Migraine is one of the leading causes of disability worldwide and is routinely dismissed as a bad headache. It is a neurological condition affecting a large number of people, particularly women, and it is substantially undertreated.
Many patients have never been offered preventive treatment and rely entirely on painkillers, which eventually makes matters worse.
Recognising Migraine
Migraine has characteristic features that distinguish it from tension headache.
- Moderate to severe pain, often on one side though not always
- Throbbing or pulsating quality
- Worsened by routine physical activity, so people prefer to lie still
- Nausea, and often vomiting
- Sensitivity to light and sound, so patients seek a dark quiet room
- Lasting four to seventy two hours untreated
Tension headache, by contrast, is a band like pressure on both sides, mild to moderate, not worsened by activity, and without nausea.
Around a third of people experience aura, most commonly visual: zigzag lines, flashing lights or blind spots, developing over five to twenty minutes and lasting under an hour before the headache.
The Stages of an Attack
Migraine is more than the headache phase, and recognising the early stages allows earlier treatment.
- Prodrome, hours to a day before: yawning, mood change, food cravings, neck stiffness, increased urination. Many patients recognise this once told to look for it
- Aura, in some people
- Headache phase
- Postdrome, the day after: fatigue, difficulty concentrating, sometimes described as a hangover
Treating during the prodrome or at the very start of the headache is considerably more effective than waiting until the pain is established. This is the most useful practical point in migraine management.
Common Triggers
Triggers are individual, and often several combine rather than one acting alone.
- Irregular sleep, both too little and too much
- Skipped meals and dehydration
- Stress, and notably the relaxation after stress, which is why weekend migraines are common
- Hormonal changes, particularly around menstruation
- Bright or flickering light, and screen glare
- Strong smells including perfume and incense
- Weather changes
- Alcohol, particularly red wine
- Certain foods in some people: aged cheese, chocolate, processed meats, monosodium glutamate
- Excess caffeine, or caffeine withdrawal
A headache diary over eight weeks recording attacks, severity, medication and possible triggers is more informative than trying to identify triggers from memory.
Medication Overuse Headache
This is the single most important and least known fact about migraine management.
Taking acute painkillers too frequently converts episodic migraine into chronic daily headache. The medication that relieves each attack becomes the cause of the ongoing headache.
The thresholds are: simple painkillers on more than fifteen days a month, or triptans, combination analgesics or opioids on more than ten days a month.
Treatment requires withdrawing the overused medication, which causes a difficult period of one to two weeks with worsening headache before improvement. Preventive treatment is usually started at the same time.
If you are taking painkillers for headache on most days, you are likely in this cycle, and continuing will not resolve it. Our neurology department manages withdrawal alongside preventive treatment.
Treating an Attack
Effective acute treatment depends on the right drug taken early enough.
- Take medication at the first sign, not once pain is severe
- Anti inflammatory painkillers at an adequate dose work well for many people
- Triptans are migraine specific and considerably more effective for moderate to severe attacks
- An anti sickness medication taken alongside helps both nausea and absorption of the painkiller, since migraine slows stomach emptying
- Rest in a dark quiet room
- Cold compress on the head or neck
- Stay hydrated
- Limit acute treatment to two days a week to avoid overuse
Triptans should not be used by people with uncontrolled hypertension, coronary artery disease or previous stroke, which needs checking before prescribing.
Preventive Treatment
Prevention is indicated for four or more migraine days a month, or fewer if attacks are severe or disabling, and it is widely under prescribed.
- Beta blockers
- Certain antidepressants at low doses, used for their pain modulating effect rather than for mood
- Anticonvulsants such as topiramate
- Calcium channel blockers such as flunarizine
- CGRP monoclonal antibodies, a newer class specific to migraine
- Botulinum toxin for chronic migraine
- Magnesium and riboflavin, which have modest evidence and are low risk
Preventive treatment takes six to eight weeks to show effect and should be given an adequate trial before being judged ineffective. Success is a fifty percent reduction in attack frequency rather than complete elimination, and expecting that helps.
Note that topiramate and valproate carry significant risks in pregnancy and require careful discussion in women of childbearing age.
Migraine in Women
Hormonal influence is substantial and shapes management.
Menstrual migraine occurs around the drop in oestrogen before a period, tends to be more severe, longer lasting and less responsive to treatment. Targeted short term prevention around that window can help.
Migraine often improves during pregnancy, particularly after the first trimester, and often worsens around menopause before settling.
An important safety point: women who have migraine with aura should generally avoid combined oestrogen containing contraception, because it increases stroke risk in this group. Progestogen only methods are alternatives. This is frequently overlooked and worth raising specifically with our gynaecology department.
Red Flags That Are Not Migraine
These features suggest a different and potentially serious cause requiring urgent assessment.
- Sudden severe headache reaching maximum intensity within seconds, described as thunderclap
- Headache with fever and neck stiffness
- Headache with new neurological symptoms: weakness, numbness, speech difficulty or confusion
- Headache after head injury
- Progressively worsening headache over weeks
- Headache worse on lying down, coughing or straining
- New headache after age fifty
- Headache with visual loss
- Headache in someone with cancer or immunosuppression
- A definite change in the pattern of a long standing headache
Thunderclap headache requires immediate assessment through our emergency department, as it can indicate bleeding around the brain.
Migraine is treatable and undertreated. Treat attacks early rather than waiting, keep acute painkiller use under two days a week, and ask about preventive treatment if you have four or more migraine days a month. If you are taking painkillers most days, that is now part of the problem.
Our neurology department at T. Nagar assesses headache and provides preventive treatment.
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