Migraine

What is migraine?

Migraine is a condition that causes episodes ('attacks') of headaches. Other symptoms such as feeling sick (nausea) or vomiting are also common. Between migraine attacks, the symptoms go completely.

Who gets migraine?

Migraine is common. About 1 in 4 women, and about 1 in 12 men, develop migraine at some point in their life. It most commonly first starts in childhood or as a young adult. Some people have frequent attacks - sometimes several a week. Others have attacks only now and then. Some people may go for years between attacks. In some people, the migraine attacks stop in later adult life. However, in some cases the attacks persist throughout life.

What are the types and symptoms of migraine?

There are two main types of migraine attack: migraine attack without aura (sometimes called common migraine) and migraine attack with aura (sometimes called classic migraine).

Migraine without aura

This is the most common type of migraine. Symptoms include the following:

• The headache is usually on one side of the head, typically at the front or side. Sometimes it is on both sides of the head. Sometimes it starts on one side, and then spreads all over the head. The pain is moderate or severe and is often described as 'throbbing' or 'pulsating'. Movements of the head may make it worse. It often begins in the morning, but may begin at any time of day or night. Typically, it gradually gets worse and peaks after 2-12 hours, then gradually eases off. However, it can last from 4 to 72 hours.
• Other symptoms that are common include: feeling sick (nausea), vomiting, you may not like bright lights or loud noises, and you may just want to lie in a dark room.
• Other symptoms that sometimes occur include: being off food, blurred vision, poor concentration, stuffy nose, hunger, diarrhoea, abdominal pain, passing lots of urine, going pale, sweating, scalp tenderness, and sensations of heat or cold.

Migraine with aura

About 1 in 4 people with migraine have migraine with aura. The symptoms are the same as those described above (migraine without aura), but also include an aura (warning sign) before the headache begins.

• Visual aura is the most common type of aura. Examples include: a temporary loss of part of vision, flashes of light, objects may seem to rotate, shake, or 'boil'.
• Numbness and 'pins and needles' are the second most common type of aura. Numbness usually starts in the hand, travels up the arm, then involves the face, lips, and tongue. The leg is sometimes involved.
• Problems with speech are the third most common type of aura.
• Other types of aura include: an odd smell, food cravings, a feeling of well-being, other odd sensations.

One of the above auras may develop, or several may occur one after each other. Each aura usually lasts just a few minutes before going, but can last up to 60 minutes. The aura usually goes before the headache begins.The headache usually develops within 60 minutes of the end of the aura, but it may develop a lot sooner than that - often straight afterwards. Sometimes, just the aura occurs and no headache follows. Most people who have migraine with aura also have episodes of migraine without aura.

Phases of a typical migraine attack

A migraine attack can typically be divided into four phases:

• A 'premonitory' phase occurs in up to half of people with migraine. You may feel irritable, depressed, tired, have food cravings, or 'just know' that a migraine is going to occur. You may have these feelings for hours or even days before the onset of the headache.
• The aura phase (if it occurs).
• The headache phase.
• The resolution phase when the headache gradually fades. During this time you may feel tired, irritable, depressed, and may have difficulty concentrating.

Less common types of migraine

There are various other types of migraine which are uncommon, and some more types which are rare. These include:

Menstrual migraine. The symptoms of each attack are the same as for common migraine or migraine with aura. However, the migraine attacks are associated with periods. There are two types of patterns. Pure menstrual migraine is when migraine occurs only around periods, and not at other times. This occurs in about 1 in 7 women who have migraine. Menstrual-associated migraine is when migraines occur around periods, and also at other times of the month too. About 6 in 10 women who have migraine have this type of pattern. Treatment of each migraine attack is the same as for any other type of migraine. However, there are treatments that may prevent menstrual migraines from occurring. See separate leaflet called 'Migraine Triggered by Periods' for more detail.

Abdominal migraine. This mainly occurs in children. Instead of headaches, the child has attacks of abdominal (tummy) pain which last several hours. Typically, during each attack there is no headache, or only a mild headache. There may be associated nausea (feeling sick), vomiting or aura symptoms. Commonly, children who have abdominal migraine switch to develop common migraine in their teenage years.

Ocular migraine. This is sometimes called retinal migraine, ophthalmic migraine or eye migraine. It causes temporary loss of all or part of the vision in one eye. This may be with or without a headache. Each attack usually occurs in the same eye. There are no abnormalities in the eye itself and vision returns to normal.

Hemiplegic migraine. This is rare. In addition to a severe headache, symptoms include weakness (like a temporary paralysis) of one side of the body. This may last up to several hours, or even days, before resolving. Therefore, it is sometimes confused with a stroke. You may also have other temporary symptoms of vertigo (severe dizziness), double vision, visual problems, hearing problems and difficulty speaking or swallowing.

Basilar-type migraine. This is rare. The basilar artery is in the back of your head. It used to be thought that this type of migraine originated due to a problem with the basilar artery. It is now thought that this is not the case, but the exact cause is not known. Symptoms typically include headache at the back of the head (rather than one sided as in common migraine). They also tend to include strange aura symptoms such as temporary blindness, double vision, vertigo, ringing in the ears, jerky eye movements, trouble hearing, slurred speech, dizziness. Unlike hemiplegic migraine, basilar-type migraine does not cause weakness. There is an increased risk of having a stroke with this type of migraine.

How is migraine diagnosed? Do I need any tests?

Migraine is usually diagnosed by the typical symptoms. There is no test to confirm migraine. A doctor can usually be confident that you have migraine if you have the typical symptoms and by an examination which does not reveal any abnormality. However, some people with migraine have non-typical headaches. Therefore, sometimes tests are done to rule out other causes of headaches. Also, with some uncommon or rare types of migraine such as ocular migraine, tests are sometimes done to rule out other causes of these symptoms. (For example, temporary blindness can be due to various causes apart from ocular migraine.)

Remember, if you have migraine, you do not have symptoms between attacks. It is the 'episodic' nature of the symptoms (that is, they come and then go) that is typical of migraine. A headache that does not go, or other symptoms that do not go, are not due to migraine.

Tension headaches are sometimes confused with migraine. These are the common headaches that most people have from time to time. See separate leaflet called 'Headaches - Tension Type'. Note: if you have migraine, you can also have tension headaches at different times to migraine attacks.

What causes migraine?

The cause is not clear. A theory that used to be popular was that blood vessels in parts of the brain go into spasm (become narrower) which accounted for the aura. The blood vessels were then thought to dilate (open wide) soon after, which accounted for the headache. However, this theory is not the whole story, and indeed, may not even be a main factor. It is now thought that some chemicals in the brain increase in activity and parts of the brain may then send out confusing signals which cause the symptoms. The exact changes in brain chemicals are not known. It is also not clear why people with migraine should develop these changes. However, something may 'trigger' a change in activity of some brain chemicals to set off a migraine attack.

Migraine is not a strictly inherited condition. However, it often occurs in several members of the same family. So, there is probably some genetic factor involved. Therefore, you are more likely to develop migraine if you have one or more close relatives who have migraine.

What are triggers?

Most migraine attacks occur for no apparent reason. However, something may trigger migraine attacks in some people. Triggers can be all sorts of things. For example:

• Diet. Dieting too fast, irregular meals, cheese, chocolate, red wines, citrus fruits, and foods containing tyramine (a food additive).
• Environmental. Smoking and smoky rooms, glaring light, VDU screens or flickering TV sets, loud noises, strong smells.
• Psychological. Depression, anxiety, anger, tiredness, stress, etc. Many people with migraine cope well with stress but have attacks when they relax, leading to so-called 'weekend migraine'.
• Medicines. For example, hormone replacement therapy (HRT), some sleeping tablets, and the contraceptive pill.
• Other. Periods (menstruation), shift work, different sleep patterns, the menopause.

It may help to keep a migraine diary. Note down when and where each migraine attack started, what you were doing, and what you had eaten that day. A pattern may emerge, and it may be possible to avoid one or more things that may trigger your migraine attacks. See separate leaflet called 'Migraine - Triggers and Diary' which gives more details and includes a diary that you can print out and fill in. There are also separate leaflets called 'Migraine Triggered by Periods' and 'Migraine - The Pill and Migraine'.

What are the treatment options for migraine?

See separate leaflet called 'Medicines to Treat Migraine Attacks' for details of the various treatment options. A brief summary is given here.

Painkillers

Paracetamol or aspirin work well for many migraine attacks. (Note: children under 16 should not take aspirin.) Take a dose as early as possible after symptoms begin. If you take painkillers early enough, they often reduce the severity of the headache, or stop it completely. A lot of people do not take a painkiller until a headache becomes really bad. This is often too late for the painkiller to work well. The only solution may then be to find a quiet, dark room to 'sleep it off'.

Take the full dose of painkiller. For an adult this means 900 mg aspirin (usually three 300mg tablets) or 1000 mg of paracetamol (usually two 500 mg tablets). Repeat the dose in four hours if necessary. Soluble tablets are probably best as they are absorbed more quickly than solid tablets. Note: aspirin has fallen from favour for the treatment of many painful conditions. However, for migraine, it often works very well and is worth a try.

Anti-inflammatory painkillers

Anti-inflammatory painkillers probably work better than paracetamol. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac, naproxen, or tolfenamic acid need a prescription. (Strictly speaking, aspirin is an anti-inflammatory painkiller.)

Dealing with nausea and sickness

Migraine attacks may cause nausea (feeling sick) or vomiting. The nausea causes poor absorption of tablets into your body. If you take painkillers, they may remain in your stomach and not work well if you feel sick. You may even vomit the tablets back. Tips that may help include:

• Use soluble (dissolvable) painkillers. These are absorbed more quickly from your stomach and are likely to work better.
• You can take an antisickness medicine with painkillers. A doctor may prescribe one. Like painkillers, they work best if you take them as soon as possible after symptoms begin.
• An antisickness medicine is available as a suppository if you feel very sick or vomit during migraine attacks. A painkiller suppository is also available.

Combinations of medicines

Some tablets contain both a painkiller and an antisickness medicine. For example, Migraleve®, Paramax®, Migramax®, and Domperamol®. They may be convenient. However, the dose of each constituent may not suit everyone, or be strong enough. You may prefer to take painkillers and antisickness medicines separately so that you can control the dose of each.

Triptan medicines

A triptan medicine is an alternative if painkillers do not help. These include: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan. They are not painkillers. They work by interfering with a brain chemical called 5HT. An alteration in this chemical is thought to be involved in migraine. A triptan will often reduce or abort a migraine attack. Some triptans work in some people and not in others. Therefore, if one triptan does not work, a different one may well do so. Most people who have migraine can usually find a triptan that works well for most migraines, and where side-effects are not too troublesome.

Do not take a triptan too early in an attack of migraine. (This is unlike painkillers described above which should be taken as early as possible.) You should take the first dose when the headache (pain) is just beginning to develop, but not before this stage. For example, do not take it during the premonitory or aura phase but wait until the headache begins. Triptans probably work much less well if taken too early on in an attack.

Preventing migraine attacks

A medicine to prevent migraine attacks is an option if you have frequent or severe attacks. It may not stop all attacks, but their number and severity are often reduced. Medicines to prevent migraine are taken every day. They are not painkillers, and are different to those used to treat each migraine attack. A doctor can advise on the various medicines available. See separate leaflet called 'Medicines to Prevent Migraine Attacks' for more details.

Migraine and children

Some points to note about migraine in children include the following:

• Migraine is common in children. It affects about 1 in 10 school age children.
• Symptoms can be similar to adults. However, sometimes symptoms are not typical. For example, compared to adults, attacks are often shorter, pain may be on both sides of the head, and associated symptoms such as feeling sick and vomiting may not occur.
• Abdominal migraine (described earlier) mainly affects children.
• Common triggers in children include missing meals, dehydration and irregular routines. So, if a child is troubled with migraine attacks it is important to try to have regular routines, with set meals and bedtimes. Also, encourage children to have plenty to drink.
• Many of the medicines used by adults are not licensed for children.
  • Paracetamol or ibuprofen are suitable and are commonly used. Do not use aspirin.
  • As regards antisickness medicines, domperidone is licensed for children of all ages, and prochlorperazine is licensed for children older than 12 years of age.
  • Triptans are not licensed for children and so should not be used.

Migraine when pregnant or breastfeeding

The good news is that about 2 in 3 women with migraine have an improvement whilst pregnant or breastfeeding. However, about 1 in 20 women with migraine find that their migraine gets worse whilst pregnant.

The bad news is that many of the medicines used to treat migraine should not be taken by pregnant or breastfeeding women.

• For relief of a migraine headache:
  • Paracetamol is the medicine most commonly used as it is known to be safe during pregnancy.
  • Ibuprofen is sometimes used but do not take it in the last third of the pregnancy (the third trimester).
  • Aspirin - avoid if you are trying to conceive, early in pregnancy, in the third trimester and whilst breastfeeding.
  • Triptans - should not be taken by pregnant women at all. Triptans can be used during breastfeeding, but milk should be expressed and discarded for 12–24 hours after the dose (see manufacturer's information on the packet).
• For feeling sick and vomiting - no medicines are licensed in pregnancy. However, occassionally a doctor will prescribe one 'off license'.
• Medicines used for the prevention of migraine are not recommended for pregnant or breastfeeding women.

Further sources of help and information

Migraine Action

27 East Street, Leicester, LE1 6NB
Tel: 0116 275 8317 Web: www.migraine.org.uk

Migraine Trust

2nd Floor, 55-56 Russell Square, London, WC1B 4HP
Tel: 020 7462 6601 Web: www.migrainetrust.org