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Migraine

NHS Direct Online Health Encyclopaedia

Introduction
Migraine refers to a recurrent severe headache. These headaches are often accompanied by nausea, vomiting, sensitivity to light and/or sensitivity to sound. Migraines tend to occur at intervals; there may be days, weeks or months between attacks. Attacks can last between 4 and 72 hours.

The term migraine comes from the words hemicrania, meaning one-sided headache. In most cases the pain occurs only on one side of the head.

Migraines are different from tension headaches. Some people experience an aura (visual disturbance) sometime before the headache and other symptoms begin. This was formerly known as a classical migraine. A migraine without an aura is a common migraine.

Migraine occurs more commonly in women than men and usually begins between the teens and the forties. As well as adolescents, the age group 30-40 is commonly affected.

Children can also be affected by migraine. Migraine attacks in children usually start in the early to mid teens (puberty), but can start at any age. Boys tend to start getting migraine headaches at a younger age than girls.

It is estimated that almost 6 million people in the UK are affected by migraine. In some cases, it appears to run in families.

Symptoms
Migraine attacks often start when you wake up in the morning. If they start during the day, the attack tends to take several hours to build up.There are five distinct stages to migraine. Not all individuals experience all the stages:

Prodromal (pre-headache) or early warning stage

Some people experience strange feelings, including changes in mood, energy levels, behaviour and appetite (including food cravings) and as well as aches and pains several hours or even days before an attack.

Aura

In about 1 in 6 cases, a migraine is preceded by a stage of neurological (brain) disturbance called an aura. Symptoms include visual disturbances such as flashes of light or blind spots (areas that you cant see), difficulty focusing and seeing things as though through a broken mirror. This stage may also include numbness and pins and needles in the arms, face, tongue or lips. There may be quite widespread weakness of muscles, usually affecting only one side of the body. Speech may also be temporarily affected. This stage normally lasts around 15 minutes to an hour.

Headache stage

In most cases there is no aura stage; the attack starts with the headache. This is usually a pulsating or throbbing pain on one side of the head. There is often nausea or vomiting, extreme sensitivity to bright light and loud sounds, and a strong desire to lie down in a darkened room. There may be stiffness of the neck and shoulders, tingling or stiffness in the limbs, an inability to concentrate and difficulty in speaking. Some people experience indigestion or diarrhoea. In rare cases there may be paralysis or loss of consciousness. This stage lasts for around 4-72 hours.

Resolution stage

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

Postdromal (after headache) or recovery phase

Lastly there may be a stage of exhaustion, tiredness and weakness.

The term status migrainosus refers to a migraine that lasts longer than 72 hours, when all the other symptoms disappear but the headache remains.

Causes
The cause of migraine is unclear.

It is thought migraine may occur when there is a decrease then increase in blood flow to part of the brain, probably caused by blood vessels narrowing then opening again. The stretching of the blood vessel wall causes pain.

In addition to any blood vessel changes, it is thought that some chemicals in the brain increase in activity during a migraine. It seems that levels of serotonin, or 5HT (a chemical that is important to brain function and has an effect on the size of blood vessels) decrease at the onset of the headache but are normal in the periods of time between attacks.

If you get migraines, you may have a more sensitive pain centre in the brain than other people. This means that things like bright lights or when you are tired affect your pain centre more.

Triggers:

Most attacks occur for no apparent reason, but some people notice triggers including:

foods, such as dairy products (particularly cheese), chocolate, alcohol (particularly red wine), caffeine, citrus fruits, nuts, fried foods and foods containing monosodium glutamate (MSG) such as Chinese food, processed meats and frozen pizzas.
bright lights (photophobia),
insufficient food or missing meals,
long journeys/travelling,
certain medication such as sleeping tablets or hormone replacement therapy (HRT),
loud noises (phonophobia),
strong smells (osmophobia),
changes in the weather,
neck and back pain,
stress or anxiety, and
tiredness, not having enough sleep or oversleeping.
There can be more than one trigger for a migraine. Being tired, in combination with another trigger can set off a migraine. It may be useful to keep a diary of your symptoms so you can look for a pattern and avoid certain triggers. Note the date of the attack, what time of day the attack began, what the warning signs were, your symptoms (including the presence or absence of an aura), what medication you took and when the attack ended. It is worth noting that some things that you may think are triggers (for example, chocolate), may have been a craving in the prodromal phase. This means that the migraine was on its way before you ate the chocolate, so the chocolate was not the cause.

Hormones:

Migraine is more common in women than men, and this is linked to hormonal changes. During the menstrual cycle, the levels of oestrogen and prosgesterone in a womens body fluctuate. Evidence shows that migraine is linked to a fall in oestrogen levels. Many women find that the worst headache coincides with the start of their period, which is when oestrogen levels are lowest. Many women find that their migraine headaches become less severe or disappear when they are pregnant.

The combined oral contraceptive pill, containing oestrogen and progesterone can make migraine worse. If you suffer from severe migraine that has neurological symptoms (classical migraine), you should not take the combined contraceptive pill. Neurological symptoms include speech and vision difficulties, and numbness or tingling affecting a limb or one side of the body. Taking oestrogen may increase your risk of having a stroke if you suffer from severe migraines.

If your first ever migraine occurs whilst taking the pill, you may have to stop taking it. If this happens, you should consult your GP who will assess the headache. If the migraine is not suggestive of any disturbance of blood flow to the brain, you may be able to continue with the combined pill.

Diagnosis
There is no test to confirm migraine. Diagnosis depends on the symptoms, so your GP will ask you how long your attacks last, how severe they are and how frequently they occur. You should also tell your GP what medication you have been taking, if any, including over-the-counter medicines.

If you do not have any symptoms between attacks and then have a headache that lasts 4-72 hours you may suffer from migraines. Your GP will ask if your headaches are:

Located on one side of the head (unilateral)
Characterised by a pulsating pain
Moderate or severe and prevent you carrying out your 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).
The doctor may suggest tests to rule out other causes of headaches. These may include a CT scan (computerized tomography) or an MRI scan (magnetic imaging resonance). Your GP will also try to rule out atension headache or a medication-overuse headache.

See your GP urgently if:

You have your first severe headache and you are over the age of 50;
Your symptoms suddenly change from your usual migraines;
You have your first severe headache that came on suddenly (within one or two minutes); or
You have a severe headache with fever, sickness and possibly a rash.
If you have a severe headache that feels like the worst headache you have ever had, you need to phone 999 or go to the Accident and Emergency (A&E) department of your local hospital.

Treatment
Most people find that sleeping or lying in a darkened room is the best thing to do when having a migraine attack. Others find that eating something helps, and others start to feel better once they have been sick.

Medication to treat symptoms of migraine

See your GP about your migraines. There is a range of migraine medication available. Taking the medication very early in the migraine attack is best because the stomach is not easily able to absorb tablets during a migraine.

Painkillers such as paracetamol or aspirin are effective in many cases, together with an anti-sickness drug such as metoclopramide (not generally recommended for children) or domperidone. Some tablets used for migraine attacks contain both; Migraleve contains paracetamol and codeine. These drugs may not suit everyone, so speak to your GP or pharmacist if you are unsure.

Some people find NSAIDs (non-steroidal anti-inflammatory drugs) are effective. They relieve swelling, pain and inflammation. They include ibuprofen (which is available over the counter) and naproxen, diclofenac potassium and tolfenamic acid (for which you need a prescription).

Effervescents (dissolvable tablets) are used by people who cannot keep tablets down. Injections, nasal sprays, wafers or suppositories (soft capsules that you insert into the vagina or anus) are other options.

Drugs called triptans (or 5HT1 agonists) are used to relieve the symptoms of migraine. Triptans make the blood vessels in your brain narrower, which can stop your brain from feeling the pain of migraine, at least partly. You may have to try more than one triptan before finding one that suits you. They include eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, almotriptan, and frovatriptan. Take them at the start of the headache stage, not before (not during the aura stage). Side effects of these drugs can include sickness, dizziness, nausea, vomiting, neck pain and stiffness, and a sensation of heaviness or pressure anywhere in the body. They should be avoided if you are over 65, or have a history of heart disease, stroke or high blood pressure (hypertension).

If your migraine are severe and do not respond to other treatment such as painkillers, your GP may suggest a drug such as eergotamine tartrate. This should not be used if you have kidney problems, heart or circulatory disease, high blood pressure or are pregnant or breastfeeding.

Medication to prevent migraine

There are drugs available that can reduce the frequency and severity of your migraines. You have to take the medication every day and can still take painkillers or triptans when you get a migraine. You will need to speak to your GP about what medication will suit you best because some drugs have side effects. Drugs that can help to prevent migraine include:

beta blockers, such as propranolol (people with asthma cannot take these),
pizotifen (these can cause weight gain and drowsiness so are usually taken at night), and
antidepressants, such as amitryptyline.
Migraine mediation and the combined contraceptive pill

Fluctuating oestrogen levels can make migraine worse. If you take the combined contraceptive pill and suffer from migraine, you may be advised to change to the progesterone only pill. If you have classical migraine, with the preliminary aura stage, you should not take the combined contraceptive pill, due to the increased risk of a stroke.

Complications
Migraine carries an increased risk of stroke, although this is rare. You should not take the combined contraceptive pill if you suffer from classical migraines (with the aura stage).
Prevention
Taking anti-migraine medication (see treatment section) when the early symptoms of a migraine begin can prevent the migraine from being prolonged or severe.

Only take the minimum amount of medication needed and do not take it too often because too much medication can actually cause a migraine. You should aim to have at least four days per week when you do not take any anti-migraine medication. Some women find that they need to take migraine medication around the time of their period as this is when migraines are likely to occur.

You should also try to find out what triggers your migraines, if anything, and avoid these things (see causes). Some people try exclusion diets, which involves cutting out something that you think might be causing the migraines until you discover the trigger.

Try to take regular exercise, eat a healthy diet, and eat regularly to keep your blood sugar levels up. Stick to your daily allowance of alcohol (avoid binge drinking), avoid stress, try to get plenty of rest and relaxation and enough sleep.

Stay healthy with this safe drinking guide Take the 5-a-day fruit and veg test See your GP for referral for treatment if you suffer from chronic (long term) neck or back pain.

In terms of complementary therapies, some people may find that relaxation techniques and herbal medicine such as feverfew (1) may help prevent migraine attacks. Acupuncture is thought to be useful in preventing migraines and other types of headache (2).


References
(1) Bandolier

(2) Hitting the headlines

© Queen's Printer and Controller of HMSO, 2005

Crown copyright material is reproduced with the permission of the controller of HMSO and the Queens Printer for Scotland.

 

 

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