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.

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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.

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  • 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…

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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.

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    • 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.

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  • 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.

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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