How to deal with Migraines

NBNeurology2019 1012
28th November 2019

Patient Information

Migraine is very common, affecting about 5 million Australians. Migraine imposes a huge cost on Australian society with direct and indirect costs  estimated at about $35.7 billion annually (Migraine in Australia, Deloitte Access Economics Report, 2018). Improving treatment of migraine should be a priority to improve the lives of people with migraine and to reduce these costs to society.

Our neurologists at Northern Beaches Neurology are experts in the treatment of migraine and can help with your migraine symptoms.

Symptoms of migraine

A lot of people seen by our neurologists with headache often believe that only severe headaches with vomiting count as a “migraine.” The truth is that migraine has many faces. A “classical migraine” is a throbbing or pounding headache that usually involves half the head and is associated with light and sound sensitivity, nausea and vomiting.

Headache in migraine can take a number of other forms such as:

  • Headache behind the eye
  • Headache at the back of the head or neck
  • Headache all over the head
  • Pain in the face or sinuses

People with migraine often experience several different types of headaches, and are more likely than others to get tension headaches.

Some people with migraine experience an “aura.” An aura means a warning before a migraine strikes that consists of various neurological symptoms. Someone with a migraine may feel irritable or hungry for several hours before a migraine hits.

The most common “aura” described by migraine sufferers is a change in vision. This could be with blotches, sparkles or zig zags in the vision, blurring of vision or double vision. Other aura symptoms include numbness or tingling in the face, arms or legs, difficulty speaking or thinking, and unsteadiness or dizziness.

Some people experience the migraine aura without much of a headache afterwards.

Besides the aura symptoms described above, some patients experience symptoms with the headache such as a droopy eyelid, blocked nose or watery eye. Migraine is often associated with light and sound sensitivity. Some people feel nausea (upset stomach) or may vomit.

It is important to see a doctor quickly if you experience any of these symptoms for the first time as these symptoms can also be experienced in serious conditions such as stroke or a torn neck artery.

Many people report specific things that trigger a migraine. Again triggers can vary dramatically and can consist of some of the following:

  • Various foods (commonly citrus, chocolate, cheese)
  • Alcohol
  • Fatigue and sleep deprivation
  • Strong smells
  • Visual effort (eg prolonged screen time or bright light)
  • Change in the weather

Some people with migraine do not know what triggers their headache.

Factors to consider in migraine management

How to manage migraine depends on a few things:

  • How often do migraines occur?
    • Occasional migraine (less than once a fortnight)
    • Frequent migraine (more than once a fortnight)
    • Chronic migraine (headaches at least 15 days a month)
  • What time of the day do migraines occur?
    • No pattern
    • Always at the same time of the day
    • Causing the person to wake up
  • Do migraines relate to the menstrual cycle?
  • Are there any avoidable migraine triggers?
  • Is there a clear warning prior to the migraine?
  • Is the migraine associated with significant nausea or vomiting?

Management of migraine without medication

There are a number of things that can help patients with any sort of migraine. Below are recommendations of things that can be tried to help treat migraine:

  1. Keep a headache diary

A headache diary is a very helpful way to look for patterns in how you experience your migraine including the time of the day you get migraines, how often you get migraines, where migraines occur in the menstrual cycle and the symptoms you get with you migraines.

Please click here for a printable monthly headache diary. or email for an excel version.

  • Try to identify and eliminate any migraine triggers

Keeping a record of foods eaten and their relationship to food can help. Some patients choose to undertake an elimination diet to see if this helps, although proper nutrition must be maintained.

  • Exercise

Regular exercise can help control migraine. We recommend relaxing low-intensity exercise such as swimming, walking and jogging. Improving core muscle strength is useful (for example Pilates and lower-intensity forms of yoga). We recommend avoiding high-intensity workouts for people with migraine, especially when headaches are present.

  • Physical neck treatments

Some people with migraine find that physical treatment of the neck can improve their symptoms. This may include massage, physiotherapy or osteopathy.

  • Acupuncture

Some patients temporarily respond to acupuncture treatment.

  • Sleep

Migraine can disturb sleep and poor sleep is associated with higher pain levels. We recommend attention to good sleep habits for people with migraine.

Medication management of a migraine

Generally speaking, medication is often required for a migraine headache. Different people respond to different medications, and there is no single medication that works for everyone. There are some basic rules for the use of medication to treat migraine. All medication should be discussed with your doctor prior use to make sure they suit your individual health circumstances.

  1. The supermarket approach

Medications that can be obtained from the supermarket are often tried first, such as paracetamol, ibuprofen and aspirin.

  • Take medication early

It is advised that headache medication is taken as soon as a migraine is recognised to maximise the likelihood of a positive response. Pain medication is often much less effective once the migraine has established as a bad headache.

  • Avoid medication overuse

People who experience frequent migraines may start taking medication regularly. We know that prolonged regular use of pain killers, especially those that contain codeine, can make your headache problem worse. Although this may seem confusing, sometimes your doctor will tell you to take less pain medication to help improve your headache problem.

  • Stronger pain killers

Some people require stronger pain killers such as those that contain codeine or other ‘opiates.’ In general, these are not considered as ideal choices for headache treatment due to side effects and the possibility of dependence. If absolutely necessary, the use of strong pain killers should be minimised.

  • Triptans

Your doctor may suggest that you try a ‘triptan’ to treat your migraine. These are headache tablets developed specifically for migraine. They should be used as soon as possible after a migraine starts. Triptans are not suitable for all migraine sufferers, depending on other health complaints and medications.

Preventative medications

Some people who experience frequent or chronic migraine may be advised by their doctor to take a preventative medication. This is a medication that is generally taken every day to reduce the risk of a migraine occurring. It is not a treatment of an individual migraine.

Below is a summary of common preventative medications used for the treatment of migraine.

  1. The ‘natural’ approach

High dose riboflavin (vitamin B2), magnesium and the herb feverfew can help some patients with mild migraine. These treatments generally have minor side effects. They can be purchased individually or in combination preparations at most pharmacies. You should consult a pharmacist or doctor before starting riboflavin or feverfew.

  • Tablet options

There are a number of medications that if taken daily can reduce the rate of migraine. These tablets include some blood pressure medications (such as propranolol and verapamil), some anti-depressants (such as amitriptyline or nortriptyline), some anti-epileptic medication (such as topiramate), and a migraine-specific preventative medication, pizotifen. Each of these medications has positive benefits and side effects and should be discussed with your doctor before use.

  • Botox for migraine

Botulinum toxin (Botox ©) is currently the most effective treatment of chronic migraine. This involves injections around the head and neck and is performed by your neurologist (link to Botox page here). Discuss with your neurologist whether Botox is suitable for your specific situation.

  • New treatments

A new class of medications called CGRP (calcitonin gene-related peptide) inhibitors have been developed. These medications may be very effective treatments of chronic and episodic migraine. These medications are currently being marketed and await assessment by the pharmaceutical benefits scheme for possible government subsidy. Some of these medications can be obtained privately although the cost is currently very high.

Migraine and contraception

Migraine occurs most commonly in women between puberty and menopause. As such, migraine can pose specific issues with contraception, in particular the pill.

Combined oral contraceptive pills (containing oestrogen and progesterone) can make migraine worse. There is also a low but significant increase in the risk of stroke in migraine sufferers who take the combined oral contraceptive pill, especially if they also smoke. People of any age who experience migraine with aura should avoid the combined oral contraceptive pill. Women aged over 34 should avoid taking the combined oral contraceptive pill if they experience migraine with or without aura. Your GP can discuss contraceptive options with you.

Migraine and pregnancy

Pregnancy is a time of a lot of hormonal and body changes and this can impact on migraine. Some patients will develop migraine in pregnancy for the first time, some patients will experience worsening of their migraine and some will find their migraine less severe. It is not always predictable.

Migraine is challenging to manage during pregnancy as a lot of the commonly used medications should be avoided. It is important to speak with your neurologist or GP regarding your migraine treatment if you are planning to become pregnant. Migraine in pregnancy is best managed in consultation with your neurologist and obstetrician.

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