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.

Headache

Migraine

“I’ve come to see you about my headache.” It’s a phrase that leaves many GPs with a feeling of dread.  Headache is a bit of a nightmare.  Most people with a severe or new headache are terrified about the worst case scenario: Cancer.  Doctors worry about missing other critical headaches and, once they’ve been ruled out, trying to reassure the patient that the headache is unlikely to be sinister but…what do they do about it?  What’s the diagnosis?

Embed from Getty Images

I have a vested interest in this subject.  I suffer with migraine with varying degrees of regularity.  If you’ve read my post about me you’ll know my Mum suffered with them and my sister does too.  I used to be appalling at managing them: I’d take a couple of paracetamol, which didn’t take the pain away, and pop myself in a dark room until the worst of it eventually eased enough for me to carry on with the merest semblance of my normal life.

I’ve suffered with migraine since I was 12.  I vividly remember my first attack.  I was in the school playground, queuing for lunch and I had felt a bit more tired that usual.  I felt like the sun was dazzling me (even though it was a typical cloudy, autumn day in England) and I couldn’t really see because bright spots were dancing in my field of vision.  Then my head was throbbing, not the worst pain I’d had, but it bothered me.  I couldn’t speak, the words just wouldn’t come out.  And it lasted for the rest of the day.  I told my Mum and she solemnly told me I’d had a migraine.

In my early 20s, when I was at medical school I sat in on a clinic with a GP who was headache specialist.  It changed my life.  I’m not exaggerating.  “Does anyone here suffer with migraine?” He looked at the four of us: two medical students, two GP-trainees.  I tentatively put my hand up.  He figured one out of four of us would suffer.  He asked what I did.  Did it work? No.  Why did I do it?  Had I seen my doctor?  No.  What was the point?  What could they do?  Apparently, quite a lot.  He gave me a little plan for what to take: Aspirin (who knew people still took that for pain?!), if that didn’t work I could try a “triptan” (more on these wonderful drugs later) and if I got them more than 4 times a month I should try a preventative medication.  And it worked.

Embed from Getty Images

And ever since then, I’ve wanted to do the same: improve people’s migraines.

Migraine – what is it?

Migraine is the 7th most debilitating disease globally. The word Migraine comes from the Greek Hemicrania meaning half a head as historically it referred to pain which affected only affected one side.  Now it is defined as a pain which can affect one or both sides of the head which is often throbbing in nature with other troublesome features such as:

  • Light or sound sensitivity
  • Nausea or vomiting
  • Tiredness

There are many different migraine subtypes and people do not have to experience flashing lights or other visual changes to be diagnosed with this.  People that do have that symptom are described as having an “aura”.  Only 10-30% of people with migraine suffer aura.  Aura doesn’t have to be visual.  The symptoms of aura typically start before the headache people can get:

  • numbness
  • dizziness
  • problems speaking
  • memory loss
  • paralysis

The headache doesn’t always have to be severe.  This is the most common misconception.  Like with most problems you can get mild, moderate or severe attacks.  Often people can take a day or two to recover and a lot of people describe this as feeling like a hangover.

Migraine does not have to start when you’re young.  It often starts at puberty and commonly affects those between in their 20s and 30s.  It affects around 1 in 7 people and women are three times more likely to suffer than men.

What causes migraine?

Embed from Getty Images

We don’t fully understand what happens during a migraine.  We know some of the substances that are involved in migraine (like serotonin and CGRP) which has helped with the development of some of the medicines used to treat it, but the full process is still a bit of mystery.  We also know that it runs in families with more that half of patients with migraine having a relative who also suffers.

Impact on society

Migraine is debilitating.  A lot of people find the headache bearable but try going to work and trying to carry on with

  • impaired vision
  • problems concentrating
  • feeling queasy
  • difficulty looking at a computer
  • not being able to sleep

It makes simple things like checking your emails or sitting through a presentation a mammoth task.  But people don’t like calling in sick for work.

“Surely you can come in… it’s just a headache”.

In the clinic I see people week on week referred in because work are concerned about their sickness absence and they give a sense that the patient is just… putting it on.

“Migraine leads to reduced productivity at work and has major implications for society”  NICE CKS

Migraine costs the UK economy an estimated £2.5 billion per year due to absenteeism.  It’s a big deal.

Embed from Getty Images

How is it diagnosed?

The most frustrating thing about migraine is that there are no tests to confirm the diagnosis: we listen to the pattern, find out if the features above are present and make the diagnosis on that basis.

The best way of knowing whether or not you have a migraine and decide on the best course of treatment is to track it.  This can be done via countless apps or using a good, old fashioned diary.  The National Migraine Centre has a version here.

For more information please see:

The Migraine Trust

The National Migraine Centre