Migraine: the facts
Migraine is among the top 20 causes of disability among adults, according to WHO
Migraine is three times more common in women than in men and is inherited in about 60 per cent of cases. Photograph: Thinkstock
Migraine is a neurological condition affecting almost half a million people in Ireland, or about 15 per cent of the total population. Symptoms vary but the most common is a one-sided throbbing headache, lasting from four hours to several days. Some sufferers – known as migraineurs – experience just one or two attacks a year; others suffer one weekly. Chronic migraine is defined as headaches on at least 15 days a month, of which at least eight days are with migraine.
Migraine is three times more common in women than in men and is inherited in about 60 per cent of cases. All age groups are affected, although most sufferers experience their first attack during puberty due to hormonal changes.
Migraine is a hugely under-diagnosed and misunderstood condition which is often dismissed as “only a headache”, but it can have a devastating impact on quality of life. The World Health Organisation found migraine to be among the top 20 causes of disability among adults of all ages, ranked as number four among women.
Causes, signs and symptoms
The typical migraine attack lasts from four to 72 hours. Symptoms include a throbbing or pulsating headache on one side behind the eye, with a heightened sensitivity to light, sound or smell. Nausea and vomiting is also common and, in rare cases, the migraineur may experience temporary paraesthesia – a numbness, weakness or pins and needles – or difficulty finding words, mixing up words or slurred speech.
Some people may feel dizzy or off balance, as if they have just stepped off a boat. Others get neck stiffness or soreness, along the nerve pathway which passes down the side of the neck into the shoulders. Some experience watering of the eye, blocked nose or a blocked or sore ear.
One in five patients experiences migraine with “aura”. The symptoms can be visual, in the form of flashing lights or shapes that get bigger and smaller in the periphery of their vision, lasting between 20 minutes and an hour. They may also experience paresthesia, pins and needles spreading from the fingers up into the arms or the side of the faces which can lead to slurred speech or cognitive impairment. These aura features can be very frightening for patients, because they are similar to symptoms of other neurological conditions.
There are certain triggers for migraine, including skipping meals or going for prolonged periods of time without eating; certain types of foods such as cheese, chocolate, red wine, tea or coffee; alcohol; hormonal changes in women at times such as ovulation, pregnancy, taking a new contraceptive pill, or menopause; interrupted sleep patterns, including too much or too little sleep; stress, even if it is positive such as the excitement of a birthday or wedding; bright light; weather changes and travel.
We recommend that patients keep a detailed record of the signs and severity of their symptoms and attacks. The Migraine Association of Ireland has a diary on its website which is compulsory for our patients at the headache/migraine clinic at Beaumont Hospital, which helps to identify how many days they are suffering with the condition and their trigger factors.
Prevention and treatment
Migraine has no cure, but the condition can be effectively managed using a combination of lifestyle changes and medical treatments. A lot of patients self-diagnose because they recognise the symptoms, due to the strong familial link with migraine. Many patients will self-medicate using over-the-counter painkillers. If the condition worsens, they should see a GP for a formal diagnosis and prescription medication if necessary. They may then be referred to our clinic for specialist treatment.
Diagnosis is made based on the symptoms they present with or describe. Tests such as an MRI brain scan are sometimes carried out for reassurance or to rule out any secondary cause for the migraine. The majority of scan results come back normal.
Acute medications attempt to relieve an attack or abort it once it has already begun. For one in three sufferers, over-the-counter analgesics such as paracetamol and aspirin or anti-inflammatory drugs such as Nurofen or Difene, will effectively relieve pain during an attack.
For more disabling attacks that don’t respond to over-the-counter painkillers, migraine-specific triptan treatments will successfully abort pain within two hours for 80 per cent of sufferers, but only if taken early during an attack. Anti-emetic drugs can be prescribed to manage nausea.
It is important that migraine sufferers don’t take too many painkillers, because they are particularly susceptible to medication overuse headache.
If patients are experiencing chronic migraine for at least six months,
preventative drug therapy is an option. This is a daily medication for at least nine to 18 months. The most common include beta blockers, anti-convulsants, anti-histamines, calcium channel blockers, anti-depressants or anti- inflammatories. Although preventive treatments reduce the frequency and severity of anticipated attacks in 50-60 per cent of cases, they are unlikely to prevent attacks altogether or be beneficial in treating an attack once it has started.
Botox blocks the release of neurotransmitters, the chemicals which carry nerve impulses and cause pain. Botox injections are now used as a preventive treatment for chronic migraine sufferers, administered in 31 injection sites across seven head and neck muscle groups, about every 12 weeks. It must be done by a doctor trained in administering Botox for migraine.
Occipital nerve block
A steroid and anaesthetic injection around the occipital nerves on the back of the head above the neck helps reduce the frequency and severity of the headache, by blocking the pain messages sent to the brain. The pain relief benefit can last from a few days to several months.
Acupuncture, herbal medicine, homeopathy, reflexology, yoga or massage can also be very beneficial to some patients, as can physiotherapy or cognitive behavioural therapy for the management of stress. Others find taking magnesium, vitamin B and Q enzyme 10 helpful.
Managing migraine in the workplace
According to the Irish Migraine Association, the average migraineur misses between 1½ and 4½ days of work annually, costing Irish businesses €252 million and a year in lost productivity. Ninety per cent of migraineurs say attacks affect their performance at work.
The work environment might be triggering the attack, so migraineurs can take steps to manage it by taking regular breaks, keeping hydrated, eating regularly, avoiding stress and deadlines, avoiding long hours and getting enough sleep. If the patient is sensitive to light, avoiding long periods on the computer or using a glare screen can help, as will avoiding fluorescent lights.
At the headache and migraine clinic at Beaumont Hospital, we often write letters of support for employees to show an employer that they have been proactive in trying to treat their condition through a specialist service.
Tension headache is experienced by 90 per cent of women and 70 per cent of men at some time in their lives. It is usually caused by stress, poor posture or inadequate lighting, and occurs at the end of a stressful day lasting between one and six hours. There are no symptoms other than the “pressing” headache, often with tension in the neck and shoulders. Chronic tension headache occurs on at least 15 days a month. This is not diagnosed as often now as it used to be; it is debated as to whether chronic tension headache is just migraine presenting in a different way.
nMigraine Association of Ireland: migraine. ie
nMigraine Trust (UK): migrainetrust. org
nBritish Association for the Study of Headache: bash.org.uk
nOuch (Organisation for the Understanding of Cluster Headache): ouchuk.org
Esther Tomkins is a clinical nurse specialist at the headache and migraine clinic at Beaumont Hospital in Dublin. She operates the Migraine Association of Ireland’s Advice Line on 01-797 9848 (2.30pm-4.30pm Monday to Thursday). The Migraine Association of Ireland also runs a confidential helpline on 1850 200 378 (0844 826 9323 from Northern Ireland, 9am-5pm Monday to Friday).