Migraine

Migraine is more than just a headache. It is a complex brain disorder that involves problems with processing sensory information (like light, sound or smells). Migraine symptoms usually spread over five phases:

1. A ‘premonitory phase’ when non-painful symptoms (e.g. yawning, tiredness, thirst, needing to urinate often, difficulty concentrating) are experienced hours or days before headache. This phase can last from few hours to a few days.
2. An ‘aura’ phase with sensory or other brain symptoms (e.g. vision problems, language problems, strange smells) occurs immediately before or at the beginning of headache in about 15% of people with migraine. The symptoms typically spread from a small area to a bigger area or vice versa. This phase usually lasts only a few minutes, but longer episodes do occur. 
3. The acute migraine attack is typically a moderate-to-severe throbbing headache, usually on one side, that gets worse with head movement. It is often accompanied by nausea, and sensitivity to light, sound, touch and smells. This phase lasts from a few hours to three days.
4. A ‘postdromal’ phase (‘migraine hangover’) of tiredness, difficulty concentrating and/or sensitivity to noise. This can sometimes last for several days.
5. An ‘interictal phase’ in between attacks of migraine, when there are no symptoms. This can be very short for people with chronic migraine.

There are around five million people with migraine in Australia (approximately one in five Australians).

Before puberty, boys and girls are equally likely to have migraine, and prevalence increases slightly with age. Migraine is more common in women than men, affecting about three women for every one man. The severity of migraine seems to reduce in older age.

Migraine can occur either with or without the aura phase, which usually lasts for five minutes to an hour in those people who experience it. The aura can last longer but that is rare.

Visual auras usually involve the appearance of a blind spot that gets bigger or an area of shimmering that grows. Other symptoms during the aura phase include speech and language problems (e.g. not being able to find the right words, or not understanding words), spreading tingling sensations, weakness or being unsteady.

The headaches associated with migraine attacks are what separates the disorder from other types of headaches.

Migraine is a genetic condition. You are born with the genes that make you more prone to migraine. People whose parents or siblings have migraine are more likely to have it themselves.

Our current understanding is that the way the brain processes sensory information is genetically affected and influenced by the environment, with particular parts of the brain more involved than others.

The fact that most people with migraine develop it after puberty, and that women are more often affected than men, suggests that sex hormones like progesterone, estrogen and testosterone are involved. The brains of people with migraine may be particularly sensitive to hormonal changes.

Migraine attacks seem to be triggered in some people. Stress, bright lights and sleep deprivation are the most reported triggers in men.

A diagnosis of migraine is made for people who have had, on five or more occasions:

1. A headache that lasts between four hours to three days
2. Associated nausea/vomiting and/or sensitivity to light or sound
3. The headache has at least two of these four characteristics:
   • One-sided
   • Throbbing
   • Moderately to severely painful
   • Made worse by movement

Migraine can be categorised as either episodic (less than 15 headache days per month) or chronic (15 or more headache days per month).

There are two aspects to migraine treatment:

1. Treatment of acute migraine attack
2. Preventative treatment

Treatment of acute migraine attack is aimed at getting what headache experts call a sustained pain free response (SPR). It is important to treat early, treat well, and treat with the most appropriate acute medications to achieve SPR.

High doses of anti-inflammatory medications like ibuprofen, aspirin or paracetamol can be effective in relieving the pain of migraine headaches. If one of these doesn’t work, others are unlikely to be helpful.

A group of drugs called triptans are specifically designed to stop the worst symptoms (usually the headache phase) of migraine. They’re best taken as soon as you feel the headache phase start (or just before if the pattern of your migraines is predictable).

Triptans must be used with caution (or not at all if you have other specific health problems or take other medications). Some triptans are available over the counter but it’s best to discuss with your doctor which one may be right for you. Your doctor can give you a prescription, which might make the drug a little less expensive for you. It’s important to use triptans correctly to get the best effect and avoid complications.

There is a variety of other drugs that can be used to treat migraine, which your doctor might suggest if anti-inflammatories or triptans don’t work for you.

It is important to not to overdo this approach. The current advice is to use acute medications no more than two times per week. Using acute medications too often will lead to medication overuse headache.

Preventative treatment of chronic migraine

If you need to take acute medications for your migraine more than 2-3 days per month, you may be better off with preventative treatment for several months (usually at least 9-12 months) to reduce the number of days you have symptoms.

For some people, lifestyle interventions like changes like diet, meditation, sleep and exercise can be helpful for managing migraine.

If you have migraine symptoms often, your doctor can prescribe drugs that can be taken daily to try and prevent the attacks. Some over-the-counter medications, such as magnesium or vitamin B2, may also be effective.

Nerve stimulation or nerve-blocking treatments may be used in some people who have migraine.

People with migraine are more likely than normal to have blood vessel disease, asthma, allergies, epilepsy, chronic pain, restless leg syndrome, depression, anxiety and post-traumatic stress disorder and other mental health problems. However, mental health problems seem to accompany migraine more in women than men, whereas physical health problems seem to be more common in men with migraine. An association between stroke and migraine seems exist in women but not men.

Migraine headaches can change in severity and how often they occur. Some people will go from episodic to chronic migraine and back again a number of times.

Migraine can have a substantial impact on quality of life, so it’s important to manage the problem as well as possible.

If you think you have migraine, or if you have more severe or more frequent headaches than usual, you should see your doctor. They may be able to help you identify and manage triggers and find a treatment that suits you.