Headache, health

Hormonal migraines

When I ask women in clinic what they think are their potential triggers approximately 75% say, “hormones” and they often open consultations with the phrase:

“I definitely have menstrual migraine”.

The majority however, do not.  Changes in hormone levels are a potent trigger for migraine attacks but only less 10% of suffers are classified as having “menstrual migraine”.  This can mean that any woman who suffers with migraine has the potential to have an attack around menstruation or at other points in the cycle where hormone levels fluctuate.  This can explain why puberty and the peri-menopausal phases can be times where women experience increasing numbers of attacks.

The hormones

The menstrual cycle is ruled by a complex of hormones which include oestrogen and progesterone as well as other substances which continuously form a feedback loop between the brain (pituitary anad hypothalamus glands) and the reproductive organs. The cycle essentially exists to ensure the body is ready for pregnancy to occur: 

  • At the beginning of the cycle the oestrogen levels begin to rise causing the the lining of the womb to build up as egg development is stimulated in the ovary and subsequently released (ovulation).  
  • In the second half of the cycle, the progestogen levels start to rise to ensure the lining stays thick in order to receive the fertilised egg for implantation and embryo development.
  • If fertilisation does not occur, the egg is reabsorbed and the oestrogen and progesterone levels begin to fall prior to menstruation.

Embed from Getty Images

What are menstrual migraines?

Menstrual migraines are typically migraine without aura that occurs only during the phase of menstruation (that is between two days before a period and in the first three days).  This type of migraine can be more prolonged than other forms.

These are thought to be triggered by the drop in oestrogen levels which occurs approximately 48 hours before menstruation or due to the release of a substance called prostaglandin during early menstruation.  

The only way to establish whether or not this type of migraine occurs is to keep a migraine diary and tracking it with your periods. 

Embed from Getty Images

Can hormones still trigger attacks if this isn’t the case?

As I’ve said, many women who suffer with migraine attacks find they are hormonally sensitive and so more likely to have attacks at some point around their period.  For the sake of semantics these migraine attacks are “menstrually associated migraine”.    People often find that they have more attacks during phases where they have a sudden surge of hormones such as puberty, pregnancy, breast feeding and around the menopause.  

How can these be treated?

This depends on whether you purely have menstrual migraine or if you have menstrually associated migraine and what stage of life you are at.  Options include:

  • Hormonal control which can be further divided into:
    • The Pill.  This can be an option for people with any type of hormonally sensitive migraine (although it is worth noting that the oestrogen component of the combined pill can make some people suffer more frequent attacks).  With menstrual migraine some people benefit from “tricycling” there pill where they take it almost continually.  Others find benefit from stabilising their hormone levels with the progestogen only pill.
  •  Embed from Getty Images
    • Oestrogen.  In menstrual migraine some people can benefit from supplementing their falling levels with oestrogen applied by patch or gel for a week around their period. 
    • HRT can be beneficial in the perimenopause but I will discuss this in more detail in another article…
    • Mefanamic acid.  People who have heavy painful periods may be familiar with this medication: it is in the same family of medications as ibuprofen (NSAIDs) and is thought to help in menstrual migraine by reducing the prostaglandin release which may contribute to menstrual migraine in some cases.
    • Frovatriptan.  This is a long-acting triptan which can be used on a regular basis around the expected migraine time to prevent attacks.  Although we usually advise against using triptans on a regular basis, taking Frovatriptan twice a day from two days before the expected attack for 6 days seems to help with menstrual migraine in some cases.
    • Preventative.  Any formal preventative has the capacity to help with menstrually associated migraine and severe menstrual migraine.  

Embed from Getty Images

Are there any natural ways of managing this?

Hopefully that’s given a brief overview about hormonal migraine.  Like with all types of migraine there is no “one size fits all” answer and most people have very individual and varying triggers, one of which is often hormones.  I will discuss migraine in pregnancy and perimenopausal migraine in more detail later on…

health

Anxiety and Depression

Are we all getting more depressed? 

Depression is the third most common reason for people to visit the GP, with anxiety being the most common psychiatric disorder people suffer.  It’s difficult for people to unpick whether they’re anxious or depressed because they often co-exist.  Like with most health problems there’s a scale: some people suffer with mild mood disorders and require a bit of support, but for others anxiety and depression can be severe, life-altering and, in its extreme fatal.  

Embed from Getty Images

How are anxiety and depression defined?

They are officially two separate conditions:

Anxiety usually refers to generalised anxiety disorder (GAD) which is one or a range of anxiety disorders which can also include more specific variants such as obsessive compulsive disorder, social phobia, post-traumatic stress disorder and so on.

  • Someone who suffers which GAD is described as suffering uncontrollable and widespread worry with the presence of physical and psychological symptoms.

Embed from Getty Images

  • These symptoms can include (but are not limited to):
    • fast heart rate
    • awareness of thumping heart beat (palpitations)
    • sweating
    • chest pain
    • dry mouth
    • shakes or tremors
    • rapid breathing
    • dizziness or light-headedness
    • feeling sick (nausea)

Depression is the feeling of low mood or inability to take pleasure in things which is persistent and interferes with your normal life.  It is completely normal to have variations in mood and feel really low from time to time, particularly at times of stress, or as a reaction to a life-event, but if the feeling stays for at least two weeks and is accompanied by other physical and behavioural symptoms it could be depression.

  • Like with anxiety, depression can give a range of symptoms.  These include:
    • Difficulty sleeping: typically waking up early in the morning, but sleeping too much can be an issue.
    • Difficulty concentrating
    • Feeling tired or lethargic
    • Change in appetite: like with sleep this can go either way with people not eating or overeating
    • Thoughts or death and dying: this is not always as extreme as wanting to end your own life but commonly in mild to moderate depression a feeling that other people would be better off without you or that life “isn’t worth living”.  In more severe cases this can develop into thoughts of or even plans for suicide.
    • Feeling agitate or conversely slowing down of movements.

Embed from Getty Images

Who is likely to suffer?

Depression can affect anyone.  Some people seem more likely to suffer from it than others but the mechanism which drives this is not fully understood.  Certain life-situations make people more likely to suffer (such as unemployment, marital breakdowns and money trouble) but undoubtedly genetics, upbringing and personality play a part too.  Having any form of chronic illness such as diabetes or heart trouble increases peoples risk.

It’s a slightly different picture for anxiety.  Although it too is a complex disorder certain characteristics make people more likely to suffer:

  • being female
  • experiencing difficulties in childhood (bullying, abuse etc)
  • having lifestyle stressors such as unemployment or dissatisfaction with work, money troubles, physical or emotional pain (such as from a a traumatic event)
  • Dependence to drugs or alcohol: this can be the cause or can just augment existing anxiety
  • Long term illnesses

Are we more depressed and anxious?

The answer to the question I asked at the beginning of the article is not straight forward.  If we look at the stats the suicide rates these tend to fluctuate year on year with the latest data showing this has fallen in the UK.  But the concerning feature that is often highlighted in the media is the high rate of male suicide which has accounted for 75% of all suicide since the 1990s.  As I said above, this is not because men are more likely to suffer from depression or even severe depression then women but it is thought that men are less likely to seek help about it.  This has prompted lots of campaigning to ensure men recognise the signs of depression, and know where to go for help.

Embed from Getty Images

The other thing we look at is numbers of people seeing their GP about anxiety or depression.  These numbers are high but this may be because we are more willing to recognise it as a problem now than in the past.  There is still a stigma attached and people will wait 6-8 years to seek help for anxiety and depression.

What can we do about it?

There are a number of tests or questionaires you can do on the internet which ask how stressed, anxious or depressed you are but truthfully if you feel you are anxious or depressed and it is interfering with your life you should go an see your GP.  It is important to see a GP if you have any thoughts of suicide.  A lot of people worry that they’re “wasting the GPs time” or that they may just be “fobbed off” with tablets. 

Generally speaking there is no “one-size fits all” approach to anxiety and depression and discussing your problems with your GP can help to identify which treatment route would be best.  There are some avenues you can explore yourself:

  • Mindfullness: this essentially means being more aware of our surroundings and our own thoughts and feelings.  It’s the basis behind a lot of meditation and can help to treat anxiety and depression as well as being more aware of developing symptoms.  Some people use apps such as headspace or calm or more information can be accessed here.

Embed from Getty Images

  • Exercise is also helpful in treating anxiety and depression.  This is due to the chemicals released during exercise (endorphins).  There is also emerging evidence that exercising regularly reduces the risk of future anxiety and depression at any age and although there was no specific “dose” suggested they advised a minimum of 150 hours of moderate to vigorous activity per week can reduce the risk of developing depression in the future by 10%.

The mainstay of treatment is counselling usually “talking therapy” using a method called cognitive behavioural therapy (CBT).  This type of therapy is useful for changing patterns of behaviour and thus reduces the symptoms of anxiety or depression.  CBT can be given as part of a group or individually, via computer programmes or, in some areas via Skype.  Most GP practices will have information on how to access this type, or other forms of counselling.

Embed from Getty Images

Medication is still used, particularly for moderate to severe anxiety or depression.  It is important to realise that this is not a “magic bullet” but can help to stabilise things in order for people to be able to access therapy or other treatments.  There are lots of different types of medications used and there is a lot of overlap between the tablets used for both anxiety and depression (for example selective serotonin re-uptake inhibitors or SSRIs are commonly used for both anxiety and depression).  Generally speaking we expect people to be on these tablets in the short-term (6-12 months) but obviously some people will need longer term treatment.

Embed from Getty Images

There are also tablets which can help with the symptoms of anxiety such as palpitations, nausea, sweating and chest pain.  Often beta-blockers such as propranolol are used.  These can be taken as and when to help with symptoms. There are not many side-effects but some people can experience dizziness, fatigue and vivid dreams   They are not suitable for asthmatics.

Suggested Links

If you need further advice please see:

Mind www.mind.org.uk 

The Calm Zone for men aged 18-35 http://www.thecalmzone.net/ 

Anxiety UK http://www.anxietyuk.org.uk/ 

Samaritans www.samaritans.org.uk 

Young Minds: support for young people and parents of those struggling with mental health issues https://youngminds.org.uk 

health

Irritable Bowel Syndrome

Cramping abdominal pains, bloating, diarrhoea or conversely bouts of constipation: these are all common symptoms of Irritable Bowel Syndrome (IBS).  It’s a pretty common problem thought to affect 10-15% of the population with only 10-20% of sufferers ever going to see their GP.  It’s far more likely to occur in women than men (2:1 ratio female to male sufferers) and commonly affects people in their 20s and 30s.

I’ve been driven to write about it because these are symptoms I see every day in General Practice and have personally suffered with and I’ve found that once it’s been diagnosed it can almost be… dismissed.

“It’s just IBS.  No need to worry”.

Embed from Getty Images

Unfortunately there are studies which show that, although IBS doesn’t limit the length of peoples lives, the quality of the lives sufferers lead can be impaired causing psychological issues and financial losses through missed time at work.

Case: Laura

Last month my friend Laura started to develop severe cramps in her stomach.  She felt sick, bloated and she started having bouts of diarrhoea.  This was unusual for her: she’s very healthy and is rarely off work.  She’s also self-employed so any time she does need to take off is unpaid.  So she took some antacids and just powered through it.  Her pain continued.  It was so bad one night that she called 111 and was advised to go to A&E.  It was December and we were in the grips of yet another winter crisis for the NHS: the hospitals were full to the brim and the staff overworked.  They assessed her and told her it was probably gastritis.  Take some Omeprazole and see your GP.

Embed from Getty Images

The pain continued.  She could barely eat over Christmas.  The pain was intermittent: she’d have periods of time where she thought she was better and go into work only for the pain to come on quickly and be so severe she’d have to return home.  She went to her GP who was very thorough.  She’d been diagnosed with IBS in her early 20s but never had any advice or testing for other things.  He wasn’t particularly happy about this “we should really make sure it isn’t any thing else”.  He arranged for a blood test (including a test for Coeliac’s Disease which is a gluten-allergy) and stool tests to check for a bug called H Pylori which can cause gastritis and another called a faecal calprotectin (to check for inflammation).

Off she went again, waiting for the results of the tests.  On my advice she’d started trying to track her symptoms to see if they were associated with any specific foods.  The blood tests and stool tests were all normal and she’d realised that her symptoms were worse every time she ate anything containing dairy.

What causes IBS?

Ok this is another syndrome where we don’t fully understand the processes involved but it is likely to be linked to a number of factors.

  • Genetics: no specific gene has been identified but twin studies suggest this has a role.

Embed from Getty Images

  • Diet: this includes intolerances and sensitivity to certain foods and up to 90% of people suffering with IBS report certain food triggers
  • Infection: some people seem to develop IBS after gastroenteritis due to changes in the normal constituents of the gut due to the immune-response and normal bacteria which make up the gut flora.
  • Psychological factors: psychological stress due to anxiety or depression can alter the functioning of the bowel.  This is due to the presence of the “brain” around the gut (a complex neurological system which exists around the gastrointestinal system).

Embed from Getty Images

  • Medications: such as antibiotics

How is IBS diagnosed?

This is tricky.  There is no definitive test to confirm the presence of IBS: it’s made by looking at the pattern of symptoms and, if necessary, ruling out other causes.  Laura’s GP was correct: her symptoms were quite severe so it was worth making sure that she was tested appropriately.  But to be honest, this may not always be appropriate and it does depend on the pattern of symptoms and how certain the doctor seeing the patient is about the diagnosis.

I personally think a symptom diary can be invaluable.  Cutting out whole food groups at random always seems to be en vogue but it can lead to deficiencies which can endanger health and wellbeing.  Keeping a diary can help to identify any patterns of symptoms and make it easier to see if certain food groups trigger them.

Embed from Getty Images

If testing is recommended I would always advise being checked for a gluten allergy (Coeliacs Disease) because it can cause similar symptoms.  Before this blood test is carried out you should make sure you’ve been eating wheat for at least 2 weeks otherwise it may be negative even if the disease exists.

Diet and lifestyle

Embed from Getty Images

The most popular treatment option for sufferers of IBS (according to the BMJ) is the low FODMAP diet.  The term FODMAP relates to a new dietary class comprising of fermentable oligosaccharides, disaccharides, monosaccharides and polyols: a list of foods which ferment and thus are poorly absorbed.  This includes common foods such as:

  • Fruits (apples, cherries, peaches and nectarines)
  • Artificial sweeteners (sorbitol, xylitol and mannitol)
  • Vegetables and legumes (including broccoli, Brussels sprouts, cabbage and peas)
  • Most lactose-containing products

This diet is restrictive which can make it difficult to stick to.  Evidence from the trials shows that even short term adherence to the diet can lead to better gut health.  The longest duration of the diet in these trials seemed to be 6 weeks but even sticking to it for as little as 3 can be beneficial.

Ideally this diet should be adopted under the guidance of a dietician but there is a good factsheet from the IBS Network.

The NICE guidance also advises that probiotics purchased over the counter may have some benefit but the evidence from trials is limited and the probiotic should be tried for between 4-6 weeks.

Embed from Getty Images

Exercise and regular physical activity are also advised in the management of IBS.  Theoretically, regular activity reduces bloating and gas retention and it is known that regular exercise reduces stress levels.  There have been some small trials which show that there was a significant reduction in IBS symptoms in patients who undertook a regular exercise programme compared to those who did no exercise.

Medications

There are no specific medications for IBS at present but the choice of medications should be based on the nature and severity of the symptoms.  The different medications can either be used in isolation or combination:

  • Antispasmodics such as Meberverine Hydrochloride or Peppermint Oil for abdominal cramps as required
  • Laxatives (but not Lactulose) for constipation symptoms.  The specific laxative Linaclotide can be prescribed for moderate-severe constipation in IBS if:
    • constipation has persisted for more than 1 year
    • all the other types of laxatives have been tried and failed
  • Anti-motility agents such as Loperamide for diarrhoea-type symptoms
  • Antidepressant medication can be tried if laxatives, antispasmodics or anti-motility agents have not worked.
    • Tricyclic Antidepressants (TCAs) such as Amitriptyline.  As with its use in migraine this would not be used to treat a suspected depression but for its neuropathic painkilling effects.
    • Selective Serotonin Re-uptake inhibitors (SSRIs) such as Citalopram or Fluoxetine if treatment with a TCA has been ineffective or poorly tolerated.

Cognitive Behavioural Therapy (CBT)

Embed from Getty Images

Use of psychological therapies such as CBT has been advised for many years now, but uptake of such treatment is low, possibly because of the stigma associated with suffering with a “mental health disorder”.  The studies show that there can be some benefit from CBT in the initial stages following treatment but the benefits are vary according to the practitioner providing the treatment, the patients adherence to the treatment and the number of sessions which are provided.  This is still advised in the NICE guidance for IBS which does not respond to lifestyle changes or medications.

What next?

If none of the above is beneficial a referral to a gastroenterologist should be made to confirm whether or not IBS is indeed the diagnosis and for guidance on further management.

For more information please see:

The gut and liver disease charity CORE

The IBS Network

The Association of UK Dieticians factsheet on IBS and diet

Headache

Medication Overuse Headache (MOH) – detoxing

In the article about acute treatment, I briefly discussed the problem of medication overuse headache (MOH).  This can be a problem in patients who suffer with migraine, tension-type headache, cluster headache and other headache disorders but is much more common in migraineurs.

It happens when people take pain-killers for too many days over a 3 month period: this ends up causing the headache instead of treating it.  The resulting headache can be more severe and unrelenting causing the sufferer to take more medication and… the problem continues.

Embed from Getty Images

It’s a frustrating paradox for the sufferer and can be difficult to get your head around (pardon the pun).

It can happen with any headache medication but for guidance I have made a list of the common ones and how often you have to take them to cause this problem:

  • NSAID medications such as ibuprofen, naproxen or aspirin and other simple pain-killers such as paracetamol are taken on more than 14 days a month
  • Triptans are taken on more than 8 days a month
  • Codeine and other opioids are taken on more than 6 days a month
  • Ergots (an old fashioned migraine treatment) more than 10 days a month

The key point to remember is it’s the number of days not the number of doses that counts.

How do I work out if I have MOH?

I do keep bleating on about migraine diaries but I find them invaluable for teasing out a pattern or helping to work out what’s causing migraine or headache.  If a diary is kept it quickly becomes obvious if someone is using too many pain-killers: you only need to take a triptan 2 days a week or paracetamol for more than 4 days on a weekly basis to cause MOH.  It’s difficult to keep track of this without noting it down.

Embed from Getty Images

What do I do?

This is the difficult part.  You have to stop taking pain-killers.  It’s tough… really tough.  I liken it to a detox: initially when the medication in question is stopped the headache gets worse.  It’s really important to be aware of this because the temptation is to reach into your purse and grab the ibuprofen to make the pain go away.  But that would be a mistake because you’d just be delaying the inevitable and your frequent headaches would continue.

The amount of time it takes to detox is dependent on which medication is causing the issue.  If the problem is a triptan, NSAID the withdrawal headache will last for 7-10 days.  If it is a simple pain-killer it’s 2-3 weeks and if codeine or an opiod is the problem it’s 2-4 weeks.

How long do I need to “detox” for.

water-drink-detox-detox-water-122444.jpeg

We advise 12 weeks to allow the medication to wash out of the system.  If there is more than one medication that is being overused it is sometimes better to stop one medication at a time.

Can anything be done to help?

There are a few options:

  1. Naproxen: this is only a possibility if you have not taken this medication much before.  This can ease the withdrawal headache.  We often start a 6 week course starting
    • 3 times a day for two weeks
    • 2 times a day for two weeks
    • 1 time a day for two weeks
  1. Greater Occipital Nerve Block: injection of steroid with local anaesthetic at the back over the head around the nerves that supply the scalp.  It works by blocking the abnormal pain signals that fire during MOH.  Typically it gives relief for up to 6 weeks: just long enough to detox from the medication.
  2. Preventative medication: see full article but often we use Amitriptyline to dampen the withdrawal headaches.

For more information please see:

The National Migraine Centre factsheet.

Headache

Migraine – Preventative Medication

As mentioned multiple times before, keeping a diary to keep track of how often you are suffering with migraine attacks and how long they are lasting can be helpful in identifying whether or not you are likely to benefit from preventative treatment.

There is guidance to decide whether or not you fit this criteria:

  1. Experience frequent disabling attacks:
    • two or more attacks per month which last 3 or more days at a time
    • quality of life is severely impaired
  1. Are at risk of Medication Overuse Headache
  2. Normal pain-killers or triptans cannot be prescribed or are ineffective
  3. Atypical migraine: hemiplegic migraine (a sub-type of Migraine with aura which causes paralysis of one side of the body) or a persistent aura.

What does it do?

I like to think of preventative medication as a sort of “reset” button: they make you less likely to have a migraine.  Essentially the aim of any preventative treatment is to reduce both the severity of the migraine and the frequency of attacks.  The best preventative can only reduce the frequency and severity of attacks by 50% so it is definitely not a cure.  It is still important to try an assess potential triggers and try to minimise them where possible.

Embed from Getty Images

None of the medications we suggest for migraine prevention have been developed specifically for the treatment of migraine.  There are a few main classes of medications which I will allude to:

  • Beta-blockers
  • Anti-epileptics
  • Antidepressants:
    • Tricyclic Antidepressants (TCAs)
    • Selective Noradrenaline Re-uptake Inhibitors (SNRIs)
  • Anti-hypertensives

There are also injectable treatments which I will discuss in a separate post.

Beta-blockers

The most common of these used is Propranolol.  Beta-blockers are often the first preventative medication tried.  They are well tolerated with few side-effects (vivid dreams, fatigue, reduced exercise tolerance, dizziness and erectile-dysfunction in men).  It is not suitable for asthmatics.

Anti-epileptics

The main one used nowadays is Topiramate.  I call this medication “marmite”: patients either love it or hate it.  It works well if you don’t get side-effects, and some people don’t.  Others on the other hand find the tingling in hands and feet, weight loss, mood changes (specifically unmasking of anxiety or depression) and cognitive slowing too difficult to deal with.  There’s no way of telling if you’ll be lucky or not.  This is also the only one that does not cause weight gain: in fact it usually gives the opposite effect.

Antidepressants

This includes my favourite class of migraine preventative: TCAs.  This is an old fashioned antidepressant but we use it a much lower dose in this setting.  Amitriptyline or (as a patient once described it to me) it’s “more refined brother” Nortriptyline is taken 2 hours before bedtime to mitigate its main side-effect: drowsiness.  This is actually a pretty good thing as it guarantees a fantastic nights sleep.  The other major side-effect is dry mouth.  Some people have vivid dreams and weight gain with it.

The other class of antidepressant SNRI is useful if people also suffer with anxiety or depression.  Venlafaxine  or Mirtazepine tend to be more effective as migraine preventers than first-line antidepressants such as sertraline, fluoxetine or citalopram.

Anti-hypertensives

This includes the relatively new kid on the block: Candesartan.  This has a very low side-effect profile apart from dizziness due to…well…low blood pressure.  The other medication which is used more commonly overseas is (as a patient once described it to me is Flunarazine which is a calcium-channel blocker.  Unfortunately it’s difficult to get hold of in the UK so its use is limited.

Others

Some patients still come to the clinic on medications such as gabapentin, pizotifen, sodium valproate, verapamil…  these are often unsuccessful.  Pizotifen does have a place in migraine prevention, but for some reason it tends to work better for children.  Gabapentin has been shown to be ineffective for migraine (although it still features in the guidelines which have yet to be updated) and verapamil is useful for Cluster Headache but not Migraine.

But what if I don’t want to take medication?

Lots of people don’t like taking medications because of the side-effects listed above.  There have been studies on supplements and vitamins and people are always keen to know what the more natural remedies are.

Embed from Getty Images

  • Riboflavin (Vitamin B2): at a dose of 400mg this has been shown to reduce the frequency (but not severity or duration) of migraine attacks.  Main side-effect: turns urine more yellow.
  • Magnesium: usually as citrate or maleate as they are better tolerated.  There is evidence that this can reduce the frequency and severity of attacks.  It is also beneficial in menstrual migraine for pre-menstrual attacks.  Dose is 600mg to be taken at night and main side-effects are abdominal cramps and diarrhoea.
  • Co-enzyme Q10: again reduces the frequency but not the severity of attacks.  Dose is 300mg per day.

The other option that people often ask us about is Botox.  But that is a discussion for another article…

Embed from Getty Images

Headache

Migraine Triggers

In my post on acute treatment I discussed preventing migraine attacks by identifying triggers.  Triggers can be internal or external and are essentially any change or event which causes a migraine to occur.

How do triggers cause migraine?

Every individual who suffers with migraine will have a “threshold”.  I like to think of this as a line: anything which pushes you over the line will cause a migraine, and the factors which push you over the line are your triggers.  These triggers tend to be multiple and work together but some will be stronger or more potent than others.

triggers
Migraine Triggers National Migraine Centre

How can I spot my triggers?

There are a few useful facts about migraine that are instrumental in identifying triggers:

  1. Migraine takes 12-24 hours to develop, which is much longer than most people suspect
  2. Different people have different triggers what causes migraine in one individual may not in another
  3. Migraine thresholds vary. That line I discussed above can move up or down at different points in your life: this can make “new triggers” appear if your line is particularly low as you are more susceptible to its effects than before.

What sorts of things act as triggers?

As I have said, triggers vary greatly from person to person but there are a few themes that are common to most people who suffer with migraine and I will list some examples:

  • Diet: You just have to enter the word migraine into a search engine and lots of posts about specific food triggers like cheese, chocolate and citrus will come up.  Although specific triggers do exist, these have largely been disregarded by headache professionals.  Historically, when people have tracked their migraine they have identified that they would ingest cheese, chocolate etc two hours before attacks: these must be triggers right?  Unfortunately not.  They are now thought to be cravings brought on by a drop in blood sugar level before the migraine starts.  However, rapid changes in blood sugar level can act as a migraine trigger so I advise people to avoid fast-burning carbohydrates (i.e. very sugary foods) where possible and concentrate on a high-protein diet eating slow burning (i.e. brown rice, brown pasta etc) carbohydrates where possible.  People should also avoid skipping meals and consider adding in healthy snacks during the day and before bed-time to prevent their blood sugars from fluctuating to often.

Embed from Getty Images

    • Sleep:  changes in sleep pattern are another common trigger.  Many people identify lack of sleep as a trigger but do not always think about their sleep routine: shifts in this normal pattern of even up to an hour each way can precipitate a migraine.  An example of this is a weekend where someone may have stayed up an hour later on the Friday night or treated themselves to a lie-in on the Saturday morning.  This can be one of the factors that results in a weekend migraine.  It can also be a particular problem for shift-workers as I certainly found when rotating through my hospital jobs.
    • Stress: this emotion does get implicated in a lot of medical and psychological problems but it certainly has a role in migraine.  Often it is noted that the migraine occurs when the stress has been alleviated (i.e. when people relax).  However, other emotions can trigger migraine too: anger, excitement, sorrow, joy… this can be particularly evident in children who often have attacks when they’re excited about events such as birthday parties or trips out.

pexels-photo-551588.jpeg

  • Hormones:  a study at the National Migraine Centre showed that 50% of women were more likely to suffer a migraine attack at the time of their period.  Menstrual migraines exclusively occur during a woman’s period but most women have attacks at other times of the month too which means this is one of their triggers but not the entire cause.  Some women who are sensitive to hormonal changes benefit from regulation of their cycle with the contraceptive pill or coil, unfortunately this can exacerbate symptoms in others.  Women who are hormonally sensitive may find their migraine attacks are much worse around the menopause and thus can benefit from HRT.
  • Neck and back pain: any type of muscular or joint pain in the neck and back can exacerbate migraine.  This can be as simple as poor posture or a muscular injury.  This can be improved with gentle exercises, physiotherapy or osteopathy.
  • Light sensitivity: although this can sometimes be a prodrome rather than a trigger, some people are light sensitive between migraine attacks and this can contribute towards causing further migraines.  Computers or VDUs can be a source of this and it is the blue-green wavelengths emitted which are troublesome.  There are programmes available which act as a screen filter and some people benefit from tinted lenses on their glasses.  Taking frequent breaks from looking at a screen is also important.

Embed from Getty Images

Why should I bother?

Most people who have migraine do not want to take medication, and taking too much can lead to problems such as medication overuse headache.  If you can identify your triggers and try to eliminate them through life-style measures you can reduce the number of attacks you have (some studies show by 50%!).  The way to identify these triggers is to keep a diary.

For more information see:

The Migraine Trust – Triggers

The National Migraine Centre Factsheet

Headache

Treating Migraines (acute treatment)

So you’ve established you suffer with migraine.  So what do you do?  As I’ve said before, I didn’t used to do much to help myself.  I’d take the wrong pain-killers and suffer through my day and I know, from my job as a headache specialist, countless others do the same.

Treatment is divided into two types: acute (immediate) treatment and preventative treatment.

This is to get rid of the symptoms you experience during a migraine.  The easiest way to work out what to take is to know why your taking it:

1.  Domperidone (anti-sickness or pro kinetic medication)

Embed from Getty Images

The first medicine I advise to take is Domperidone and it helps with nausea and vomiting.  This occurs because the stomach is directly affected by the migraine process: it stops emptying in a process called gastric paresis.  This means anything sitting in the stomach cannot move forward into the part of the gut where it will be absorbed.  This happens in all migraine regardless of whether or not people feel queasy.  Gastric paresis also means that any medicines taken won’t be absorbed properly.  The main function of Domperidone is get the stomach to empty (termed pro-kinesis) and this helps any pain-killer to work better.

2.  Soluble Aspirin

The next medication is a good old fashioned pain-killer: Aspirin.  This has largely fallen out of favour as a analgesic for most conditions but it works well for migraine and headache.  Because the gut has slowed down it is best to take this in the soluble form so it is better absorbed.  Better still, it should be dissolved in a sugary, fizzy drink.  The fizz helps improve the absorption of the aspirin.  The sugar helps to reverse a drop in blood sugar that occurs before the migraine starts (often making people crave sweet or salty food such as cheese or chocolate… more on this in the article about triggers).

Embed from Getty Images

Other non-steroidal anti-inflammatories (NSAIDs) such as Ibuprofen or Naproxen can be used at high dose if this does not help. This is not a suitable medication if you suffer with gastritis or for some asthmatics so I would advise speaking to your GP if this applies to you.

3.  Triptans

If the migraine is severe or if the symptoms don’t improve 45 minutes after steps one and two have been take a Triptan should be tried.  This class of medicine are specific painkillers developed for the treatment of migraine and headache.  There are 7 of them on the market and treatment usually starts with the first one that was developed: Sumatriptan (Imigran) which is available over the counter.

Some people find they can have side-effects (usually drowsiness or nausea) with this medication or it is not effective.  It can be tried in higher doses via the GP or taken via a different route if it does not work fast enough (a nasal spray and self-injection are available).  If it is not suitable, one of the other 6 triptans can be tried.

Is there a limit to how often I can take pain-killers?

In a word: yes.  Unfortunately, if you suffer with migraine you can develop a problem called Medication Overuse Headache.  It’s a strange phenomenon which seems only to affect people who suffer with headache disorders, most commonly migraine.  It happens if you take too many painkillers in a month for 3 consecutive months and causes a more severe headache or worsening of migraine features.  As a guide it occurs if:

  • NSAID medications such as ibuprofen, naproxen or aspirin and other simple pain-killers such as paracetamol are taken on more that 14 days a month
  • Triptans are taken on more than 8 days a month
  • Codeine and other opioids are taken on more than 6 days a month.

If you think this may be a possibility, I would advise speaking to your GP about how to detox from painkillers and consider whether a preventative medication may be suitable.

Are there any medications I should avoid?

Yes. There are some strong pain-killers which are not suitable for the treatment of migraine.  The advice of most headache specialists is that patients who suffer with migraine should avoid codeine and other morphine-type medication (opioids).  They are not particularly helpful in getting rid of migraine symptoms and often worsen the gastric slowing I described earlier.  They also are prone to cause rebound-headaches.  They are often prescribed by doctors due to the fact that migraine can be very painful but they should be avoided at all cost where possible.

What can I do to stop getting migraines?

Embed from Getty Images

Most people don’t like taking medications.  This is where migraine prevention comes in.  The most effective way to stop having migraine is to identify what your triggers are.  These are different in everyone but I have written an article to help identify them.  Again, keeping a diary is key to identifying what your triggers are.

If you find you are suffering with migraines more than 4 times a month, or if they are so severe they are stopping you from effectively carrying out your daily life, it is worth considering preventative treatment.