How To Treat A Migraine

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1 Managing your migraine

2 There is a great deal of help available to relieve the symptoms and reduce the severity and frequency of migraine attacks, but there is, as yet, no cure for migraine. The success of any treatment needs the intelligent co-operation of the sufferer. Therefore, a greater understanding of what migraine is, what triggers attacks, the signals that tell us an attack is about to begin, and what action can be taken by doctor and patient, is important. It must be emphasised here that migraine is a complex condition with a great deal of individual variation, so sufferers have to be their own detective and follow up their own clues. A family doctor who will actively and sympathetically join in the detective work is a wonderful asset for any migraine sufferer. The very nature of migraine makes it impossible to recommend any one treatment, and finding the right one for each of us takes time, during which it is easy to get discouraged and despairing. However, it is well worth persevering and the rewards can be great. What is migraine? It is believed that everyone has the capacity to suffer from migraine but, in 10-15% of the population, there is an increased susceptibility, a lower threshold at which an attack is triggered, which may be inherited, as migraine often runs in families. Migraine with aura (formerly known as classic or focal migraine) affects about 10% of sufferers. An attack begins with neurological symptoms (sometimes called an aura), most commonly visual disturbances, which can be flashing lights before the eyes, blind spots in the vision, tunnel vision, zig zag lines or even temporary blindness. Other aura symptoms can be memory loss, confusion, slurred speech, numbness or pins and needles in the limbs. These symptoms can be very frightening, particularly at first. Some sufferers experience only the aura without any other symptoms but for most people the attack proceeds as for migraine without aura. Most sufferers experience migraine without aura (formerly known as common migraine). For most people the worst symptom is an intense, throbbing headache which often affects only one side of the head (not always the same side). This is usually accompanied by a dislike of light (photophobia) and increased sensitivity to noise so that even everyday sounds appear to be amplified (phonophobia). Other symptoms may include sensitivity to smells (osmophobia) and gastrointestinal disturbances which can vary from a feeling of nausea or a dislike of food to prolonged vomiting and diarrhoea.

3 Migraine attacks can last for between 4 and 72 hours and sufferers are usually free of symptoms between attacks. A general rule is that, if your headaches are accompanied by two or more of the above mentioned symptoms, occur episodically and affect your ability to continue with normal daily activities, they are probably migraine. On average, sufferers experience 13 attacks a year. Some unfortunate people regularly get as many as one a week, whereas others can go for months between attacks and then have several in quick succession. If there were a single cause of migraine attacks, it might be possible for them to be cured by a single drug. This is, unfortunately, not the case because symptoms differ from person to person. Individuals may have several kinds of attacks at various periods of their life and each may require a different treatment approach. Migraine sufferers can also get other types of headache from time to time and it is important to differentiate between them and treat each type appropriately. What triggers an attack? It is believed that the release of serotonin (5HT) from its storage sites into the bloodstream causes changes to the neurotransmitters and blood vessels in the brain, resulting in a migraine. However, exactly what prompts this chain of events is still unknown. This is where the detective work begins! Most of us will have realised that certain circumstances sometimes start a migraine. The following list of so-called triggers is a pretty comprehensive one: some you will instantly recognise; others you may not think apply in your case. Check them anyway; you may discover something useful. Emotional stress: Anger Excitement Worry Shock Tension Depression, often after a stressful experience Strangely, the end of a busy or stressful time, when you are looking forward to resting or relaxing.

4 Physical stress: Trauma, such as a blow to the head Change in sleep patterns, e.g. a liein at the weekend Tension in neck and / or shoulders Diet / food: Environmental: Travelling Over-exertion / over tiredness (both physical and mental) Bending or stooping, as in gardening or housework Changes of routine, such as shift work, a new job, going on holiday Long gaps between meals, insufficient food, fasting or dieting Alcohol, particularly red wine, sherry or beer Certain foods, such as chocolate, cheese, citrus fruit, fried food Monosodium Glutamate - in many soups and meat products Bright light Flickering or flashing lights Intense or penetrating smells Hormones: Menopause Puberty Aspartame - an artificial sweetener Loud noise, particularly high-pitched noise Change of climate or weather - cold winds A stuffy atmosphere; central heating Smoking The contraceptive pill Hormone Replacement Therapy Menstruation and the pre-menstrual period Pregnancy - although 75% of mothers-to-be find that their migraines cease in the later stages of pregnancy, in some, their migraines become worse.

5 Other triggers: Use of sleeping tablets High blood pressure Toothache or other dental problems, teeth grinding Eye strain Congested nose / sinus problems Anything causing pain or discomfort to the face, neck or head - even wearing an unaccustomed hat can cause trouble Trigger factors are not the same for everyone, and any one trigger does not always start an attack, even in a person sensitive to that trigger. For many people there is not just one trigger but a combination of factors which individually can be tolerated but, when several occur together or accumulate over a short period of time, a threshold is passed, triggering an attack. Warning signs As well as being aware of all these trigger factors, migraine sufferers must also be on the alert for their own particular warning signs, which tell them that an attack is on the way. They are the signal for immediate action. Once again, these warning signs can vary a great deal in different people, and we just have to be aware of the ones that apply to ourselves. Warning signs can include: Excitability Unusual hunger Visual disturbances Depression Exhilaration Speech difficulties Unusual pallor Thirst or fluid retention Pins and needles sensations Tension Unusual energy Constant yawning Irritability Unusual tiredness Mental aberrations Weakness and trembling Sensitivity to light, noise or smells Change of bowel function Phantom smells which aren t really there It could probably be claimed that some of us exhibit many of these conditions most of the time, but it should be remembered that it is the unusual for which we must be on the look-out.

6 Action It can be extremely helpful to keep a diary to help you to identify your own personal trigger factors and warning signs. When you look back at your record you may find that a discernible pattern emerges and that relatively minor modifications to your diet and / or lifestyle could reduce the frequency and severity of your attacks. If you recognise a warning sign that tells you a migraine may be starting, stop what you are doing, drink a couple of glasses of water, stretch and take some deep breaths. Don t wait for the pain to start. Simple over the counter analgesics, such as aspirin or paracetamol can be very effective if taken at this stage. Stopping and resting can take courage and determination in some circumstances, but a short rest at this stage could save a lot of pain and distress later. The list of things that migraine sufferers do to help themselves once an attack has started is endless. Most people take their usual tablets and then rest somewhere away from noise and bright light. Soluble tablets or powders work more quickly but, if you have only ordinary tablets, try taking them with a sweet fizzy drink. In addition, it is helpful if the sufferer can sit or lie down in a quiet, dark room and, if possible, sleep. Sleep by itself can, if long enough, relieve the headache in some cases. A cold cloth on the head eases the pain for some, but others much prefer something warm on their head or neck. Some people find that activity such as a brisk walk can abort an attack in the early stages; fresh air can also help, as can relaxation techniques. Vomiting can be very distressing. Sips of a fizzy drink will sometimes stay down, when even plain water comes straight back. Most of us prefer not to take drugs if possible but with an attack of migraine, speed in taking action can make the difference between a normal day and one spent in pain and misery. Remember that, however busy you are, a short rest in the dark, early on in an attack might save time in the long run. If treatment is not started early enough to prevent an attack developing, a short rest might reduce the severity of an attack, and perhaps enable you to carry on your day s activities.

7 Treatments There is now a wide range of migraine treatments available including acute treatments to take when an attack strikes, or preventative treatments which are designed to be taken on a daily basis to reduce the frequency and severity of attacks. The main types of drugs used for the acute treatment of migraine are painkillers, anti-sickness preparations, antihistamines, 5HT agonists (known as triptans) which have been specifically developed for the treatment of migraine and act on the serotonin levels in the brain, and, although rarely used, there are drugs based on ergotamine tartrate which affect the blood vessels. Painkillers Preparations for pain relief that you can buy without a prescription will contain one or more of the following drugs: Aspirin: A non-steroidal anti-inflammatory drug (NSAID) which relieves pain and reduces inflammation and fever. It is unsuitable for asthma sufferers and can damage the lining of the stomach, so avoid it if you have a stomach ulcer. Ibuprofen: Another NSAID with similar effects to aspirin but less likely to cause stomach irritation. It is not recommended for anyone who has high blood pressure, kidney problems or stomach ulcer. Paracetamol: Relieves pain and reduces fever. Should cause no side effects in recommended dosage. Not to be taken by anyone with kidney or liver problems. Codeine: Related to morphine, and so allowed only in small amounts in nonprescription medicines. Found in combination with other painkilling drugs. Even small doses can cause constipation in some people.

8 With only these four drugs to work with, many brands of painkillers will be the same as each other. Some are easier to swallow, some fizz or dissolve in water, some have added ingredients such as caffeine, bicarbonate of soda, muscle relaxants or an antihistamine. Tablets that contain caffeine are meant to give a lift - not a good idea if you plan to rest or sleep. On the other hand, if you still have to struggle home, or even try to carry on working, a little caffeine might be what you need. You will get as much or more caffeine from drinking a cup of coffee with your painkillers as you would from taking special, more expensive, combination tablets. Some painkillers have a small amount of antihistamine in them, which seems to help many migraine sufferers (see our booklet Pain and Painkillers for more information). It is best to take tablets with a drink while sitting or standing up. Remain upright for about a minute after taking them and then lie back and rest if you can, to give them a chance to work. Prices of over-the-counter painkillers vary a great deal and this variation does not seem to have much relationship to the actual ingredients in many cases. For example, one well advertised brand of tablet, containing aspirin, costs over four times as much as another identical one. When you have found a drug that suits you, ask the chemist for the cheapest version of it. Basic painkillers can be prescribed by your doctor but, if you pay for your prescriptions, it is probably cheaper to buy them over the counter. Remember to read instructions on packets and / or the patient information leaflet inside and, if you are in the slightest doubt about how or when to take any drugs or if you are taking other medication, ask your pharmacist for advice. Too many painkillers can actually cause extra headaches. Stronger painkillers Stronger painkillers can be prescribed by your doctor. These are mostly based on narcotic drugs, can be addictive and have side effects. If possible, it is best to stick with the milder painkillers, taken at the right time, in the appropriate dosage, to get the maximum effect. Your doctor can also prescribe other NSAIDS (e.g. diclofenac, naproxen) which may be more effective than those you can buy over the counter. Tolfenamic acid tablets are also available on prescription.

9 Anti-sickness drugs Many people find that even strong painkillers have no effect on the severe pain of a migraine headache. Research indicates that the stomach can slow its normal activity during an attack, a condition known as gastric stasis, when nothing in the stomach is absorbed into the bloodstream and therefore no benefit is gained from any tablets that have been swallowed. If gastric stasis can be ended, then comparatively mild painkillers may be sufficient to relieve the pain. Metaclopramide and Domperidone, two drugs normally prescribed for nausea and vomiting, can make our stomachs work normally again, allowing painkillers to get to work. Either of these drugs can be taken with your usual painkiller; early on in a migraine for best results. The golden rule is: recognise your warning signs and take painkillers before the pain starts - add an anti-sickness drug mentioned above and you have a very good chance of preventing your migraine from developing. Domperidone is also available as a suppository, useful if vomiting has already started. Severe and persistent vomiting can result in dehydration, i.e. lowering of body fluids, and can make you feel very ill indeed. Some migraine sufferers consider that vomiting is the worst part of their attacks; there is no doubt that retching makes any head pain much worse and, if this can be controlled, the whole situation becomes more bearable; painkilling drugs stay down, and sleep may be possible. The anti-sickness drugs mentioned are available on prescription only but some people find that over the counter products for digestive problems (e.g. Gaviscon) are effective alongside simple painkillers. Prochlorperazine is available over the counter as Buccastem M. Your doctor can also prescribe preparations containing both painkillers and anti-sickness medication (e.g. Migramax, Domperamol and Paramax). Tranquillisers and anti-depressants For some people small doses of drugs such as diazepam may be helpful at the start of an attack. Ergotamine tartrate and dihydrioergotamine Some people can stop their migraines from developing by taking preparations which contain ergotamine. These are not painkillers but stop the pain of a migraine attack by acting on the blood vessels. They work best if taken as soon as a migraine is signalled. Research has shown that some people do not absorb ergotamine easily when it is taken by mouth and, often, a lower dose is effective, if taken in another way. As well as tablets, it is available in suppository form.

10 Ergotamine is not suitable for migraine sufferers who have very frequent attacks, as there is a limit to the amount that can be taken in any one week. Large overdoses can be very dangerous and overuse over a period can cause side effects very similar to another migraine attack with headache and sickness. Ergotamine is available on prescription only. Ergotamine based drugs such as Cafergot, Lingraine and Migril should NOT be taken concurrently with beta blockers or 5HT agonists. 5HT agonists The newest drugs for the treatment of migraine are 5HT agonists also known as the triptans. These act on a naturally occurring substance in the brain called serotonin, which is believed to be implicated in migraine attacks. These drugs have brought many sufferers a level of relief they had previously thought unimaginable but, unfortunately, they are not suitable for everyone. They should not be taken by anyone with uncontrolled high blood pressure, vascular disease, renal impairment, heart disease or a sensitivity to sulphonamides and they are not recommended for people under the age of 18 (12 for Zomig) or over 65, or for women who are pregnant or breast feeding. They should not be taken concurrently with ergotamine, some anti-depressants, lithium, methysergide or other 5HT agonists and it is recommended that you advise your doctor or pharmacist about any other medications that you may be taking either on prescription or which you have bought yourself. Possible side effects include a feeling of tightness or pressure in the throat, chest or neck, tingling of the limbs, a feeling of heaviness or weakness, increased sensitivity of the skin, dizziness or drowsiness and nausea. Such effects are usually mild and of short duration. There are seven products in this group: Imigran (sumatriptan which is available in injection, tablet and nasal spray form, Zomig (zolmitriptan) in tablet and rapimelt (dissolves in the mouth) form, Naramig (naratriptan) in tablet form, Maxalt (rizatriptan) in tablet and wafer (dissolves on the tongue) form, Almogran (almotriptan) in tablet form, Relpax (eletriptan) in tablet form and Migard (frovatriptan) in tablet form. Acute migraine treatments are available in a variety of forms including tablets, powders, soluble tablets, capsules, suppositories, injections and nasal sprays. It may well be worth trying a treatment which is administered in a different way, if your current treatment is not bringing you significant relief.

11 Acute treatments for migraine are not designed to be taken every day. If you are regularly taking one of the above treatments on more than 3 days a week or more than 15 days each month, you should consult your doctor to confirm your diagnosis and discuss other options. Long term preventative treatment (Prophylaxis) If, while trying to avoid your own particular triggers, learning to relax and generally leading a healthy life, you still get four or more migraines a month, then your doctor may decide to prescribe other drugs to be taken every day to control attacks. Long term preventative treatment is now possible for many sufferers but it is usually only considered when attacks are frequent. The drugs used are not suitable for everyone. They include: Beta blockers (e.g. propranolol or atenolol): These drugs were originally developed to treat patients with high blood pressure but have been found to be effective in the prevention of migraine. Side effects can include nightmares, hallucinations, tiredness and cold extremities. Beta blockers should NOT be taken at the same time as ergotamine preparations. Propranolol should not be taken concurrently with 10mg tablets or wafers of Maxalt. 5HT antagonists (e.g. pizotifen): Reduces the severity and frequency of attacks in about one third of sufferers. Drowsiness and increase in weight are the most common side effects. Clonidine (Dixarit): Probably most useful for those sufferers whose attacks are associated with certain foods and also for menopausal women who are experiencing hot flushes. Tranquillisers and anti-depressants: Low doses of anti-depressant drugs (e.g. amitriptyline) have been shown to be effective in preventing migraine even in migraineurs who have no symptoms of depression. Sometimes migraine sufferers can become anxious or depressed and research has shown that symptoms of depression are present in a higher proportion of migraine sufferers than in the population as a whole. It must be emphasised that anyone suffering from depression must be treated by their doctor. Anti-convulsants: Certain drugs which were originally developed to treat epilepsy such as sodium valproate (Epilim) have also been found useful in low doses for migraine prophylaxis. Methysergide (Deseril): Helpful to some people but, because of potential side effects, treatment must be discontinued for at least one month in six.

12 Calcium channel blockers: Effective in treating familial hemiplegic migraine. Results of some trials with other types of migraine are encouraging but more research needs to be done. Aspirin: 75mg of aspirin daily has been shown to be helpful in preventing attacks in some people. Please consult your doctor before trying this and ensure that you take the correct dosage (many tablets contain 300mg). Botox injections: originally used for cosmetic purposes, is now licensed as a long term preventative treatment for use in chronic migraine. To be eligible for this treatment, individuals need to experience headaches for 15 or more days per month, with migraine on at least 8 of these days. Almost all drugs used in long term preventative migraine treatment have side effects on some people, a few serious. Obviously they are not prescribed without weighing up the advantages and disadvantages. Some of the drugs take a while to have any effect and need to be taken for a period of time, even several weeks, before any benefit is achieved. Patience and perseverance are required to find out which, if any, are suitable for each of us; long term preventative migraine drugs have changed the lives of many sufferers. Preventative treatments will be most effective if taken at a regular time every day. It is important to realise that preventative tablets will not help an individual attack. It is a long term solution which needs to be taken at a regular time each day and may take several weeks to show full benefit. Preventative medication can reduce the frequency and / or severity of attacks but seldom eliminates them entirely. You may also need an effective compatible acute treatment for any breakthrough attacks. Ask your doctor or pharmacist whether you can take your usual tablets for individual attacks if needed while you are taking preventative treatment. Other treatments Some migraine sufferers turn to non-medical treatment in their attempts to find relief. As pointed out earlier, there are considerable variations in people s response to drugs and likewise with other treatments; similarly they can also have unpleasant side effects in some people. Many people, when trying an alternative or complementary therapy, say, Well, at least it can do no harm. This is not true.

13 Herbal and homeopathic remedies: Practitioners of herbal and homeopathic medicine recommend a consultation so that suitable remedies can be tailored to the individual. If you buy remedies over the counter or by mail order, remember that the claims of efficacy may not be scientifically proven, the products may not have been clinically trialled and accurate measurements of the ingredients may not be guaranteed. Feverfew: A double-blind trial at the City of London Migraine Clinic showed that Feverfew (Tanacetum Parthenium) was effective as a long term preventative treatment for migraine in approximately 70% of those who participated. Vitamin B2 in doses of 400mg daily has been shown to be helpful but the long term effects are not known. Magnesium has also been shown in trials to be beneficial. Acupuncture: If this is going to help (and it does help some), it will begin to have an effect after two or three treatments. Don t go on and on spending money in the hope that things will improve. Most people who have been helped have to go back for one or two sessions every now and then, to be topped-up. There are a number of qualified doctors all over the country who also practise acupuncture. Physiotherapy: This can help those whose migraines are triggered by tension in neck and shoulders or by neck problems. Chiropractic and osteopathy can help some people, especially if they think their migraine has been triggered as a result of accident or trauma. Cranial osteopathy may particularly help people who experienced difficult births. The Bowen Technique: The results of a recent small study were very encouraging. Yoga, hypnosis and meditation: Often used as a way of calming emotions and becoming more relaxed. Relaxation: This is a technique that everyone should try to learn. It can he used to encourage sleep and relieve tension and stress. You will feel the benefits throughout your life. Reflexology: Involves the use of massage of reflex areas in the feet and hands. Aromatherapy: Essential oils to inhale, use for massage or in the bath. They have a very calming and relaxing effect.

14 Special tinted glasses, hot or cold packs, dental splints, devices that emit electronic impulses and magnetic devices have also been helpful for some people. If you decide to try one of the alternative options, please consult a qualified registered practitioner and ensure that he / she has adequate insurance. Your GP or health centre may be able to recommend one. Keep your GP informed of any other treatments you are trying and advise your alternative practitioner of any medication you are taking. Self help measures Perhaps the first stage of understanding your migraine is to keep a diary to try to identify your trigger factors. You may find that an identifiable pattern emerges and that, by making a few minor changes to your diet or lifestyle, you can reduce the frequency and / or severity of you attacks. The diary is also useful to record the frequency, severity, length and symptoms of your attacks and the effect they have on your quality of life (e.g. how much time you need to take off work, if you need to retire to bed, the things that you are unable to do etc.) and thus help your doctor to prescribe appropriately for you. Avoid foods to which you know you are sensitive but do not make dramatic changes to your diet, based on reported sensitivities in other people. Everyone is an individual with their own particular trigger factors. Remember that a balanced diet is important and ensure that, if you eliminate a certain group of foods from your diet, you replace all the essential vitamins and minerals from other sources. Eat regularly, avoid sugary snacks and include slow release carbohydrate foods in your diet. Low blood sugar is a major factor for many people so it is important to eat regularly (intervals of no more than 4 hours during the day and 11 hours overnight) to keep blood sugar levels stable, avoiding dramatic peaks and troughs. A high carbohydrate snack before bed can be particularly beneficial for people who wake with a migraine or for children who often have a long overnight fast. Drink plenty of water - at least 2 litres a day. Limit your intake of drinks containing caffeine and alcohol. Regular exercise can help to prevent attacks and is beneficial to your overall well being. Get plenty of fresh air and practise deep breathing.

15 Maintain a regular sleep pattern - limit late nights and weekend sleep-ins. Ensure that ventilation indoors is good and try to keep rooms at a constant temperature. Avoid strong perfumes etc. Avoid bright lights, flashing or flickering lights (e.g. fluorescent). Avoid large reflective surfaces (e.g. plain white walls). Wear sunglasses and / or a hat in bright sunlight. Ensure that computer screens are properly adjusted and fitted with antiglare filters. Take care with your posture and ensure that your working environment is as ergonomically designed as possible (e.g. chair at the correct height, back rest properly positioned, avoid the need to stretch or twist the body or remain in awkward positions for long periods). Learn relaxation techniques. Recognise your limitations and try not to push yourself too hard - put yourself first at least once every day. Consult your GP for an accurate diagnosis and to discuss treatment options. Keep going back if necessary until you have your migraine under control. Remember that there is, as yet, no miracle cure for migraine but it is possible to manage your condition rather than allowing it to control your life. As there is no one cause for most of us there will not be just one remedy, we may need a combination of treatments, lifestyle changes or a combination of both to enable us to bring our migraine under control. We are all individuals and it is very much a matter of trial and error until you develop a management plan which works for YOU. It is possible to substantially improve your quality of life. Migraine attacks can suddenly stop, or gradually lessen at any time of life. This sometimes makes it difficult to be certain if any one particular treatment has helped. Although not a life-threatening condition, migraine can have far reaching effects on quality of life. It can make us depressed, even suicidal; it can make us unreliable at work or home. It can make us timid, we can become afraid of taking responsibility, wary of planning outings and holidays, reluctant to attend parties. We fear that we may let down our colleagues, disappoint our families and friends or spoil the fun by being ill. We must remember that many, many people have found ways to control and manage their attacks - so if at first you don t succeed, try, try, try again. Don t give in, be brave, do something about your migraine NOW.

16 For further information, advice on migraine management and for updates on the latest migraine research, please contact Migraine Action by calling , ing or visiting the charity s website at All of our information resources and more are only made possible through donations and by people becoming members of Migraine Action. Visit to support one of our projects or visit to become a member. 4th Floor, 27 East Street, Leicester. LE1 6NB. Tel: Fax: Web: Registered Charity No Copyright 2010 Migraine Action This publication provides information only. Migraine Action and its officers can accept no responsibility for any loss, howsoever caused, to any person acting or refraining from action as a result of any material in this publication or information given. Whilst this booklet has been reviewed for accuracy by members of Migraine Action s Medical Advisory Board and other experts, the information does not necessarily reflect the views of individuals. Medical advice should be obtained on any specific matter.

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