Migraine: how to live with it
This section has been written by Dr Anne MacGregor and offers advice for migraine sufferers on living with migraine. It covers the following: What is Migraine? What happens in an attack? What causes an attack of Migraine? The most common triggers. How you can help yourself. What treatment is available? What non-drug treatments are available? What if it is not a migraine?
Nearly everyone has had a headache at some time or other. The pain is usually mild and you'll still have been able to go to work of meet friends. A couple of painkillers will have done the trick and you'll have felt better again quite quickly.
A migraine attack is quite different. It is so painful that you may have to stop what you're doing.“My temples felt like they were about to explode. The pain was like a small garden rake over my eyes and top of my head, digging in and scraping away. My head felt like a blown up balloon that was about to explode.” (patient description)
Everything becomes an effort and you feel weak and look pale. The only way that you can cope is to draw the curtains and go to bed. Tablets don't seem to do anything, however many you take, even if you can keep them down.
Migraine affects as many as 20% of the population. Women are three times more likely to have migraine than men. The first attack usually happens when you are a child or a teenager. It is rare for a first attack of migraine to happen after the age of 40 although there may be a gap of many years between attacks. Migraine has been recognised for centuries and was recorded in the earliest historical writings. Many famous people have been afflicted with migraine, for example, Lewis Carroll. Some people say that he wrote 'Alice in Wonderland' based on his experiences as a migraine sufferer.
Many people try to struggle through an attack thinking that little can be done to help them. Certainly in the past, it was considered something that you had to 'live with' and very little was known about the condition. As more research has been done and specialist migraine clinics have opened, there has been a rapid increase in our knowledge, although the picture is by no means complete. Nowadays, more can be done to help the migraine sufferer to make the attacks less severe and occur less often.
What is migraine?
Migraine is a complex condition but is not life-threatening. Nature has provided us with the ability to feel pain so that we can protect ourselves from further injury.
Migraine is only one of many different types of headaches and comes in different forms. In general, it is a recurring headache which lasts from 4 hours up to three days.
About 10% of migraine attacks have a warning 'aura' which happens before the headache starts. This 'aura' lasts from a few minutes to up to an hour. You may notice flashing lights or zig-zag lines which move across in front of your eyes, as well as blank spots when you look at things.
“My eyes go out of focus, nearly always the left one, with dazzling white lights. This lasts about half an hour before my eyes clear. Afterwards, I have this terrific headache that lasts about 2 days”. (patient description)“ I see zig-zag lines in a frame round everything that I look at, and occasionally seem half blind with 'flat' vision”. (patient description)
Difficulty talking or finding the right words, and feeling weak or numb in some parts of the body, are other symptoms that you can experience during the 'aura'.
“Visual impairment is the first symptom. This is followed by pins and needles in my hand which travels up my arm to my neck and into my mouth causing my tongue to numb and speech to be slightly impaired. The headache then follows”. (patient description)The headache may only affect one side of the head
but can be all over. The pain is often throbbing and made worse by movement.
You probably feel nauseous and may even be sick. Most sufferers are also sensitive
to light and sound.
“The pain begins at the front of my head and travels all
over my head making the back of my head feel very heavy. I have to stay as
still as I can otherwise it gets worse. I can't sit in a room with the lights
on or the TV as the light affects the strain on my eyes to my head. I feel
very sick”. (patient description)
“I crawled upstairs and closed my curtains and went to bed. That pain was very severe in my temple and my head was on fire. I then started to feel sick. I managed to get to the bathroom where I was sick.” (patient description)
The headache usually lasts for two to three days but you may still feel washed out for a couple more days.
“When I get a migraine it makes me very ill and really puts me out of action for 2-3 days. The first day, I can feel one coming on and then the full blown migraine emerges and I feel wretched. As the second day progresses, the pain finally begins to lessen. The third day leaves me with a vague pain and feeling absolutely shattered by otherwise okay.” (patient description)
The term Migraine with aura (formerly known as Classical migraine) is used when an 'aura' is followed by a headache. The 'aura' may happen on its own, without the headache, and is termed Migraine aura without headache. Most people (80-90%) have attacks of headache without the 'aura' - the headache is the first main symptom, followed by the sickness etc. This is termed Migraine without aura (common migraine).
What happens in an attack?
Even if you don't have an 'aura' before the headache, you may have noticed
other feelings that make you aware an attack is starting. An attack of migraine
can actually be divided into five distinct stages. There are two stages that
may be present before the headache.
Symptoms and signs during
phases of complete classic migraine attacks. Reproduced with permission from
Blau JN. Migraine: theories of pathogenesis. Lancet 1992; 339: 1202-7.
1. PRODROMAL PHASE: Before an actual attack starts, you may notice that you feel very tired and yawn a lot more. Before other attacks you may have had the opposite feelings - lots of energy and getting all your work done in half the normal time. Some women find that they recognise the start of a migraine attack when they approach the housework with great enthusiasm! Others crave certain foods - often sweet. These sorts of feelings are noticed by about two thirds of sufferers and may only be apparent when you look back on an attack. Relatives and friends may be more aware of these subtle changes in mood or behaviour than you are. The symptoms usually start several hours or the day before the attack.
2. AURA: as mentioned above, an aura before an attack is experienced by about 10% of migraine sufferers. It lasts from a few minutes up to an hour. There may or may not be a gap between the end of the aura and the start of the headache phase.
3. HEADACHE PHASE: The headache may stay in one place or shift to affect different parts of the head, even swapping sides. The most common accompanying symptoms are dislike of light, dislike of sound and nausea. Some people become more sensitive to certain smells and strong smells may even trigger an attack. Most are off their food, but some are extra hungry in spite of the nausea. The typical picture of someone during a migraine attack is a person lying in bed with a hot water bottle, the curtains drawn, a bowl beside the bed and the rest of the family on tip toes.
4 & 5: RESOLUTION & RECOVERY: After the headache has gone, feelings of lethargy and generally being 'washed-out' remain. It can take a couple of days to get over this. Some people are more lucky and find they have extra energy immediately after an attack - it may have something to do with the feeling of relief!
What causes an attack of
migraine?
Most people have read that certain foods such as cheese and chocolate can
trigger an attack. This is certainly true for some people but it is usually
much more complicated than that. You may have wondered why the same triggers
do not always result in an attack. This is because it is necessary for more
than one trigger to be present to cross the 'threshold', resulting in the
attack (see diagram).
The 'threshold' theory of
migraine. Reproduced with permission from MacGreor EA. “Menstrual”
migraine: towards a definition. Celphalagia 1996; 16: 11-21.
It is usually the final trigger that is most obvious but those underlying
triggers are equally important. For example, if you drink a glass of wine
on its own you do not always have an attack of migraine. However, if you drink
the same glass of wine on an empty stomach, had a particularly stressful day
at work and had drunk lots of coffee to keep going - an attack is more likely.
All those triggers are equally important - stress, coffee, lack of food and
the glass of wine. Dealing with any of your triggers may help you have fewer
attacks.
The most common triggers are:
Lack of food - missing meals (especially breakfast), snack lunches or sugary snacks instead of a proper meal can all result in an eventual drop in blood sugar which can lead to an attack. This is particularly important for children who use up a lot of energy and are growing quickly.
Specific foods - a few people notice that certain foods seem to trigger an attack. The most common foods are chocolate, alcohol, dairy foods and citrus fruits.
Changes in sleeping pattern - too much and too little sleep - a Saturday morning 'lie in' or a run of late nights.
Hormonal changes in women - migraine attacks may be made worse by the oral contraceptive pill although some women do notice an improvement when they are taking it. It is wise to stop the 'pill' if attacks become more frequent or more severe. It should not be taken if you have attacks with an 'aura'.
Head and neck pain - muscle tension affecting the neck and shoulder muscles may be a trigger, particularly if you are hunched over a desk or VDU all day, or do a lot of driving. Simple neck exercises and awareness of the way you sit and stand can help considerably, or even regular massage if you wish. In a few cases, migraine can be aggravated by specific dental problems.
Environmental changes - bright lights, loud noise, strong smells, travelling etc. can all trigger attacks in some people. If you are particularly sensitive to bright lights then it may worth buying a good pair of sunglasses or glasses with photochromic lenses.
Exercise - regular exercise, without overdoing it, can help prevent migraine attacks but exercise done once in a while when you are unfit can trigger an attack.
Travel - a long journey or flight, especially if it involves a change in meal and sleep patterns.
Stress - often in the period of time after the stress (including the weekend after a stressful week or the first few days of a holiday).
How can I help myself?
1. Identify prodromal symptoms. Ask friends and relatives if they notice any changes in you before the migraine attack starts. Look out for any differences in mood or behaviour in the 24 hours before the headache.
2. Keep a diary. Several triggers are necessary which when added together can result in an attack as the 'threshold' is crossed. Sometimes, the attack can be prevented by removing as many of these triggers as possible and keeping below the 'threshold'.
Keep a diary (click on migraine diary for an example) and for each attack note down:
1. The date.
2. The day of the week.
3. The time the attack started.
4. What symptoms were present and their timing in relation to the headache.
5. How long the attack lasted.
6. What treatment was taken.
7. What time it was taken.
8. What trigger factors were present or had built up.
3. Identify triggers. After you have recorded several attacks in this way, you should have a better idea of your triggers. You can then divide the triggers into two groups - those which you can do something about (missing meals, drinking red wine) and those which are out of your control (menstrual cycle, travelling). Try dealing with the triggers within your control. Cut out any specific triggers that you suspect, one at time. If you try to deal with too many all at once, you can't be certain which are most relevant to you. If you know that you have a particularly difficult period at work, be extra careful to make sure you don't miss meals or have too many late nights. Most people find it difficult to 'relax', but an active hobby (playing sports, cycling to work, walking the dog) can help to relieve stress.
Hormones are only an additional trigger. Hormonal changes are difficult to control, but attacks may be helped by eating small, frequent meals, avoiding sugary snacks and alcohol, getting adequate sleep etc. in the week or ten days before your period.
The diary card can help point out less obvious trigger factors. If you find that most of your attacks start late morning or late afternoon, it may be lack of food that is the problem and you can try eating a mid morning or mid afternoon snack. Attacks on waking may be due to sleeping in, neck problems or again, too long since food (try a late night snack).
4. Take treatment early. During a migraine attack, the body systems shut down and drugs are not easily absorbed. It is important to take migraine treatment without delay as early as possible in a migraine attack. This means that simple treatment can be effective.
5. Carry a dose of treatment about with you. Drugs can be taken without delay if you have them on you. Ideally keep a couple of biscuits and a small carton of drink with you so that you are not taking the tablets on an empty stomach.
What treatment is available?
Treatment falls into two main groups, 'acute' treatment and 'preventative' treatment.
ACUTE TREATMENT: This includes drugs which are taken only when you have an attack. Simple drugs bought from the chemist for migraine may be enough to abort at attack if taken early. If this is not effective, your GP may prescribe an anti-sickness drug to be taken in addition which can help the drugs to be absorbed. Your GP can also prescribe stronger drugs for migraine if necessary.
PREVENTATIVE (PROPHYLACTIC) TREATMENT: If you are having frequent attacks of migraine which interfere with your work or social life, your doctor may prescribe a short course of tablets which you take every day to prevent the attacks. Prophylactic drugs can help to break the cycle of frequent attacks and give you a 'breathing space'. There are many different drugs available from your doctor.
What non- drug treatments are available?
'Alternative' medicine can often help the migraine sufferer. Those with neck tension or back problems may be helped by simple hot or cold pads put on the back of the neck or where it hurts most. You may benefit from a course of treatment of osteopathy, acupuncture or massage. Postural problems may be helped by the Alexander Technique. If stress is a problem, you could try biofeedback or relaxation techniques. Herbs such as feverfew have helped some people but they should be used under guidance as they are still drugs. Feverfew can be taken in any form (dried or fresh leaves, tablets etc.) and can take up to 6 weeks before taking effect. One suggested dose is 25mg daily increasing up to 200mg if necessary. Some people notice that they get mouth ulcers or stomach upsets and feverfew should not be taken in pregnancy.
What if it is not migraine?
Depression, stress or muscle tension may also result in a daily headaches which feel like a tight band around your head. Regular use of pain killers or ergotamine which are used for the treatment of headache may make the underlying problem worse, also resulting in daily headaches. Unlike a migraine attack, you can usually carry on working if you have these types of headache. Migraine attacks do not occur daily - you should not have any migraine symptoms between the attacks. However, it is possible to have more than one type of headache at the same time. You can have migraine attacks at the same time as any of the above types of headaches.
Headaches can also be a symptom of an underlying medical problem. It is very important that you see your doctor to make sure of the correct diagnosis of your headache, particularly if you notice any changes in the pattern of headaches or the symptoms, even if a previous diagnosis of migraine has been made.
This information is also available in the booklet “Migraine: How to live with it” which was sponsored by an educational grant from Shire Pharmaceuticals as a service to migraine sufferers. You can obtain a copy by sending a stamped addressed envelope to the City of London Migraine Clinic, 22 Charterhouse Square, London EC1M 6DX.