All about migraine

It’s Migraine Awareness Week from 23 to 27 September. Find out more about symptoms and treatment for this disabling condition from headache specialist Dr Michael Long and the MSG’s consultant neurologist Dr Basil Ridha. 

‘It’s just a headache!’. The impact of migraine is often under-estimated. In reality, migraine is the most prevalent, disabling, long-term neurological condition taking into account years lost due to disability.  

It is the leading cause of years lived with disability in those aged 15 to 49 and is estimated to cost the UK economy up to £9 billion a year in lost productivity.  It is three to four times more common in females and the perimenopause can be a particularly troublesome period.  

What are the symptoms? 

A typical migraine headache is a moderate to severe one-sided throbbing headache associated with sensitivity to light and noise, nausea and sometimes vomiting. However, not every headache affecting a migraine sufferer fits these characteristics. Milder headaches at times of missing meals, excessive tiredness, sleep deprivation can be on the spectrum of migraine. Migraine sufferers may also have sensitivity to motion sickness, hangover headaches with alcohol or menstrual periods. In children migraine can first present as recurrent abdominal pain.  

Migraine frequently runs in families and if you have one parent with migraine you have a one in two chance of having migraine yourself. It is likely that genetics set our migraine threshold and therefore how likely you are to have a migraine attack.  

Migraine headache characteristics may vary from one person to another. Even in the same person, the headaches can change in their characteristics with age. There are different ways of classifying migraine such as the presence or absence of preceding visual disturbance, called visual migraine aura. Aura occurs in around one in four of those with migraine and not with every attack.  

One important way of classifying migraine is according to the number of days per month with headaches: It is classified as episodic if less than 15, or chronic if 15 or more. The reason this is important is because some of the available medications are indicated for episodic and others for chronic migraine.  

Managing and treating migraine 

A major advance in the understanding of migraine is realising the role of a chemical called CGRP as a mediator of pain transmission in the brain. Therefore, reducing the amount or blocking the function CGRP may be a treatment target.  

Management of migraine involves avoiding triggers such as disrupted sleep pattern, missing meals or dehydration and minimising stress. However, rarely do people have a single trigger and searching for a specific trigger is often unhelpful. Acupuncture has been shown to help some people.  

Medications for migraine fall into one of two baskets: those taken to abort a headache while it is developing (acute) and those taken daily to reduce the frequency or severity of headaches (preventative).  

Acute treatments include taking high dose of non-steroidal anti-inflammatory medications such as ibuprofen or naproxen, high dose soluble aspirin or one of a group of medications called “triptans”. For some with migraine, and especially if your attacks are associated with nausea or vomiting, then taking an anti-nausea medication may help. Rimegepant, a newly-available acute treatment which works by blocking CGRP can be used if others are not effective or not safe to use.  

One important factor to consider with acute medication is a condition called medication overuse headache. If you take any acute medication for more than two to three days per week this can lead to a previous episodic headache becoming chronic. This affects up to one in two of those in headache clinics and is difficult to treat. To avoid this, if you have headache on more than four to five days per month then we would usually recommend preventative medication.  

There are several preventative medications which can help reduce or switch off migraine. They include some anti-depressants such as amitriptyline, blood pressure lowering medications such as propranolol or candesartan or anti-epileptic medications such as topiramate. Vitamin B2 (riboflavin) and magnesium supplement have also been shown to act as a preventative medication. It is difficult to predict which patient is going to respond to which preventative medication, so it always a matter of trial and error.  A common mistake is to decide on the effectiveness of any of the preventative medications before allowing a month of treatment at the maximum tolerated dose.  

Patients with chronic migraine who fail to respond to at least three preventative medications mentioned above may be eligible for treatment of one of the following:  

• A once-monthly injection under the skin with a medication with antibodies binding and blocking CGRP. One example is Erenumab.  

• Botulinum toxin injections, totalling 31 injections over the head and neck region administered once every three months.  
• Atogepant: a newly available medication which blocks CGRP.  

Migraine may masquerade with symptoms other than headaches, such as visual difficulties, brain fog or dizziness and vertigo. It can mimic a mini-stroke with speech disturbance or one-sided numbness or weakness, or concern about sudden brain haemorrhage or meningitis.  

Specialist help in Guernsey 

In Guernsey, GPs can seek specialist input to manage patients with challenging migraine by referring them to outpatient neurology at the MSG. Headache service provision has recently expanded with a new joint headache clinic led by Dr Michael Long, headache specialist. Input from the pain management team at the MSG may also provide a holistic approach to management.  

Awareness of migraine and that is much more that just another headache is the first step to accessing appropriate diagnosis and treatment.