and can severely affect your quality of life. Some people need to stay in bed for days at a time.

However, there are effective treatments and methods that can help to prevent migraines (see Migraine - treatment and prevention). Most people find ways of managing their migraines so that there is little disruption to their lives.

Stages of migraine

There are five distinct stages to a migraine, although not everyone goes through all the stages:

1. 'Prodromal' (pre-headache) stage. Some people experience changes in mood, energy levels, behaviour and appetite, and sometimes aches and pains several hours or days before an attack.

2. Aura. Some people experience a sensation, or aura, just before their migraine starts. Symptoms of aura include flashes of light or blind spots, difficulty focusing, and seeing things as if you are looking through a broken mirror. This stage normally lasts around 15 minutes to an hour.

3. Headache stage. This is usually a pulsating or throbbing pain on one side of the head. You usually have nausea or vomiting, and extreme sensitivity to bright light and loud sounds, with a strong desire to lie down in a darkened room. This stage lasts for four to 72 hours.

4. Resolution stage. Most attacks gradually fade away. Some people find the headache stops suddenly after they have been sick. Sleep often relieves the symptoms.

5. 'Postdromal' or recovery phase. There may be a stage of exhaustion and weakness afterwards.



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Symptoms of migraine

A migraine is an intense headache that usually occurs at the front or on one side of the head. However, the area of pain can change position during an attack.

The pain is usually a severe throbbing sensation that  gets worse when you move.

Symptoms of aura

About one third of people with migraines have warning symptoms, known as aura, before the migraine. These include:

  • visual problems - you may see flashing lights, zigzag patterns or blind spots
  • stiffness or a tingling sensation like pins and needles in your neck, shoulders or limbs
  • problems with co-ordination - you may feel disorientated or off-balance
  • difficulty speaking
  • loss of consciousness - this only happens in very rare cases

Aura symptoms typically start between 15 minutes and one hour before the headache begins. Some people may experience aura with only a mild headache.

Symptoms accompanying a migraine

Symptoms associated with a common migraine (migraine without aura) include:

  • nausea - you may feel queasy and sick; this may be followed by vomiting
  • increased sensitivity - you may have photophobia (sensitivity to light), phonophobia (sensitivity to sound) and/or osmophobia (sensitivity to smells), which is why many people with a migraine want to rest in a quiet, dark room

These often begin at the same time as the migraine and usually disappear once the headache eases.

The symptoms below can also occur during both common or classical migraines:

  • poor concentration
  • sweating
  • feeling very hot or very cold
  • abdominal pain (which can sometimes cause diarrhoea)
  • a frequent need to urinate

Not everyone experiences these symptoms when they have a migraine, and they do not usually all occur at once.

The symptoms of a migraine can last anywhere between four hours and three days. They will usually disappear when the headache goes. You may feel very tired for up to seven days after a migraine attack.

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Causes of migraine

Migraines are thought to be caused by changes in the chemicals of the brain. In particular, levels of serotonin (the 'feel-good' chemical) decrease during a migraine.

Low levels of serotonin can make the blood vessels in a part of your brain spasm (suddenly contract), which makes them narrower. This may cause the symptoms of aura. Soon after, the blood vessels dilate (widen), which is thought to cause the headache. The exact reason for the drop in serotonin is not yet fully understood.

Hormones

Some scientists believe that fluctuating levels of hormones are closely linked to the cause of migraines.

Some women who experience migraines say they are more likely to have an attack around the time of their period. This is known as a menstrual migraine. Just before women have their period, levels of the hormone oestrogen fall.

Women can have menstrual migraines from two days before to three days after the first day of their period. About 1 in 7 women who have migraines only have an attack around the time of their period. This is known as a pure menstrual migraine. Around 6 in 10 women with migraines have attacks at other times too.

Migraine triggers

Many factors have been identified as triggers for a migraine. These triggers include emotional, physical, dietary, environmental and medicinal factors. They are outlined below.

Emotional triggers

These include:

  • stress
  • anxiety
  • tension
  • shock
  • depression
  • excitement

Physical triggers

Physical triggers include:

  • tiredness
  • poor quality of sleep
  • shift work
  • poor posture
  • neck or shoulder tension
  • travelling for a long period of time

The menopause can also trigger migraines.

Dietary triggers

Dietary triggers include:

  • lack of food (dieting)
  • delayed or irregular meals (see below)
  • dehydration
  • alcohol
  • the food additive tyramine
  • caffeine products, such as tea and coffee
  • specific foods such as chocolate, citrus fruit and cheese

When you do not eat regular meals, your blood sugar levels fall. If you then eat a sugary snack, blood sugar levels shoot up. These 'peaks and troughs' could trigger migraine attacks.

Environmental triggers

Environmental triggers include:

  • bright lights
  • flickering screens, such as a television or computer screen
  • smoking (or smoky rooms)
  • loud noises
  • changes in climate, such as changes in humidity or very cold temperatures
  • strong smells
  • a stuffy atmosphere

Medicines

Some medicines can trigger migraines, including:

  • some types of sleeping tablets
  • the contraceptive pill
  • hormone replacement therapy (HRT), which is sometimes used to treat the menopause 
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Diagnosing migraine

There is no specific test to diagnose migraines. On your first visit, your GP may give you a physical examination and check your vision, co-ordination, reflexes and sensations. These checks will be carried out to make sure there are no other underlying conditions causing your symptoms.

To give an accurate migraine diagnosis, your GP must identify a pattern of reoccurring headaches along with the associated symptoms. Migraines can be unpredictable, sometimes occurring without the other symptoms. So obtaining an accurate diagnosis can sometimes take a long time.

To help with the diagnosis, it can be useful to keep a diary of your migraine attacks. Note down details, including the date, time and what you were doing when the migraine began. It is also helpful to make a note of the food you ate that day as this can help your GP identify any potential triggers.

Your GP may ask if your headaches are:

  • on one side of the head
  • a pulsating pain
  • moderate or severe, preventing you carrying out daily activities
  • made worse by physical activity or moving about
  • accompanied by nausea and/or vomiting
  • accompanied by sensitivity to light (photophobia) and/or noise (phonophobia)

When to see your GP

You should see your GP if you feel that you cannot manage your migraines with over-the-counter painkillers, such as paracetamol. Also see your GP if you experience:

  • aura symptoms that occur on the same side of your body with every attack
  • your first ever migraine when you are over 50 years of age
  • a change in your usual migraine symptoms
  • more frequent migraine attacks

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Treating migraine

There is currently no cure for migraines. However, a number of treatments can be used to ease the symptoms.

It may take time to work out which is the best treatment for you. You may need to try different types or combinations of medicines before you find the most effective ones.

Painkillers

Many people who have migraines find that over-the-counter painkillers, such as paracetamol and aspirin, can help to reduce their symptoms.

When taking paracetamol or aspirin, always make sure you read the instructions on the packaging and follow the dosage recommendations. Children under 16 should not take aspirin unless it is under the specific guidance of a healthcare specialist. Aspirin is also not recommended for adults who have (or have had in the past) stomach problems, such as a peptic ulcer, liver problems or kidney problems.

Painkillers are usually the first treatment for migraine. They tend to be more effective if taken at the first signs of a migraine attack. This gives them time to absorb into your bloodstream and ease your symptoms.

Some people only take painkillers when their headache becomes very bad. However, this is not advisable because it is often too late for the painkiller to work. Soluble painkillers (tablets that dissolve in a glass of water) are a good option because they are absorbed quickly by your body.

If you cannot swallow painkillers because of nausea or vomiting, suppositories may be a better option. These are capsules that are inserted into the anus (back passage).

If over-the-counter painkillers are not effective, your GP or specialist may prescribe you a stronger painkiller.

Triptan medicines

If ordinary painkillers are not helping to relieve your migraine symptoms, triptan medicines might be the next option. Some triptan medicines, such as sumatriptan, are available without prescription over the counter. Others require a prescription from your GP.

Triptan medicines are not the same as painkillers. They cause the blood vessels around the brain to contract (narrow). This reverses the dilating (widening) of blood vessels that is believed to be part of the migraine process. Triptans are available in the form of tablets, injections and nasal sprays.

Triptan medicines only work for some people. If one type of triptan medicine does not seem to work, ask your GP about other types.

Anti-inflammatory medicines

Some people find that anti-inflammatory medicines such as ibuprofen are effective in treating the symptoms of migraine.

You can buy ibuprofen over the counter at a pharmacy, and it is available on prescription. However, do not take ibuprofen if you have (or have had in the past) stomach problems, such as a peptic ulcer, or if you have liver or kidney problems.

Diclofenac, naproxen and tolfenamic acid are anti-inflammatory medicines that are only available on prescription.

Anti-sickness medicines

If nausea is a symptom of your migraine, you can take anti-sickness medicines. These are prescribed by your GP and can be taken alongside painkillers.

As with painkillers, anti-sickness medicines work better if taken as soon as your migraine symptoms begin. They usually come in the form of a tablet, but are also available as a suppository.

Combination medicines

You can buy a number of combination medicines for migraine over the counter at your local pharmacy. These medicines contain both painkillers and anti-sickness medicines. If you are not sure which one is best for you, ask your pharmacist.

Many people find combination medicines convenient. However, the dose of painkillers or anti-sickness medicine may not be high enough to relieve your symptoms. If this is the case, you may prefer to take painkillers and anti-sickness medicines separately. This will allow you to easily control the doses of each.

Ask your GP or pharmacist if you are not sure which medication is most suitable for you.

Migraine clinics

If you are not responding to treatment or your migraines are not being well managed, your GP may refer you to a specialist migraine clinic for further investigation. Reasons for being referred include:

  • doubt over the diagnosis of migraine
  • a rarer form of migraine is suspected
  • other headaches besides migraine are present
  • treatment is not working well for you
  • your migraines or headaches are getting worse and/or more frequent

Treatment for pregnant women

In general, migraine treatment with medicines should be limited as much as possible when you are pregnant or breastfeeding.

If medication is essential, then your GP may consider prescribing you a low-dose painkiller, anti-inflammatory or anti-sickness medicine for the shortest possible time. Aspirin and triptans should be avoided.

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Complications of migraine

Stroke

Migraines are associated with a small increased risk of ischaemic strokes. An ischaemic stroke occurs when the blood supply to the brain is blocked by a blood clot or fatty material in the arteries.

The reason why ischaemic strokes are linked  to migraine is not entirely clear. An ischaemic stroke as a result of a migraine is very rare.

Another risk factor for ischaemic stroke is the use of the combined oral contraceptive pill. Medical professionals generally advise women who experience migraine with aura not to use the combined contraceptive pill.

Women who have migraine without aura can take the combined contraceptive pill. However, if you take the combined contraceptive pill and you have aura symptoms or your migraines become more frequent, see your GP as soon as possible to discuss alternative forms of contraception.

Mental health problems

Migraine is associated with an increased risk of mental health problems, including:

  • depression
  • manic depression
  • anxiety disorder
  • panic disorder

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Preventing migraine

Although there is no cure for migraine, it is possible to bring the condition under control using any of the following preventative measures as well as treatments.

Avoiding triggers

One of the best ways of preventing migraines is recognising the things that trigger an attack.

Keeping a migraine diary is helpful. You may find you tend to have a migraine after eating certain foods or when you are stressed. By avoiding this trigger, you can prevent a migraine.

Recognising the signs

Some people who experience migraines begin to feel unwell up to a day or so before a migraine attack. The strange sensations that are sometimes felt before a migraine are known as the prodrome. They can include:

  • a change in mood
  • tiredness
  • hyperactivity
  • food cravings

As these feelings are not specific to migraine, it can be difficult to identify them as warning signs. Try to be aware of how you feel before a migraine. Perhaps ask your relatives or friends if they notice any changes in you before you have a migraine.

Medication

Medication is available to prevent a migraine attack. These medicines are usually given if you have tried other preventative measures and you are still experiencing migraines. Your GP may also prescribe these medicines if you experience very severe migraine attacks, or if your attacks happen frequently.

Medications used to prevent migraines are outlined below.

Beta-blockers

Beta-blockers include propranolol, metoprolol and timolol. They are traditionally used to treat angina and high blood pressure. It is not known how beta-blockers prevent migraine attacks.

Beta-blockers are unsuitable for people with:

  • asthma
  • chronic obstructive pulmonary disease (COPD)
  • vascular disease
  • heart failure

Possible side effects of beta-blockers are cold hands and feet, tiredness and hallucinations (seeing or hearing things that are not real).

Amitriptyline

Amitriptyline is a type of antidepressant, but it has also been shown to prevent migraines. The medicine is usually started on a low dose, which can be increased if necessary. Amitriptyline can be used in combination with beta-blockers. It is unsuitable for people who:

  • have had a heart attack
  • have heart disease
  • have an irregular heart beat
  • have epilepsy

Anticonvulsants

Topiramate is a type of anticonvulsant. Anticonvulsants are usually used to prevent seizures in people with epilepsy, but can also help prevent migraines. Topiramate is currently the only anticonvulsant licensed for migraine prevention in the UK.

Other drugs

A large number of other drugs have been suggested for the prevention of migraine, but there is limited evidence as to how effective most of them are. They include:

  • the antimigraine medicines pizotifen and methysergide
  • the anticonvulsants gabapentin, lamotrigine and levetiracetam
  • selective serotonin reuptake inhibitors (a type of antidepressant)
  • verapamil (used to treat high blood pressure)

These medicines will only be prescribed when other treatments have failed.

Advice and support

To find out more about migraines and their management, contact The Migraine Trust.

You can call the information and enquiries line on 020 7462 6601 or email on info@migrainetrust.org

You can also join The Migraine Trust's online community through Facebook.

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