15 tips to manage migrainesThe intense pain of migraine can often render sufferers unable to function, with some even needing bed rest during an attack. Here, neurologist Dr Jennifer Dineen provides a comprehensive guide to these acute headaches, from triggers to treatments
Migraine is an episodic disorder characterized by a severe headache. In general, it is associated with nausea and/or light and sound sensitivity. A migraine can just involve a headache, or can be associated with other neurological symptoms such as flashing lights or tingling in an arm or leg, known as an aura. Very rarely, it can occur with just the aura and no headache.
Studies have shown that up to 90pc of people suffering from a migraine have moderate or severe pain, while three-quarters have a reduced ability to function during the headache attacks, and one-third require bed rest during their attacks. It has also been shown that most people treat their symptoms with abortive treatments - which are taken once a migraine has taken hold - over preventive treatments, therefore increasing their risk of medication overuse headaches.
1 What type of headache occurs in migraine?
The headache of migraine is usually - but not always - on one side of the head, often around the eye. It tends to have a pulsatile or throbbing quality, especially as the intensity increases. As the attack intensity increases, patients may experience nausea and vomiting as well as sensitivity to both noise and light. Untreated, it can last as little as four hours or as long as several days.
2 What is a migraine aura?
A migraine aura is identified by a gradual development of symptoms lasting no longer than one hour, followed by complete resolution. Migraine aura usually impacts vision (such as flashes of light or zig-zags in part of your vision) or sensation (usually a tingling and rarely a numbness) and, in rare instances, language or motor function. The aura usually develops over more than five minutes and the symptoms should have a migrating or travelling pattern; these two features help to distinguish it from a mini stroke.
3 What are migraine triggers?
Migraine triggers are factors that are known to bring on or exacerbate migraine. Common triggers include stress, hunger, hormones in women, lack of sleep, alcohol, neck pain and sleep disturbances. It's worth identifying your own particular migraine triggers and working out how best to deal with them.
4 How should migraine management begin?
If you suffer from migraine, the first thing you should do is start a headache diary. Keeping a written record of headache frequency and severity will help you in planning preventive treatment. Write down as much detail as possible, including information on your need for acute medications and the potential triggers for your headache. A migraine diary can be downloaded from the Migraine Association of Ireland website. Non-pharmacological measures such as biofeedback, relaxation therapy or cognitive behavioural therapy can also be very helpful.
5 Which medications should be taken?
If your migraine is mild to moderate, it's best to start with anti-inflammatory medication. However, if it's moderate to severe, start with a triptan to ease your symptoms.
In order to avoid an overuse headache, medications should be taken within strict parameters: anti-inflammatories, such as naproxen, should be used on less than 15 days per month; triptans, such as sumatriptan, should be used on less than 10 days per month.
6 How do you treat an acute attack?
When treating a migraine with abortive medications, early intervention is very important. 'Central sensitisation' is the condition that causes the severe pain in a migraine, and taking your medications early, when the pain is mild, is the best way to try and avoid this from taking hold.
If the pain is already severe at onset, however, early intervention may not be as effective. Your doctor will advise you that adequate drug dosages should be used along with the appropriate routes of administration, and that this should be combined with anti-nausea medications if you have associated nausea.
7 What is the expectation of regular migraine treatment?
If you allow yourself to expect a complete resolution of migraine through the use of preventive medications, your judgement may become clouded in terms of how effective these medications are in reality. This, in turn, may lead to inadequate trials of medications. Instead, the expectation should be to reduce headache frequency by 50pc and also to reduce the intensity and duration. Headache freedom may be an unrealistic goal early in treatment.
8 What is a medication overuse headache?
A medication overuse headache (MOH) is a chronic daily headache evolving from an episodic migraine, due to overuse of one or more migraine abortive medications. It significantly affects quality of life. The condition tends to develop when using triptans on more than 10 days per month, or when using anti-inflammatory medications on more than 15 days per month. The pain experienced with MOH may be different to that of the typical migraine.
9 What is chronic migraine?
Chronic migraine is defined as headaches occurring on more than 15 days per month, requiring the prescription of preventive treatment. Nevertheless, preventive treatment may also be warranted when migraine attacks occur less frequently but cause significant impairment.
10 Are there other chronic daily headaches aside from migraine?
Hemicrania continua (HC) is a chronic daily headache that may be mistaken for chronic migraine. Features they have in common are the one-sided nature of the condition and superimposed painful exacerbations. HC is also associated with tearing from the eye and a drooping eyelid during painful exacerbations; this is not seen in chronic migraine.
11 How is migraine different from a tension headache?
A tension headache has some distinguishing features from migraine. It occurs on both sides of the head, often across the forehead. It is non-pulsating in nature and is not aggravated by routine physical activity. It usually isn't associated with nausea.
12 What is menstrual migraine?
Migraine may be menstrually related. This is tied to the oestrogen withdrawal that occurs just before menstrual periods. If periods are regular and predictable, patients can take abortive medications regularly for the few days preceding - and the first few days of - menstruation.
13 Are there symptoms that would warrant further investigation?
When you have a chronic daily headache that is possibly chronic migraine, there can be certain "red flags" in your medical history and examination that may suggest an alternative cause for the headache. Sudden onset of headache, headache associated with fever and neck stiffness, headache triggered by cough, exertion or orgasm, and headaches that occur during pregnancy - or just after giving birth - are all factors which will require further investigation.
14 What other tests should be done and when?
An MRI brain scan can't diagnose migraines,but it can help doctors rule out other medical conditions that may cause your symptoms. Your doctor might send you for an MRI, for example, if your symptoms occur during exercise or if you have a rapid onset of either pain or aura symptoms. In addition, an MRI should be undertaken in patients who are under the age of 10 or over the age of 50 at onset, if there's a change in the migraine's frequency or intensity, or if the headache feels different to the typical migraine.
Patients with a prolonged aura, or an aura in the context of starting the oral contraceptive pill should also be sent for a scan. Other symptoms your doctor will look out for in this context can include fever or abnormalities on the physical examination.
15 What if migraine occurs during exercise?
If migraine occurs exclusively during exercise, and this has already been adequately investigated by your doctor, then treating with anti-inflammatory medication (such as indomethacin) before exercise may help eliminate the symptoms.
* Dr Jennifer Dineen is a neurologist at Beacon Hospital. She has a broad range of expertise in areas such as migraine, epilepsy, stroke, movement disorders and others, and a special interest in autonomic and peripheral nerve disorders
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