Migraine

MIGRAINE

Expert Care for all Neurological Conditions

Overview

It’s estimated that about 1-2% of people worldwide suffer from chronic migraine. Migraine is more common in women than in men. Research by the World Health Organisation has established migraine as the 6^th highest cause of years lost to disability. The onset peaks between the ages of 35 - 45 years. The natural history of headache is to improve. Unfortunately, individuals with migraine will experience periods of time when they are more susceptible to headache. We do not know the exact cause of migraine, but researchers believe that the answer lies in genetics, with migraines tending to run in families. Women are about three times as likely as men to experience migraines, most probably due to hormonal factors. Women might experience a migraine just before, or just after, the start of their period; find that oral contraception (the pill) can trigger or help migraines; changes of headache in pregnancy; experience migraines as they approach the menopause, or hormone replacement therapy (HRT) triggers migraines. In many, but not all patients it is possible to identify triggers. It may be difficult to identify triggers as they differ between sufferers, and it is often a combination of factors that act together to trigger an attack.

Symptoms & Diagnosis

Each migraine can follow a different pattern and this can change over the course of a lifetime. There are several phases of a migraine. Before an attack starts people may feel tired or yawn more, some may have more energy or experience craving, or find they need to pass urine more. This is known as the premonitory phase. These can start several hours of days before the migraine attack. The next phase is the Aura which is described below. This is experienced in 20-25% of those with migraines. The headache phase follows this with the symptoms described above. The final phase is the postdrome/recovery phase . At this stage the headache has gone but is left the person feeling tired and washed out. People commonly feel tired for up to two or three days after a migraine.

The pain of migraine headaches can be severe, throbbing and is often accompanied by excessive sensitivity to light (photophobia), loud sounds (phonophobia), or smells/odours, as well as nausea and/or vomiting. Migraines commonly last between 4-72 hours and can be made worse by movement. People who have fewer than 15 attacks per month, each one lasting between four and 72 hours, have episodic migraines. These are the most common sorts of migraines. Every year, about 2.5% of migraine sufferers progress from episodic attacks to chronic ones. Chronic migraine is when someone has 15 days or more of headaches with at least 8 of those being migraines. Although migraines are not life-threatening they can have a significant impact on the quality of people’s lives, including their family and social life and employment. Some patients also experience aura. Aura is the name given to part of the migraine made up of a range of temporary neurological symptoms including visual changes (flashes of lights, loss of vision, zigzag patterns), tingling sensations, speech problems, dizziness, weakness on one side of the body and, very rarely, loss of consciousness. Theses symptoms usually begin in one place and move over time allowing us to distinguish from the symptoms of a stroke which typically have a sudden, abrupt onset. Auras can last from five to 60 minutes, and usually happens before the headache. It is also possible to have the aura without the migraine (acephalic/silent migraine). Imaging of the head, neck and balance centres may be requested by the consultant as part of the diagnostic work up.

Around 40% of migraine sufferers will experience significant vestibular symptoms (vertigo, balance disturbance) before their attack or as a main symptoms. Those who experience balance disturbance, room spinning (vertigo), motion intolerance and other more common migraines symptoms are likely to have vestibular migraines. The underlying mechanisms are unclear but it is thought to be another manifestation for migraine aura. Management of this involves a multidisciplinary approach, working closely with neuro-otology colleagues and vestibular rehabilitation physiotherapists.

Treatments & Key Areas We Specialise In

Acute treatments

There is no absolute cure for migraine, but there are lots of treatments are available to help ease the symptoms of a migraine attack. When a migraine attack occurs, most people find that lying down in a quiet, dark room is helpful. Sleeping may help and some people find that their symptoms die down after they have been sick. Along with medical treatments, lifestyle modification is also important. This includes getting better sleep with a regular routine, eating healthier, stress management using mindfulness for example, and moderate exercise. Treatment for migraine falls into two main groups, “acute” treatment, and “preventative” treatment. Occasionally, “transitional” or “bridging” treatments are also used; these can produce a beneficial effect quickly, but effect is generally short-lasting. A headache diary can be very helpful in guiding treatment and monitoring response.

Acute (abortive) treatments are used to stop a headache once it has already started. These include painkillers such as aspirin and non-steroidal anti-inflammatories and triptans (painkiller specifically for migraine headaches). Triptans are available in different forms to suit individuals needs (tablets, injections and nasal sprays). Some people develop short-term side effects when taking them including chest or throat tightness, a rushing feeling in the body or tingling in the fingers are often reported but are not harmful. Anti-sickness medication can also be used to help the nausea and vomiting but is mostly used to help you absorb your painkillers faster. A combination of treatment, including a tripan, anti-sickness plus either aspirin or an anti inflammatory taken all together at the start of an attack can be better then using the same drugs, one after the other over a few hours. It is important to avoid taking painkillers on more than 10 days per month as this can make things worse by triggering medication overuse headaches. This may lead to a daily headache and may make it more difficult to treat the migraine with preventative drugs.
Preventative treatments

If you are having migraine headaches more than three to four times per month, or regular headaches you may need to go on a preventative medication. Preventative (Prophylactic) treatments are used to prevent the headaches from occurring in the first place, they are not pain medications. There are several oral treatments (drugs originally developed for epilepsy, high blood pressure or depression) as well as some injectable ones (Botulinum toxin A Botox and CGRP monoclonal antibodies). Transitional Treatments are used to obtain temporary relief while waiting for the preventive treatments to start working. This includes Greater Occipital nerve blocks.
Non invasive stimulators

Because not everyone can take drugs (e.g. pregnant women or those trying to conceive) there are also non-drug devices that can prevent attacks or help during one. These should be discussed with the consultant before trying especially if Pregnant or considering starting a family. These include:

• The Cefaly device is an electrode attached to a strap that you wear on your forehead. It can be used during an attack, leaving it on for an hour as it buzzes the nerves going into the brain. It can also be used every evening for 20 minutes to prevent pain.
• The single-pulse transcranial magnetic stimulation device (sTMS) is placed on the back of the head and the magnetic pulses stimulate electrical activity in the brain. It can be used up to twice a day to prevent migraines, and give yourself four more pulses during an attack. Research is limited as to the long-term effects and therefore this treatment is only given by headache specialists.
• Nervio is a patch worn on the arm that can be activated during a migraine with a cellphone app. It sends signals to the brainstem to block the pain. It’s only approved for people with episodic migraines and isn’t available in the UK at the moment.
• External nerve stimulators: There is emerging evidence for handheld nerve stimulators as a way to reduce the pain and frequency of migraine attacks. The device is held on the side of the person’s neck and works by giving out an electrical current to stimulate a nerve in the neck. These devices have been approved as safe to use by the National Institute for Health and Care Excellence (NICE) but more research is needed to confirm exactly how effective they are. Currently, the device is not routinely available on the NHS.

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