Q. Can I be cured?
A. It is not possible to cure a patient of migraine but we can improve the control. By addressing trigger factors (see below), it is possible to reduce the frequency of attacks. It is often the case that various trigger factors need to come together on a particular day to provoke an attack.
Other elements of management revolve around the development of a healthy lifestyle with regular food, exercise and sleep, together with the optimal use of both acute and preventative drug therapies.
Common trigger factors
- stress
- lack of food
- certain foods - such as chocolate, cheese, red wine, citrus fruits, coffee, tea, tomatoes, potatoes
- caffeine withdrawal
- physical activity
- smoking
- menstrual cycle
- trauma
- fatigue
Q. If I were to have children, are they likely to have migraine?
A. If migraine has developed fairly early in an index case and the attacks are also severe, it is quite likely that the children may develop migraine.
Q. Why does the intensity of migraine vary?
A. It is sometimes possible to identify changes in lifestyle that will create more stress and, therefore, more attacks. It is common for migraine sufferers to do very well when under stress but, when the stress is relieved, for instance at weekends, attacks tend to break through.
Stress created by examinations can make attacks occurring in the late teens much more difficult to cope with and this may contribute to an increasing frequency of attacks. It is also true to say that the ebbing and flowing of frequency and severity often occur for no identifiable reason.
Q. What happens inside my head during a migraine attack?
A. When the various trigger factors work together to initiate an attack, it would seem that an area of the brain called the hypothalamus, becomes active. This then influences the trigeminal nerve (sensory nerve to the face) and the blood vessels which supply blood to it.
Many of these changes appear to be fueled by the reduction in a brain chemical called serotonin (5-HT1B and D). It seems to be necessary for both the neurological tissue (nerves) and blood vessels to interact to cause the symptoms of migraine.
Q. I have found it helpful to take medication at the beginning of an attack. Is it usual for most people with migraine to find this?
A. In general, it is always best to take a treatment as early as possible in an attack - even before the headache begins if warning signs make that possible. Traditionally, patients will try simple pain-killers before seeing a doctor but when doing so they sometimes make the mistake of waiting until the headache is established before taking the medication.
In general, it is always best to take a treatment as early as possible in an attack - even before the headache begins if warning signs make that possible. Traditionally, patients will try simple pain-killers before seeing a doctor but when doing so they sometimes make the mistake of waiting until the headache is established before taking the medication.
One of the problems in migraine is that the stomach fails to empty as quickly as usual and this leads to a reduction in the absorption of drugs. It is, therefore, necessary to take a larger dose of pain-killer before achieving a reasonable blood level. It is my usual advice to suggest three aspirin, paracetamol or Nurofen right at the beginning of an attack. If this approach fails, the doctor will often suggest adding in a drug which helps the stomach to empty and reduces nausea as the next step. This drug would be taken alongside the analgesic.
There are several more specific migraine therapies, such as triptans, which doctors can prescribe but most of the modern treatments are only licenced for use in patients from the age of 18 upwards.
It has recently been suggested that pain-killing drugs and anti-sickness drugs may actually work in a completely different part of the migraine cycle than that related to serotonin. Some patients find that medications which replace low serotonin (triptans) are initially effective but they then have a recurrence of headache within the next 24 hours. There would, therefore, be a rationale for taking an anti-sickness and analgesic combination in addition to a triptan. This is called ‘rational polypharmacy’.
Q. Apart from avoiding my trigger factors, is there anything I can do for myself without seeking a prescription from my doctor?
A. It is thought that a generally more ordered lifestyle with a regular sleeping and eating pattern, together with exercise, can be of help. There are also some ‘over the counter’ treatments which can be taken on a daily basis to reduce the frequency of headache. These include Feverfew, vitamin B2 and magnesium supplements. Some patients have also found aspirin in low dosage to be quite useful.
Q. My mother says that her headaches were much worse when she was pregnant. Will this be the case if I get pregnant?
A. In fact it is usual for headache to decrease during pregnancy, at least in the last 6 months. In the first few weeks of pregnancy, however, attacks can be more frequent and severe but this usually subsides by week 12.
Most patients choose to take no specific headache medication at the time of conception and during the first 3 month of pregnancy because drugs may influence the development of the foetus, but doctors can prescribe treatments which are safe during pregnancy.
Q. Would the oral contraceptive pill make my headaches worse?
A. It is very difficult to judge whether the pill will worsen migraine. It is certainly true to say that it will in some patients but, in the majority, their headaches are actually improved. If migraine attacks occur in the pill-free week, it is possible to run several packets of the pill consecutively to limit the chance of bleeding to once every 3 months or so. It is sometimes necessary to try different forms of pill to achieve the optimal headache situation.
Q. My mother is now in her forties and having much more migraine. Is this common?
A. It is common for migraine to be worse in the time around the menopause. However, it is also more common for chronic daily headache (CDH) to develop at this time. CDH is defined as headache occurring on a daily or near daily basis and it is often a combination of migraine with background tension-type symptoms. This condition requires a slightly different treatment from that recommended for migraine but the GP does have various options available.
Q. Is there anything new in headache treatment?
A. Over the last decade, we have had four new drugs released from the same family which replace the low serotonin levels mentioned as the biochemical change associated with migraine. Three more of this family will be launched over the next 12 months. Research into other new drugs has to date proved unsuccessful but much work is being done in an effort to identify medications to use both for responding to headaches and preventing them.
A considerable amount of progress has been made in assessing patients and their need for treatment. The major step forward has been the concept of viewing patients in terms of their headache impact rather than just their symptoms. In general, doctors are now encouraged to ask questions about disruption to normal activities and, certainly, if patients discuss these areas, they are more likely to receive a sympathetic hearing.
We are indebted to the Migraine Action Association for their help in compiling this section.
