Migraine

As many as one in five women and one in fifteen men suffer from migraines and they can be triggered by many causes including food, stress, dehydration, hormones and many more.

The National Migraine Centre's Medical Director Dr Giles Elrington joined us at GNHQ in June 2012 to give us some answers. Dr Elrington is a Consultant Neurologist with particular subspecialty in both headache and multiple sclerosis and The National Migraine Centre the only independent, charitable clinic in the UK that is entirely focused on headaches and migraines.

Q: Despite being a "headachey" person until recently I had only ever had one full on migraine (blinding pain, nausea, inability to tolerate light.) But recently I have had a couple of dreadful and long-lasting headaches with nausea which drugs (paracetamol and ibuprofen) don't seem to touch. The head pain is always at the front - behind my ears and top of my nose) Does that sound like migraine? FeeTee

A: Almost all headachiness is migraine. You don’t have to have a full-on attack all the time – it can be mild migraine. Migraine can describe the attack or also the tendency to attack. Like asthma – you can have asthma and feel fine, you can have asthma and have a bit of a wheeze, you can have asthma and be in intensive care – and migraine is the same.

Lots of people have migraine with mild head pain that can be anywhere in the head – behind the eyes, where the head joins the neck , anywhere in the head or even face, neck or shoulder. You can even have migraine without having headache: aura migraines or, in children, abdominal migraine. Headache is not an essential part.

Q: After a lifetime of migraine, including 6 hospitalisations, I asked my GP to refer me to one of the Scottish Migraine clinics. He said there were no new treatments and GPs were the usual people to treat the condition. He said control of my stress was the key, and told me to "use meditation". 1northernbelle

A: I disagree that stress control is helpful in migraine. Though of course we all need to look after our stress levels. The first thing to think about in treating migraine is your body clock. Try to keep to the same pattern every 24 hours. Have at least three meals a day, including fibre-containing breakfast shortly after getting up. Don’t go short on fluids. Take it easy with caffeine and alcohol. Minimise pills. If you have migraine twice a week or more you might consider a daily medication to reduce attack frequency.

Two attacks or fewer you can treat with rescue medication (ie something to take as and when required.) Start with either 900mg aspirin or 600mg ibuprofen (ideally dissolved in water) and add domperidone (20mg) which sadly is not French champagne but can be bought over the counter in a pharmacy as Motilium. If that is disappointing take a triptan drug at the start of head pain. Sumatriptan prescribed as a generic drug by your GP is very good value – you can buy branded Imigran without prescription but it’s more than 10 x the price of the generic drug. Treat once at the start of the attack, aim to be pain free within 2 hours, if not rethink your acute rescue strategy.

Remember not all attacks will respond in the same way. So treat three separate attacks before concluding lack of benefit. There are six other triptan drugs and it’s worth trying them all until you decide which one works best for you. Beyond pills and lifestyle the NHS in England and Wales will be offering Botox injections for chronic migraine from about September this year. Specialists also sometimes use nerve block injections to treat migraine. Rarely we need to put electrodes into the brain for very severe cases. We are experimenting with electrical and magnetic devices to see if they help without pills. Nothing new? Just pills? My apologies to your GP but I disagree.

If you can face travelling all the way down to London you are welcome at The National Migraine Centre where we see patients who refer themselves. Because we are not in the NHS we ask for a voluntary donation of £100 which is a lot less than it costs us to provide the service.

Q: Can you please explain the effect of weather changes on migraines? I only get them when thunderstorms are threatened. alchemillamollis

A: Lots of people get the same thunderstorm effect as you do. Sadly we have not yet learned how to adjust the weather. It’s often worth looking at migraine triggers but obviously only the ones that we can change.

Q: My migraines started after the onset of the menopause......so I'd like to know whether hormonal change could be the trigger? SpamW

A: It’s easy to overestimate the effect of hormones on migraine. Women whose migraines occur only during their period have normal hormones, it’s the migraine which is abnormal. Migraine beginning after the menopause is not triggered by hormones.

Q: I have suffered with migraines for about ten years. I have pretty much given up drinking more than one glass of wine and I have to ration my screen time (although my job that entails looking at a screen most of the day). I have recently been prescribed domperidone tablets to take at the onset and they do seem to be making a difference. Does this suggest that the migraines are in some way connected with my digestive system? distaffgran 

A: Domperidone is helpful for many people with migraine – which certainly affects the digestive system. But the trigger for the attack is in the brain not the gut. Migraine definitely improves with age though the menopause is less relevant than people often want to think. Strong visual input can worsen migraine. This doesn’t just apply to computer screens. Try changing the colours on your screen, get the best quality screen you can, possibly a screen filter.

Q: I've had migraines since I was 11. Now in my late 50's, I'm giving up hope of ever growing out of them. I have migraine-free spells for several weeks then they will suddenly start again. Very often each migraine will last several days with a nagging one-sided headache that responds to nothing, it seems. I'm not even sure if that is indeed migraine. I've recently been changed from co-dydramol to prescription co-codamol tablets but both are ineffective at least 50% of the time. Is there anything else I can do to help myself with this, either fending them off or treating them? SueDonim

A: You will most certainly have migraine. Co-dydramol and co-codamol are not recommended and actually quite often make migraine worse. If you abandoned these medications and took no pills at all for your migraine you’d probably have a difficult couple of weeks and then find you had a lot less migraine. If taking no pills is impossible for you try the medication suggested to 1northernbelle or ask your GP for a prescription for naproxen 250mg 3 times daily after meals absolutely regularly, pain or no pain, for two weeks to three months until your migraine becomes infrequent or absent. Overuse of these codeine and paracetamol medications is the single commonest reason for migraine to go from bad to worse.

Q: I have had migraine from the age of 20 and am now 64. I very often wake in the early hours with a migraine and stumble out of bed and take a sumatriptan and just lie there for a couple of hours until it goes. My triggers are going too long without food, alcohol any kind, flickering lights, even ironing something stripey can trigger it! Kate1947

A: Can I say it sounds like you have migraine tiggers not migraine triggers! Seriously though your triggers are shared by many other people and it’s often good, if possible, to avoid these and minimize sumatriptan if possible.

Q: Can you advise us about the lack of balance that seems to be associated with chronic headaches please? I have tried drugs from the doctor but they did not seem to have any effect on the balance issues - it is as if I am drunk and wearing my reading glasses whilst trying to walk in a straight line! randomangel59

A: Lack of balance is common in migraine. Doctors often try drugs like stemetil but they don't work well for migraine. Domperidone is usually better, you can take this 20mg three times a day when your balance is bad. If it's bad most of the time a prophylactic like amitriptyline taken for many months can be helpful both for the headache and the imbalance.

Q: I have been told not to take Maxalt during the aura stage - is this true? If so is there anything I can take to alleviate the aura symptoms? skilegs

A: Maxalt can work in the aura stage but only for headache not for aura. Some people find that triptans like Maxalt work only if taken when headache begins. At aura onset you could try soluble aspirin or ibuprofen, plus domperidone (see earlier answers) which may perhaps shorten the aura and can help the headache.

Q: I think I have migraines (severe headaches that can make me physically sick and only touched by a combination of ibuprofen and paracetamol) but my husband dismisses them as stress headaches. Who is right? barbarab

A: You are right and not your husband. Many people are vulnerable to stress when they’re brewing a migraine. It’s easy to think it’s the stress causing the migraine. In the hours or day before a migraine things that normally don’t wind you up become stressful because of changes in your brain. This is a good day to take care of your diet plenty of water, normal sleep pattern, no alcohol.

Q: I would like to know more about migraine in children. Are the symptoms different and is it more difficult to diagnose? Also - are there any natural remedies that may be suitable for youngsters? floro

A: Migraine in children, compared with an adult's, tends to be shorter, more symmetrical, more vomiting, less aura. The short attacks can be hard to treat as drugs often take a couple of hours to work. People under 16 should not use aspirin. Triptans work in children but are largely unlicensed. Regularity of lifestyle, meals and fluid are important for children with migraine. What could be more natural than that?!

Q: When people have a cold they often say they have flu (but clearly don't) And when people have a bad headache they often say they have migraine. Is that the same sort of thing? Or is there something specific about actual migraine that differentiates it from other bad headaches? gdadbob

A: Almost all bad headaches are migraine. The point about migraine is that it is usually headache plus either nausea or vomiting, or light and noise sensitivity. These associated symptoms can be relatively mild. Migraine is also worse with mild exercise, better with rest though this need not be profound.

Q: I wonder why I can drink beer but not wine, which triggers a 3-day whammy? ? Anyone else have that experience? BiblioQueen

A: It's often the other chemicals, not just alcohol, in drinks that can cause migraine. Dehydration can worsen migraine and you get more water with your beer than your wine.

Q: I have been told that my first migraine was diagnosed at 18 months and I suffered on a six- to eight-week cycle until my periods started. I was warned that they might come back with the menopause, but so far so good. Are there many findings of hormone related-migraine? Phoenix

A: Hormones can trigger migraine attacks but most women have attacks which are not triggered by hormones. Obviously hormones trigger migraine only from the menarche to the menopause. Before and after that, hormones are stable. It is the change in hormones (oestrogen drop) which triggers migraine. Yours are clearly not hormonally related. I wouldn't be worried about the menopause.

Q: I read somewhere that Botox has recently been recognised by the NHS as a treatment for migraine - about 30 injections to the head and neck (not the face) every few months. Can this be true? I've suffered migraines for years and years, and I'll try anything, but this seems quite drastic. It is worth trying? Grannyruth

A: Botox is effective for chronic migraine - that is at least 3 months of headache more often than not. Botox is given every three months. About one in four people are much better after one or two sets of injections. One in four don't respond at all. One in two go on having injections for a while and improve after each set of injections. It's quite expensive so when it becomes available on the NHS for people aged between 18 and 65, they will first have had to address medication overuse, and then try three different prophylactic medications before the NHS will fund this. The National Migraine Centre does not insist on these prerequisites but you do have to pay for the toxin yourself - and it's quite expensive.

Q: Is it possible that migraines could be made worse or even caused by medication? I was recently referred to a doctor who advised me to stop taking Anadin Extra (which I had been taking daily) to rule out the possibility. I had a crashing headache for the first couple of days but then nothing for five days, which is a record for me. If medication could be to blame, any advice on how to get through the bad days without painkillers? Praxis

A: I wish more people knew this. If you have a tendency to migraine and take any short term treatment more than two or three times a week the migraine goes from bad to worse. Complete "cold turkey" cessation of all medications is tough particularly for the first couple of weeks. But then there is gradual improvement. Some experts like to add another drug such as regular naproxen, or Botox, or topiramate, while withdrawing overused medications. Others prefer pure cold turkey on the grounds that this works well for many and all drugs have possible side effects.

How to get through the difficult days? First be sure that this is an important and efective treatment. Clear your diary. Time off work. Help with childcare. Husband cooks own meals (as if they didn't) and make some space in the spare room - and get some ice packs in the fridge. There really is light at the end of the tunnel.

This is the single commonest problem encountered by headache specialists. "Medication overuse headache" accounts for four out of ten headache patients referred to specialists. I am undermining my private practice by telling you this!

Q: Can you resolve a dispute in my family? Is it pronounced my-graine or me-graine? fridaygran

A: Whatever you like! The word comes from hemicrania which means half head pain. So if you say this fast in a fake Italian accent I think you say me-graine. But it really doesn't matter what you call it.

Q: I was interested to see that you are also interested in MS, as this was part of the differential diagnosis when I became ill. The diagnosis now seems to be atypical migraine - but I have never been convinced by this, as headache is not the main feature, although it is often present alongside "giddiness" and sometimes pain centred on my right ear with tingling down the right side of my tongue.

I have had every scan and test in the book and the truth is that no-one knows what is really happening.
I have learned to live with it - do I have a choice?! - and use a stick when the instability is particularly bad. I am now 63. Mishap

A: You’d be amazed that MS and migraine are sometimes confused. We have some very strong new treatments for MS and a few years ago a patient died from a side effect of one of these strong treatments and the autopsy showed no evidence of MS. With hindsight, it became clear that the patient had migraine not MS. It’s always worth rethinking diagnoses. Just because a doctor seems clever or important does not always make the doctor right.

Q: I had my first migraine aged 13 - blinding headache, wonderful art deco aura with speech, writing and movement affected. They were sometimes linked to food (strong cheese, red wine) and bright sunlight but they mainly seemed to be linked to hormonal changes. After the menopause I seemed to be free of them until recently: I've had 3 in the past 3 weeks. In my mind they seem to be linked to the slight dizziness and muzziness I've had with sinusitis linked to allergic rhinitis. Could this be the case? 

I'm also interested in something I read about migraine being a symptom of Hughes Syndrome. My daughter was diagnosed with this in relation to recurrent miscarriages. Is there a link and is the condition hereditary - i.e. should I get tested for this? GadaboutGran

A: I think it's more likely that your rhinitis symptoms and dizziness are part of the migraine. Of course I am biased because I'm a migraine doctor. To a hammer everything looks like a nail. Doctors have to watch out for this. Hughes' Syndrome has a broad spectrum and the blood tests that diagnose it are quite commonly abnormal in healthy people. Sometimes I wonder if doctors diagnosing Hughes' Syndrome may have a bias as perhaps I do. Both migraine and Hughes' Syndrome cluster in families but are not strongly inherited. It is possible to have both. Your GP can advise you about testing for Hughes' Syndrome.

Q: I started migraines at about the age of 15/16 and I'm now 67 and thankfully the days of being confined to bed in a darkened room for 36 hours every 2-3 weeks with a bucket by the side seem to be over. I have been taking Naramig for the past 10 years, but still get bad headaches -once or twice a week. I've tried taking paracetamol (with and without codeine), ibruprofen (I can't take aspirin) immediately I sense a headache coming on and they dull the pain but only the triptans completely remove it together with the sense of disorientation and heightened reaction to sound and light. There is never any rhyme or reason to it. What will set a headache off one day, won't on another! busilizzie

A: I agree that paracetamol with and without codeine is not good for migraine. You might find increasing ibuprofen does to 600mg (ask your doctor for this on prescription – the granule preparation) and take it in water with domperidone 20mg which makes the stomach empty properly (the stomach goes on strike in migraine) It may work almost as well as Naramig. But if Naramig (naratriptan) works well why not take it each time? Perhaps because it’s more expensive than generic sumatriptan – though there should be a generic naratriptan available soon. You are right that triggers don’t always set migraine off: it doesn’t always rain when there are clouds in the sky.

Q: My 12 year-old grandson has very suddenly started getting headaches, which the GP has diagnosed as migraine although he says the pain is at the back of his head, rather than behind one eye, which is my experience of migraine. He has had three of these headaches in the last fortnight. Mostly they come on in the afternoon but one lasted nearly three days. They have all been accompanied by fairly violent nosebleeds. He has twice vomited with them and goes very pale. The latter two were cured after long sleeps. Should we be worried? And what can we do? tidymind

A: Pain localisation is non specific in migraine. Does your grandson need a drink and a snack when he gets home from school? Sleep is certainly a good treatment for migraine but better to avoid the attack if possible with a regular diet and plenty of water.

Q: I'm 60 and after a lifetime of migraines I have finally found medication that works for me. My GP's advice was to take 3 aspirin (max 900mg) if it seemed to be a migraine coming on and if the aspirin hasn't worked after an hour I take one tablet (Maxalt Melt 10mg Oral Lyophilisate). Cerasus

Q: Due to cutbacks I have been told I can no longer have Imigran but have to have the generic sumatriptan which does not work as well for me. I have looked up Maxalt and it is cheaper than sumatriptan and considered to be more effective. Should I ask for this instead? Humbertbear

A: Maxalt is a brilliant medication. It is slightly cheaper than branded sumatriptan (Imigran) 100mg but more than ten times the price of generic sumatriptan. I’m sorry that Humbertbear is disappointed with generic sumatriptan but it really contains exactly the same chemical as branded sumatriptan. Are you sure that the dose didn’t change? Sumatriptan 100mg helps about one in ten patients who do not respond to sumatriptan 50mg. Not all attacks respond the same. If you were picking it off a supermarket shelf at 30p versus £6 which would you choose?

Q: I have been plagued by migraines for over 10 years. I have tried without success to identify any triggers and have tried stopping certain foods/drinks to no avail. When they strike they are totally debilitating and I end up spending hours with my head/face pressed into a hot water bottle after taking as many co-codamol tablets as I dare. Over the years I have been prescribed things such as Imigran and Maxalt but I am yet to find my "wonder drug". I have seen a lovely neurologist but no tests were carried out. I have also tried using sinus wash solutions wondering if that is the problem? SpamW

A: Sinus washing won't work. And co-codamol may well make matters worse. Keep trying with different triptans - there are five others - and be very picky about what time in the migraine you take the triptan. As soon as possible after pain begins. Cutting foods out is a waste of time.

You don't say how often it's happening. Consider keeping a migraine diary. there are good ones on the Migraine Centre's website. Talk to your GP about a prophylactic drug to take every day, once you've got a couple of months on your diary. Reassuring to hear your neurologist was very nice - we don't always have a good reputation, as we see so many incurable diseases. But migraine can be helped. People with migraine do not need any tests or scans.

Q: I know roughly what my triggers are - alcohol, too much eye strain, lack of sleep... But although I can definitely do something about the first of these, there's a limit to what I can do about the others. Do I have to accept migraine as part of my life? feroshus

A: Health means the tolerance of imperfection. But you should be able to do something about your migraine. If your GP or local specialist can't help why not come to National Migraine Centre?

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