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MIGRAINE

| Headache | The Diagnosis of Headache | Migraine | Tension Headache Syndrome | Cluster Headache | Other Migraines | Other Headaches |
| Treatment of Headache |

1. Migraine headache without aura


Migraine headache is diagnosed readily if an individual has headaches that last between four and seventy-two hours. If there are two of the following characteristics

a) Moderate to severe headache
b) Lateralised headache
c) Throbbing or pulsatile pain
d) Pain made worse with exercise

There should also be one of the following.

a) Photo and/or phono phobia
b) Nausea and/or vomiting


2. Migraine headache with aura

The term aura means that there is a neurological deficit of some kind that usually precedes the headache for up to one hour. This may be a visual disturbance with zigzag lines or blotches in the vision. It could be a speech disturbance or even weakness or numbness down one side.

The cause of migraine

The cause of migraine is not fully known. There are whole text books written on the changes that occur during a migraine attack. In simple terms, there is involvement of the so-called trigemino-vascular pathways which are a series of nerve fibres that run from the brain stem (the back part of the brain). These nerve fibres end up on all the blood vessels in and around the brain and also go to a lot of the skin and bone around the scalp. Chemicals are released by these nerve fibres that cause blood vessels to constrict and dilate producing the pain. Why this happens is not known although there is a genetic factor. About 70% of people with migraine will have a family history.

There is much interest in lady patients as to whether or not hormones are in some way involved. I am not convinced particularly except to say that there are a subgroup of patients who do have menstrual migraine or menstrual associated migraine when it seems as if there is a hormone association. This type of migraine can be particularly difficult to treat.

Treatment

The management of migraine is as follows.

1) A good headache diary
2) Identification of risk factors or triggers in the environment that can be avoided
3) Non drug treatment
4) Drug treatment

Drug treatment

Drug treatment can be either preventative therapy taken on a regular basis to stop attacks happening or it may be acute treatment that is given when an attack starts.

Acute treatment

The best acute treatment still involves taking three aspirin or three paracetamol or three ibuprofen at the very onset of the attack together with an anti-sickness pill. The anti-sickness pill is essential as part of migraine is that you do not absorb the tablets you take. The anti-sickness pill has to be prescribed by a doctor. You should not take more than one dose of three tablets without having discussed the situation with a doctor.

If this fails, then there are a group of new tablets called the triptans. There are five of these now on release. They can be prescribed in a tablet form of different strengths. There is a nasal spray and also a wafer that dissolves on the tongue which I find very helpful. There is also a way of injecting the medicine yourself which is the so-called gold standard of treatment as it works the quickest and in the most people. The tablets cost the Health Service between £4 and £8 a tablet. The injection is about £20. Many people are unable to get the treatment because general practitioners feel that it is too expensive. Only in the United Kingdom is this a problem as the rest of Europe and North America readily prescribe the medication for those that need.

Preventative treatment

There are a number of tablet therapies that can be used to prevent attacks. These need to be taken on a daily basis. Each of them has their own set of specific side-effects. Most patients however will go on to treatment very comfortably for about three months. The usual rule is that if you can go three months without attacks, then you can come off treatment with the headache being pushed into remission. If you are on prophylactic treatment, you can still take acute treatment if any breakthrough attacks occur.

Alternative therapies

There are a large number of alternative therapies that claim to have an effect on migraine. I am not going to list them all here as it would take several pages. The rule of thumb is as follows. All alternative therapies (acupuncture perhaps being the exception) work on about 30% of patients which is the same as a placebo response. The drug therapies work in between 60%-80% of people.

Childhood migraine

Migraine is very common in children. Over 20% of migraine sufferers will actually have their first attack before the age of ten. Migraine can present in children just as abdominal pain or even attacks of dizziness with vomiting. Usually there is a strong family history and often there are major social problems which on occasion may not be obvious such as problems at school. It is very difficult to do trials of treatment in children because there is a very high rate of spontaneous settling in three months after migraine headaches start. Referral to a specialist is recommended.