Why is Migraine such a pain?
- You’re basically a zombie for 1-3 days.
- You may not get much sympathy – lots of people still think that migraine is the same as headache.
- Many teenagers and young adults were told just to get on with it – and may not now realize that there are very effective treatments out there.
- It’s too easy to reach for the pain killers – but at the risk of developing withdrawal headaches.
What are the common Migraine Triggers?
Migraine triggers – these vary enormously. They are important to consider although you can only get so far by looking at migraine triggers. It can be helpful to keep a headache diary (eg. migrainetrust.org headache diary). A common trigger is a change of sleep pattern such as going to bed late. Stress is another common trigger, although people with long term frequent migraine will know that the migraines themselves cause considerable stress – it’s a two-way thing. Chocolate and cheese, oranges and red wine are common triggers.
Headache diaries are very helpful because the record leaves out the guesswork. Headache Diary Pro is a recommended app by the UK National Health Service, and is available on IOS. The customizable app allows you to track symptoms & triggers, and to find links you might otherwise not recognise. It is helpful to print off the report and discuss it at your appointment.
Migraine is around 3 times more common in women than men, and women often notice how migraines are more likely at certain times in their menstrual cycle.
What is the best medication for an acute migraine?
These are some of the words that “go” with migraine and justifiably highlight their aggression:
- sufferers of migraine
- attacks of migraine
- Severe or throbbing
Migraine need treating, and fast.
Anti-inflammatory medication like ibuprofen and naproxen have an important role, as does paracetamol. Those with nausea or vomiting are likely to benefit from anti-nausea pills that also speed up how quickly the stomach empties eg. metoclopramide or domperidone tablets.
The medication called “tripans” are prescribed by your GP & used at the onset of an acute migraine. This class of medication may be extremely helpful. Whilst not a panacea for all migraine sufferers, they can make a huge difference and it’s really rewarding to see the difference they can make to people’s lives. There are a wide variety of different brands of triptans with sumatriptan (imigran) being the best known. Some people find that one triptan is better than another. The migraine guidelines don’t state that one is “better” than another, though, because individual response is so different. Interestingly, for the 15% of migraine suffers who get aura before the headache, a UK migraine guideline clearly states that the tripans do not work when they are taking during any aura and only work if taken early in the onset of the actual migraine headache
Medication overuse headache commonly occurs with long term use of either:
- over the counter analgesics or anti inflammatories taken on most days or
- or prescribed pain killers or “triptans” taken on at least 1 day in 3 long term
What medication may help prevent migraine?
Preventative (prophylactic) medication are used to reduce the number of migraine attacks. Examples include the following: betablocker, Topirimate, a Tricyclic (amitriptyline), Pizotifen, valproate, and gabapentin. It’s not uncommon to need to try 2 or 3 different preventative tablets before you find one that help, and each one needs to be tried for a decent period of time (preferably 2-3 months).
Historically Pizotifen was often used first – but side effects are common. There is something to be said for starting-out on the most effective treatment first, and the cost of all these medications has plummeted in recent years.
What are the issues for migraine in women?
Migraine is a common women’s health issue and is often worse at the time of menstruation. Sometimes, migraine only occurs around menstruation when it’s called menstrual migraine. Menstrual migraine is worse than non-menstrual migraine, and you shouldn’t put up with it!
There are a number of preventative options for migraine in women.
A Review of menstrual migraine in the journal headache in 2015 concluded that The Triptans are the most effective treatment for acute attacks. What about preventative treatment? The triptans may also be used (outside of the product license) for several days in a row before the onset of the period. This is called “mini preventative” treatment because the prevention medication is taken for only for a few days per month. This is often very effective. There are other options too such as the contraception pill. Hormonal contraceptives may improve or worsen migraines. Some women use magnesium, an oestrogen patch, or normal migraine preventative medication.
The safety of the combined oral Contraceptive pill and migraine is an issue. There is an increased risk of stroke in everyone who has migraine with aura: just over two times increased risk of stroke. There is also a small increased risk of stroke taking the combined pill. Therefore, the combination of combined pill and migraine with aura is generally regarded as a no-no. The way forward is a discussion of risk and alternative contraceptive options. The guidelines are pretty didactic but the patient makes the ultimate choice based on the information available.
The safety of Migraine preventative medication (prophylaxis) in pregnancy needs to be discussed. Most if not all have some sort of warning in the packets. When regular prophylaxis is needed, there are options where the risks are small and the benefits may outweigh the risks. Triptans for acute attacks are generally safe but sumatriptan has been around the longest and its safety data reassuring – however, manufacturers advise to avoid – again, this is for discussion with your doctor.
What is Chronic Migraine?
Chronic Migraine can be looked on as simply migraine occurring very frequently. The formal definition is that a headache occurs on at least 1 day in 3, with some of the headaches being migraine so that there’s a migraine at least every other day. Chronic migraine is truly disabling.
There are other causes of daily headaches and chronic tension-type headache along with medication-induced headaches are also common. Chronic migraine sufferers often have a mixture of different types of headache. It’s not surprising that people with chronic headaches may be taking pain killers frequently but, unfortunately, the pain killers themselves may end up causing headaches.
People with migraine know what an unpleasant experience it is. Some people (around 10%) go on from acute migraine to develop chronic migraine. It’s thought to be a problem stemming from abnormal neurotransmitter activity (ie. the chemical messages sent in the nervous system) around the base of the brain, with reduced inhibitory neural pathways (the central nervous system pathways that reduce pain).
All of the standard migraine preventative medication has a role. Topirimate & Amitryptyline seem to be emerging as front-runners. A detailed chronic migraine BMJ Review 2014 also supports the role for Botox which is subsidised by medicare when administered for chronic migraine suffers who must fulfil the medicare criteria and be injected by a specialist (usually a neurologist) who is accredited by medicare. The waiting time to see such specialists even privately may be several months.
Studies show the these treatments to help chronic migraine but do not stop migraines completely. The goal is to reduce the number of migraines. Each preventative therapy should be tried for at least 2 months at the dose recommended. Pain killers & Anti-inflammatory medications need to be limited to an agreed quanitity.
Biologics for Migraine
Biologics is a term that refers to therapies that target the immune system. These agents are better known for treatment of auto-immune diseases such as Rheumatoid arthritis, Psoriasis, and ulcerative colitis.
Biological agents have now been developed as a migraine preventer. The TGA approved Fremanezumab in 2020. Short term trials show that ‘fremanezumab is better than placebo, but the difference is small.’ A consultation with a neurologist is required to access biological agents.
Who should I see about my Migraine?
The GP will help you get a good handle on treatment:
- For acute attacks
- For preventative treatments
- For menstrual migraine
Botox or biologics require a referral to a neurologist so that:
- Stringent medicare criteria are satisfied, and
- The PBS loopholes/expense be discussed in detail.