Migraine

Reviewed by Dr Jeni Worden, GP

What is a migraine?

A migraine is a throbbing, intense headache in one half of the head. It can affect people of all ages. The cause of migraine is not known.

During an attack, the blood vessels in the brain dilate and then draw together with stimulation of nerve endings near the affected blood vessels. These changes to the blood vessels are probably what cause the pain, but migraine is still a condition that is poorly understood.

Are migraines hereditary?

There is often a predisposition for migraine within the family of migraine sufferers, but it is not certain how large a role heredity plays. Migraine is a fairly common condition, affecting about 20 per cent of females and 6 per cent of males in their lifetime. Although it can come on later in life this is unusual. About 90 per cent of migraine sufferers have their first attack before they are 40.

What might trigger migraine?

Most people suffering from migraine are aware that different foods, such as cheese, chocolate, wine or citrus fruits, can cause the attacks.

Other things that may trigger an attack include exercise, anxiety, stress, bright lights, loud noise, the contraceptive pill and travel. These particular causal factors vary from patient to patient. Some women experience attacks more frequently around the time of their menstrual periods.

Migraine sufferers should avoid factors such as alcohol, lack of sleep and foods that are known to cause attacks.

What are the typical features of migraine?

People often use the word 'migraine' to refer to headaches of many different types. So-called 'classical' migraine attacks have several features:

headaches that occur in bouts of between roughly 4 to 72 hours.

the headaches usually affect one side of the head at a time, although both sides may be affected in separate attacks.

the headaches are usually throbbing and worsened by normal physical activity

nausea and/or vomiting

preceding symptoms, called the 'aura' that most often are visual, such as zigzag lines or flashing lights across or at the edges of the fields of vision

other symptoms can include sensitivity to light and sound, or non-visual aura such as a sensation of tingling in the body.

Only about 15 per cent of people experience visual aura before an attack. 'Common migraine' refers to the majority who have all the other symptoms but no aura. Rarely some people with migraine experience transient loss of power of a limb with severe attacks, or temporary difficulty with speech.

In addition to an interview, the doctor should also perform a physical examination. If there is any doubt about the diagnosis, the doctor will refer the patient to an expert on diseases of the brain (neurologist).

Diagnosing migraine

The first-ever attack of migraine can look like many other conditions, including meningitis or even a stroke so great care can be needed in making the initial diagnosis. Once several attacks have occurred however the pattern becomes recognisable. Depending on the circumstances it may be necessary for the person to see a specialist (neurologist) to have investigations such as a brain scan.

Other tests, such as those for 'allergies' or which seek to identify triggers for the migraine are of little help. Blood tests are normal in migraine.

How is a migraine treated?

The first line of treatment is always to try and identify trigger factors, which means keeping a careful record of events, mainly of foods that have preceded an attack. Particular foods are identified as migraine triggers in about 20 per cent of sufferers. The large female preponderance within migraine sufferers points to the importance of hormonal factors such as the menstrual cycle, which are not modifiable. Many women also find that the oral contraceptive pill worsens attacks, and if so it should be stopped.

People suffering a migraine should try to rest in a dark, quiet room.

Treatment of migraine is most effective if given at the start of an attack.

Simple painkillers such as paracetamol (eg Panadol), aspirin (eg Aspro clear) or ibuprofen (eg Nurofen), can be effective at relieving migraine and are usually the first treatment tried. They are preferably taken in soluble form, as these are absorbed by the body faster. If nausea or vomiting are a problem then suppositories may be preferable, alternatively an antisickness medicine can be taken with the painkiller. Your doctor may prescribe the antisickness medicines domperidone (eg Motilium) or metoclopramide (eg Maxolon); these also speed up the absorption of the painkiller. There are also products available that combine these with a painkiller, eg Paramax, Migramax, Domperamol.

If simple painkillers and antisickness medicines consistently fail to relieve migraine attacks, then the most popular modern remedies are the 'triptan' group of drugs. These are prescription medicines and include sumatriptan (Imigran), rizatriptan (Maxalt) and zolmitriptan (Zomig), among others. These drugs cause the blood vessels around the brain to contract, thus counteracting the dilatation that seems to part of the initial migraine process. They come in various forms, including nasal sprays, injections and tablets that dissolve on the tongue, which can be useful if nausea and vomiting are a problem during the migraine.

If attacks are sufficiently frequent or last a long time, preventive treatment or prophylactic treatment as doctors call it, may be recommended. This usually involves taking daily medication, so may not be appropriate for people who suffer only occasional migraines. Examples of medicines that can be used in this way are: propranolol (eg Inderal LA), pizotifen (Sanomigran), amitriptyline and valproate (eg Epilim) (the latter two are not licensed for this purpose).

Often several kinds of medication need to be tried and perhaps combined before the most effective treatment for each individual patient can be found. Alternative therapies, such as homoeopathy and acupuncture, are popular even if the evidence supporting their effectiveness is poor or absent. The herbal remedy feverfew has shown some efficacy in preventing migraine. Lifestyle and dietary advice are always important.

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