How do I know if it’s migraine?
Headache is just one symptom of migraine. As well as the headache, most sufferers will have nausea/vomiting and/or sensitivity to light, sound and smells. Migraine attacks last from 4 to 72 hours, where as a tension type headache would usually last for just a couple of hours. Migraine attacks tend to be debilitating and reduce the ability of the person affected to function – unlike other less severe types of headache. 20% of people with migraine will get an ‘aura’. This is usually a visual disturbance which is present before the headache phase of the attack, and lasts for about twenty minutes on average. Other aura symptoms include pins and needles, slurring of speech, difficulty in articulation, etc. Keeping a detailed migraine diary is key to diagnosing the condition.
90% of people who believe they have sinus headache actually have migraine. Sinus headache is infrequent. You can also be tested for sinus problems.
Is my migraine inherited?
Yes. If there is a family history of the condition, then this is a key indicator that you could be affected.
The exact mode of inheritance is poorly understood. Complex genetic factors are involved increasing its risk up to fourfold. If both parents suffer from migraine then you have about an 80% chance of developing migraine. If one parent suffers then you have a 60% chance.
Most migraineurs have experienced their first attack by their late teens. A 25-year-old’s risk of developing migraine is still much greater than the general population when both his/her parents suffer from migraine. Some years ago, a major breakthrough was made in this field when scientists discovered that an abnormality on Chromosome 19 passed on through families was responsible for a rare type of migraine called Familial Hemiplegic Migraine.
Is there something serious causing the pain of migraine?
It is important in the first place that a correct diagnosis is established if you have headaches. If you think you might have migraine, you should still consult your doctor so that you can be reassured that a more sinister underlying problem is not the cause of the problem. Although sinister headaches are very rare, it is sometimes best to have tests such as MRI or CAT scans done to rule out other causes. Migraine is itself a ‘primary’ or ‘organic’ headache – in other words, migraine is itself the problem and it is not a symptom of a more serious underlying illness.
Should I get a brain scan?
There is no test for migraine, so a brain scan is not a useful tool in diagnosis. However, it can be used to rule out any underlying sinister secondary cause of headache. Your GP will usually be able to make an accurate call on whether a scan is needed or not, after taking a clinical history and performing some routine neurological tests. The red flags which point to further investigation include:
- Headache beginning after the age of forty
- Change in pattern of your headache
- Prolonged aura or repetitive aura
- First/worst headache
- Headache triggered by coughing or sneezing
- Headache accompanied by a rash, fever and/or stiff neck
- Headache accompanied by shortness of breath or symptoms affecting eyes/ears/nose/throat
- Worsening headache
- Thunderclap headache (sudden onset, severe headache)
Is it alright to take over-the-counter medications?
It is alright to take over-the-counter medications for migraine, if they work. However, acute medication should not be taken on anymore than approximately six days per month. Some neurologists will even say that four days is the maximum. Remember, too, that it is not the number of tablets taken per month but the days per month on which you take tablets (even if it is just 1-2 per day). Overusing acute drugs can lead to medication overuse headache. This is headache on 15+ days per month, over three months – due to the overuse of acute medications, including triptans. The only cure for MOH is complete withdrawal.
Keep track of your use of medications in your migraine diary. If over-the-counter medications are not working, then you should look at taking the migraine specific triptans. If you find that even these are not stopping the attacks or you are taking them more than 4-6 days a month, then you may have to consider a preventative medication.
My medication is not working – what else can I do?
If over-the-counter medications do not work or you are using them on more than 4-6 days in the month, then you should consider a more migraine specific acute medication such as a Triptan. These are available on prescription only.
There are six different Triptan medications available in Ireland. All six work slightly differently. If one doesn’t work then try a different one. Usually, you will know after two attacks whether your Triptan is going to work for you. If you find that you get extreme nausea/vomiting with your attacks, then taking triptans in a nasal spray, rapimelt or injectable form may help. Also, an anti-nausea drug can help in absorbing the medication e.g. motilium.
If you are having attacks more than two to three times per month, then you should consider a preventative. This needs to be taken daily for more than three months before you make a judgement on whether it is working. You need to be patient. If after three months, there is no improvement then you can switch to another preventative. This process can take time.
Keep a diary to assess whether there is any benefit and whether there are side-effects. You will usually start on a low dose and increase gradually to avoid severe initial side-effects. You need to stay on a preventative for about twelve months to break the cycle of attacks, and then taper down gradually. You should then be able to revert back to using acute medications.
If you have tried more than three to four preventatives medications without success, then you should see a specialist to consider other treatment options such as an Occipital Nerve Block or Botox.
I can’t work out my trigger factors
It is essential that you keep a migraine diary if you are not already doing so. This can help you to identify patterns to your attacks. Write down absolutely everything you can think of in the days leading up to your attack e.g. foods, eating and sleeping patterns, emotional state, weather, changes in routine, events, hormonal issues, etc. Keep the diary for four to five attacks and then study it for patterns.
We talk about a migraine threshold – this is the point you need to reach before an attack is triggered. In most people, it takes a combination of triggers to reach this stage – so often it is not just one specific thing that is setting your attacks off.
Don’t just focus on food, this is only a factor in about 20% of cases. Excluding whole food groups from your diet is not beneficial.
In fact, triggers are not at play in every case. Identifying triggers can lead to a reduced number of attacks – but it is unlikely that it will eliminate attacks altogether.
Routine is important to those affected by migraine so try, as much as possible, to eat regularly, sleep at similar times, take exercise and keep hydrated.
Is my migraine linked to my menstrual cycle?
About 60% of women find that their menstrual cycle is directly related to their migraine. This is called Menstrually-related Migraine.
Pure Menstrual Migraine is diagnosed when attacks occur exclusively just before or during menstruation in at least two out of three menstrual cycles and at no other times during the cycle.
Around the time of puberty there is a rapid rise in the incidence of migraine in young women due to changes in the levels of oestrogen, and this hormone will continue to play a large role in many women’s migraine throughout their life. For women who have Menstrual Migraine, the elimination of the hormonal trigger with the onset of menopause can result in significant improvement, although it is rare for attacks to disappear entirely.
I feel ‘woolly-headed’ after a migraine attack. Is this normal?
Very much so. When the headache phase is over, you enter the postdrome or ‘recovery’ phase. This stage of the migraine attack includes symptoms such as tiredness or a feeling of being washed out. Some people experience the opposite – full of energy, even euphoria. These sensations may last for up to 24 hours.
I get tingling in my arm during a migraine attack. Is this normal?
About 95% of migraine auras are visual but they often include other symptoms such as tingling. What typically happens is that it starts in the fingertips, spreads up the arms into the mouth and often into the tongue, lasting for maybe 20 minutes. These are typical aura symptoms. The sensation is like that of having slept on your arm.
What drugs can be taken during pregnancy?
For most women, migraine improves during pregnancy, particularly in the second and third trimesters. However, if attacks persist, only in extremely rare cases will a doctor consider medication. The only drug considered safe throughout pregnancy and breastfeeding is paracetamol.*
Before taking even paracetamol during pregnancy you should first consult your doctor. Medication of any type may be harmful to the developing foetus, especially in the first three months so usage should be discontinued as soon as you discover that you are pregnant.
Note: Please remember that no drug can be considered completely without risk during pregnancy.
What is the best medication for migraine?
There is no easy answer to this question. Migraine medications are very individual. One person might respond very well to a particular drug, yet the same drug might have no impact at all for another person. So the best drug is really the one that works for you.
Up to a third of people with migraine can satisfactorily manage migraine with over-the-counter treatments such as paracetamol, codeine, ibuprofen or aspirin. Some people find that these work better if taken with an anti-nausea drug.
Non-steroidal anti-inflammatory drugs are also used as a first line therapy. These may be particularly useful for those who get their attacks at around the time of their menstrual cycle. In recent years, Triptans have become the first-line medications of choice in Ireland. Statistically these medications work in 60-80% of cases.
Why was I prescribed an anti depressant for migraine when I know I’m not depressed?
About half the medications used for migraine were not actually developed for migraine in the first place.
Beta Blockers, which were developed for regulating blood pressure were the first drugs to be shown to have an ‘unintended’ side effect of actually helping migraine.Since then, low dose Tricyclic anti-depressants have also been shown to help migraine. In doses lower than normally prescribed for depression, these drugs affect neurotransmitters in the brain that are altered at the start of a migraine attack.
Using these anti-depressants, your migraine threshold is increased, making it more difficult for a migraine to occur. So it is the actions that the drugs have on receptors related specifically to migraine that are beneficial, rather than any actions that they have in relation to depression.
What is the risk of stroke if I am a migraine sufferer and am on the pill?
Migraine with Aura is a risk factor for stroke. This risk is increased in young women who are on the pill and increased further still if you smoke. However, the absolute risk is still very low. Those who are affected by migraine with aura should not take the combined contraceptive pill. It is advisable that people with migraine with aura use the lowest possible dose AND reduce their exposure to other risk factors e.g. Stopping smoking is a necessity if you have migraine and are on the pill.
Can I use complementary treatments in conjunction with medications
There is little scientific evidence for alternative/complementary therapies specifically for migraine. What does exist is often based on small scale studies and anecdotal stories. However, alternative therapies can play a part in reducing the frequency and severity of migraine.
We would suggest that you try to match the therapy to the trigger. For example, if stress is your trigger then relaxation therapy may help. Always make sure you see a registered practitioner and keep your doctor informed. Some herbal preparations can negatively interact with certain medications.
Always check the credentials of complementary practitioners before undergoing treatment and approach the treatment with the same caution and judgement that you would with any drug treatment.
What specialist do you recommend?
Migraine can usually be managed at GP level. If you are unhappy with your GPs approach, then you could consider moving to another local doctor.
Only the worst cases should be referred on to a neurologist or one of the country’s specialist migraine/headache centres. There are five clinics in Ireland – three in Dublin, one in Cork and one in Galway. Unfortunately, the waiting lists vary from about one to two years. A referral letter from your doctor is also necessary.
Another option is to see a consultant neurologist privately. Do make sure that you see someone with an interest in migraine/headache. Fees per visit are about €250 – but this may be covered if you have private health insurance. Dr Martin Ruttledge at the Hermitage Clinic, Lucan is one of Ireland’s leading specialists.