Migraines and How To Manage Them
We have all had a headache at some time, but headaches are not all the same and like all things medical are categorised and sub divided.
Headaches can be divided into Primary headaches and Secondary headaches.
Primary headaches further subdivide into Tension, Migraine and Cluster headaches.
Secondary headaches are usually more sinister and as they are associated with underlying disorders and include, headaches associated with medication overuse, raised intracranial pressure and infection.
Headaches are then deemed acute or episodic if the sufferer has pain for up to 14 days a month, or chronic if more than 15 days a month in any 3-month period.
Starting with Primary headaches this is the category Migraine falls into, the difference between them is mainly the type of pain and the accompanying symptoms.
The most common type of headache is known as a Tension Headache, which is characterised by being a generalised headache, with no associated symptoms like nausea.
The location of the pain is typically bilateral, i.e. both sides of the head and the pain quality is described as pressing/tightening but non‑pulsating. The pain is usually mild to moderate. Tension headaches often involve soft structures such as muscles – often muscles in the neck.
The exact cause of a Tension headache is not known but triggers can include: Stress and anxiety, dehydration, missing meals, poor posture, bright sunlight, noise, and certain smells.
When to get help
The NHS advises there is usually no need to see a GP for the occasional Tension headache but do see a GP if you get these several times a week and they are severe.
You should seek immediate medical help if: (this applies to ALL type of headache)
Your headache comes on suddenly and is like nothing you have had before
Your headache comes on after an accident involving a blow to the head.
Your headache is accompanied by a stiff neck, confusion, fever, and vomiting
Your headache is accompanied by muscle weakness, numbness, confusion, or slurred speech.
A rarer form of headache which is far more unpleasant than a Tension headache is a Cluster Headache.
With Cluster Headaches the pain location is Unilateral (around the eye, above the eye and along the side of the head/face). The pain quality is Variable i.e. (can be sharp, burning, throbbing, or tightening). The pain intensity is described as Severe or very severe. Cluster headaches most often effect men in their 30s and 40s although anyone can get them.
Other symptoms include: On the same side as the headache: red and/or watery eye, nasal congestion and/or runny nose, swollen eyelid, forehead and facial sweating, constricted pupil and/or drooping eyelid
The exact cause of cluster headaches like tension headaches is not clear, but they have been linked to activity in part of the brain called the hypothalamus. Strong-smelling chemicals, such as perfume, paint or petrol, can sometimes trigger an attack.
If you think you suffer or do suffer from Cluster headaches, there is a very helpful organisation you can get in touch with – they have a really easy name to remember – OUCH which stands for Organisation for the Understanding of Cluster Headache.
When to get Help:
Cluster headaches are the only type of headache where NICE guidelines recommend discussing the need for neuroimaging for people with a first bout of this type of headache with a GP who has a special interest in headache or a neurologist.
The last type of Primary Headaches are Migraines.
Migraines are characterised by the following symptoms:
Location of the pain can be unilateral (i.e. one side of head) or bilateral (both sides)
Pain quality is described as Pulsating throbbing or banging. The pain intensity is usually moderate or severe.
There can be unusual sensitivity to light and/or sound. Other symptoms include nausea, tingling, numbness, and visual disorders.
Often chronic migraine sufferers wake up with a headache and can have a headache all day long.
When to get help
The NHS advises You should see a GP if you have frequent or severe migraine symptoms that cannot be managed with occasional use of over-the-counter painkillers
You should also make an appointment to see a GP if you have frequent migraines (on more than 5 days a month), even if they can be controlled with medicine.
What causes a Migraine?
The cause of the pain of migraine is not fully understood but the latest thinking is that a trigger causes abnormal electrical event known as a Cortical Spreading Depression, this is a wave of electrical activity that spreads across the brain releasing neurotransmitters in an overreaction to the trigger. It is thought that the inflammation as a result of long-term migraine can even cause changes to the brain which may explain the change in symptoms over the years.
The website of the Association of Migraine Disorders states how “Almost all migraine sufferers have a problem with a specific part of the nervous system, called the trigeminal nerve. The trigeminal nerve is a network of wiring that attaches to special sensors.”
Firstly, someone who suffers from migraine is known as a migraineur There is a school of thought that being a migraineur confers an evolutionary advantage as the migraineur’s brain is more active than usual, open to stimuli and generally more switched on.
Triggers - Common Triggers of migraine are: stress, change in atmospheric pressure, lack of sleep, aromas.
Cheese, chocolate, and alcohol are commonly thought to cause migraines, but modern research surprisingly does not support this, the trigger with food and drink is usually going too long without eating and / or dehydration.
Likewise eye strain is often thought to be a cause of headache but surprisingly there is little evidence that this causes headache, although eye strain may contribute to triggers – Prof Peter Goadsby , who in 2021 was awarded the world’s top Brain Prize from the Lundbeck Foundation for his pioneering migraine research, describes how it's rare to have glasses correct major problems with headache but not uncommon to have a migraine sufferer have a worsening of the headache because of some change in their prescription glasses.
Hormonal changes in women are another common trigger.
Some people suffer migraines after exercise, this is commonly due to not eating or drinking correctly leading to – hypoglycaemia and dehydration.
Stages of a Migraine attack
A migraine attack typically but not always, has distinct stages - Dr Mark Wetherall Consultant Neurologist from the London Headache Centre described the various stages as:
1st Phase: PRODOMAL (lasts few hours to days) – warning phase, typically Food cravings, irritability, yawning, depression, difficulty sleeping, nausea, seem to be mediated by Stimulation of dopamine circuits in the brain. Dopamine is a neurotransmitter involved in behaviours involved in appetite or reward. Before a Migraine episode, people can get food cravings for certain food.
2nd phase: AURA -phase of neurological dysfunction – typically just before headache. The most typical aura are visual positive aura like flashing lights or zig zags, negative aura are a blind spot. People can have sensory aura like a tingle or numbness spreading down the body, people may have a motor aura effecting muscles which can involve difficulty speaking.
3rd Phase: PAIN - Sensory processing areas of the brain send out signals that involve the release of chemicals the most important being CGRP (Calcitonin Gene Regional Peptide)
4th phase: POST DROME phase – around 20% suffer this phase which can go on for 2 to 3 days. Often described as a migraine hangover where the sufferer feels tired, depressed, and find it hard to concentrate.
Migraines are thought to be inherited. One headache specialist nurse speaking on BBC radio 4’s Inside Health program described it as “the biology always sits, ready to be awakened”. American Neurologist Dr David Dodick described around 120 genes that have been identified that confer an increased risk of developing Migraine. The more of these genes or their variations you have inherited, then the more likely you are to experience more severe form of migraine.
Migraines or any form of headache for that matter are not pleasant but reassuringly, they are rarely a sign of something more sinister. For example, a doctor described how of people presenting in a migraine clinic who had brains scans only 2 in 1000 scans would show up an anomaly requiring further investigation.
Studies have shown that during a migraine attack the release of CGRP – a small protein-is probably increased. One migraine treatment using monoclonal antibodies’ aims to stop CGRP binding to the cells which reduces the activity of cells involved in migraines.
Another common migraine trigger some may find surprising is pain killing medications – this is known as analgesia rebound.
Dr Andy Dowson director of headache service from Kings College London gave an example on BBC Radio 4’s Inside Health program of how a study in a rheumatology clinic where patients were given pain killers for joints – those that previously had migraine generally developed even more headaches, those that had no previous migraine generally didn’t.
Dr Dawson went on to say that due to the analgesia rebound, migraine suffers are often advised to give up long term medication in specialist headache clinics.
Is Migraine a serious problem?
Migraine is ranked globally, by the World Health Organisation, in people under the age of 50 as the single most disabling medical condition in the world and the leading cause of disability among all neurological disorders. It affects approximately 12% of the general population in Western countries, and affects three times more women than men.
Economic Cost of Migraine
An article published in 2019 in News Medical Life Sciences by Dr Ananya Mandal, MD stated that the cost of migraine attacks is estimated to be more than €27 billion per year in the EU . Almost a tenth of this cost is accounted for by the use of triptans to relieve symptoms, while $15 billion is accounted for by indirect costs such as work absenteeism.
The article quotes a US study that showed migraine accounted for an average of 8.3 days absenteeism and 11.2 days of reduced productivity per individual each year, with an overall estimated cost to employers of US$ 3,309 per sufferer.
In the UK migraine accounts for around 20% of the annual sick leave under the NHS as an employer in the UK. Migraine costs the NHS around £20 to 30 million per year and forms around 0.1% of total NHS expenditure.
So, any disease that accounts for around 20% of annual sick leave in a large organisation like the NHS – Britain’s largest employer, is a serious problem.
What is concerning with a problem this large is the effectiveness of the most common treatments , especially when the director of headache service from Kings College London , Dr Andy Dowson states that “ by far the biggest problem that we have in secondary care clinics is analgesic dependent painkiller induced headaches” – this indicates that one of the biggest contributors to the migraine problem is actually the drugs that are supposed to treat it, then this surely means it’s time to consider alternatives.