Migraine

Migraine

Migraine is a common health condition. It affects around 1 in every 5 women and around 1 in every 15 men. They usually begin in early adulthood.

A migraine is usually a moderate or severe headache felt as a throbbing pain on one side of the head. Many people also have symptoms like nausea, vomiting and increased sensitivity to light or sound.

There are several types of migraine, including:

• migraine with aura – where there are warning signs before the migraine begins, like seeing flashing lights
• migraine without aura – the most common type, where the migraine occurs without warning signs
• migraine aura without headache, also known as silent migraine – where an aura or other migraine symptoms are experienced, without a headache

Some people have frequent migraines up to several times a week. Other people only have occasional migraines. It’s possible for years to pass between migraine attacks.

Symptoms of a migraine

The main symptom of a migraine is usually an intense headache on one side of the head. In some cases, the pain can occur on both sides of your head and may affect your face or neck.

The pain is usually a moderate or severe throbbing sensation. The pain gets worse when you move and may prevent you from carrying out normal activities.

Other symptoms associated with a migraine include:

• nausea
• vomiting
• increased sensitivity to light and sound – which is why many people with a migraine want to rest in a quiet, dark room

Some people experience other symptoms, including:

• sweating
• poor concentration
• feeling very hot or very cold
• abdominal (tummy) pain
• diarrhoea
• dizziness (light headedness)

Not everyone with a migraine experiences these additional symptoms. Some people may experience them without having a headache.

The symptoms of a migraine usually last between 4 hours and 3 days. You may feel very tired for up to a week afterwards.

Symptoms of aura

About 1 in 3 people with migraines have temporary warning symptoms, known as aura, before a migraine. These include:

• visual problems – such as seeing flashing lights, zig-zag patterns or blind spots
• numbness or a tingling sensation like pins and needles – which usually starts in one hand and moves up your arm before affecting your face, lips and tongue
• difficulty speaking

Sometimes, you might also experience:

• feeling dizzy or off balance
• loss of consciousness – although this is unusual

Aura symptoms typically develop over the course of about 5 minutes and last for up to an hour. The aura might start before the headache or you might experience it at the same time as a headache. Some people may experience aura followed by only a mild headache or no headache at all.

Speak to your GP if:

• you have frequent or severe migraine symptoms

Phone 999 if you or someone you’re with experiences:

• paralysis or weakness in one or both arms and/or one side of the face
• slurred or garbled speech
• a sudden agonising headache resulting in a blinding pain unlike anything experienced before
• headache along with a high temperature (fever), stiff neck, mental confusion, seizures, double vision and a rash

These symptoms may be a sign of a more serious condition, like a stroke or meningitis. You should be assessed by a doctor as soon as possible.

Causes of a migraine

The exact cause of migraines is unknown. They’re thought to be the result of abnormal brain activity temporarily affecting nerve signals, chemicals and blood vessels in the brain.

Around half of all people who experience migraines have a close relative with the condition. This suggests that genes may play a role.

Migraine triggers

It may help to keep a diary to see if you can identify a consistent trigger. It can be difficult to tell if something is a trigger or if what you’re experiencing is an early symptom of a migraine attack.

There might not always be a trigger for your headache.

Possible migraine triggers include:

Hormonal changes

Some women experience migraines around the time of their period. This might be because of changes in the levels of hormones like oestrogen around this time.

These types of migraines usually occur between 2 days before the start of your period to 3 days after. Some women only experience migraines around this time. This is known as pure menstrual migraine. Most women experience them at other times too. This is called menstrual related migraine.

Some women find their migraines become worse during perimenopause. However, they might improve or disappear a few years after your last period.

Emotional triggers

• stress
• anxiety
• tension
• shock
• depression
• excitement

Physical triggers

• tiredness
• poor quality sleep
• shift work
• poor posture
• neck or shoulder tension
• jet lag
• fasting or low blood sugar (hypoglycaemia)
• strenuous exercise, if you’re not used to it

Dietary triggers

• missed, delayed or irregular meals
• dehydration
• alcohol
• the food additive tyramine (found in some cheeses and cured meat)
• caffeine products, such as tea and coffee
• lack of caffeine (if you’re used to regular caffeine)
• specific foods such as chocolate, citrus fruit and cheese

Some people crave chocolate before a migraine begins. This can be a sign that you’re about to have a migraine rather than the chocolate being the trigger for the migraine.

Environmental triggers

• bright lights
• flickering screens, such as a television or computer screen
• smoking (or smoky rooms)
• loud noises
• strong smells
• changes in weather (windy weather or stuffy atmosphere)

Medication

• some types of sleeping tablets
• the combined contraceptive pill
• hormone replacement therapy (HRT), sometimes used to relieve symptoms of the menopause

There are other types of medications that can cause some people to experience migraines.

Speak to your GP if you start to experience migraines after starting to take new medication.

Diagnosing migraines

There’s no specific test to diagnose migraines. For an accurate diagnosis, your GP must identify a pattern of recurring headaches along with the associated symptoms.

Migraines can be unpredictable, sometimes occurring without the other symptoms. Obtaining an accurate diagnosis can sometimes take time.

Your GP might do a physical examination and check your vision, co-ordination, reflexes and sensations. These will help rule out some other possible underlying causes of your symptoms.

Your GP may ask if your headaches are:

• on one side of the head
• a pulsating pain
• severe enough to prevent you carrying out daily activities
• made worse by physical activity or moving about
• accompanied by nausea and vomiting
• accompanied by sensitivity to light and noise

Migraine diary

To help with the diagnosis, it can be useful to keep a diary of your migraine attacks for a few weeks. Note down details like:

• the date
• time
• what you were doing when the migraine began
• how long the attack lasted
• what symptoms you experienced
• what medication you took (if any)

Taking too many painkillers is a reason why migraines can become difficult to treat. This is called medication overuse headache. Keep a record of what painkillers you take and how often you take them. You shouldn’t take painkillers on more than 10 days every month in the long-term.

It can be helpful to make a note when your start your period, if you have one. This can help your GP identify potential triggers.

Read more about keeping a migraine diary on The Migraine Trust website.

Referral to a specialist

Your GP may decide to refer you to a neurologist (a specialist in conditions affecting the brain and nervous system). They’ll do further assessments and offer treatment if:

• a diagnosis is unclear
• you experience significant migraines not controlled by your current treatment

Treating migraines

There’s no cure for migraines. There are treatments available to help reduce the symptoms. During an attack, many people find that sleeping or lying in a darkened room can also help.

It may take time to work out the best treatment for you. You may need to try different types or combinations of medicines before you find the most effective ones. If you can’t manage your migraines using over-the-counter medicines, your GP may prescribe something stronger.

Always make sure you read the medication instructions and follow the dosage recommendations.

Children under 16 shouldn’t take aspirin unless it’s under the guidance of a healthcare professional.

Aspirin and ibuprofen are not recommended for adults who have a history of stomach problems, like stomach ulcers, liver problems or kidney problems. 

Painkillers

Many people find that over-the-counter painkillers, like paracetamol, aspirin or ibuprofen, can help to reduce their symptoms.

They tend to be most effective if taken at the first signs of a migraine attack. This gives them time to absorb into your bloodstream and ease your symptoms.

You shouldn’t wait until the headache worsens before taking painkillers as it’s often too late for the medication to work. Soluble painkillers (tablets you dissolve in a glass of water) are a good option because they’re absorbed quickly by your body.

Taking too many painkillers can lead to medication overuse headache. You should not take them more than 15 days per month.

If you can’t swallow painkillers because of nausea or vomiting, you should speak to your GP about anti sickness medication or suppository options. Suppositories are capsules that you insert into the anus (back passage).

Opiates like codeine should not be prescribed as a treatment for migraines. They’re not any more effective than triptans and painkillers and can cause nausea and medication overuse headache.

Triptans

If over the counter medication is not helping your symptoms, your GP might recommend a triptan and/or anti sickness medication.

Triptan medicines are a specific painkiller for migraine headaches. They’re thought to work by reversing the changes in the brain that may cause migraine headaches.

Triptans are available as tablets, injections and nasal sprays.

Common side effects of triptans include:

• warm-sensations
• tightness
• tingling
• flushing and light headedness
• feelings of heaviness in the face, throat, limbs or chest

Some people also experience nausea, dry mouth and drowsiness. These side effects are usually mild and improve on their own.

Taking too many triptans can lead to medication overuse headache. You should not take them more than 10 days per month.

Your GP will usually recommend having a follow-up appointment once you’ve finished your first course of treatment. This is so you can discuss their effectiveness and whether you had any side effects.

If treatment is not effective or causes unpleasant side effects, your GP may try prescribing a different type of triptan. Everyone reacts differently to each type of triptan.

Triptans can be taken at the same as painkillers and/or anti-sickness tablets to improve their effectiveness. Your GP will discuss this with you.

Anti-sickness medicines

Anti-sickness medicines, known as anti-emetics, can treat migraine in some people. They can be effective even if you don’t experience nausea or vomiting. They can be taken alongside painkillers and triptans.

Anti-sickness medicines work better if taken as soon as your migraine symptoms begin. They usually come in the form of a tablet.

Side effects of anti-emetics include drowsiness and diarrhoea.

Some anti-sickness medication can cause involuntary movements, normally in the face. Speak to your GP if you experience involuntary movements.

Combination medicines

You can buy some combination medicines for migraine without a prescription at your local pharmacy. These medicines contain both painkillers and anti-sickness medicines. If you’re not sure which one is best for you, ask your pharmacist.

It can also be very effective to combine a triptan with another painkiller, like ibuprofen.

Many people find combination medicines convenient. However, the dose of painkillers or anti-sickness medicine may not be enough to relieve your symptoms. If this is the case, it may be better to take painkillers and anti-sickness medicines separately. This allows you to control the doses of each.

Opiates like codeine should not be prescribed as a treatment for migraines. They’re not any more effective than triptans and painkillers and can cause nausea and medication overuse headache.

Treatment during pregnancy and breastfeeding

In general, migraine treatment with medicines should be limited as much as possible when you’re pregnant or breastfeeding. Instead, trying to identify and avoid potential migraine triggers is recommended.

If medication is essential, paracetamol and sumatriptan are safe to take during pregnancy and when breastfeeding.

If you’re pregnant or breastfeeding, speak to your GP or midwife:

• if you’re getting regular migraines
• before taking medication

High doses of aspirin should not be taken to treat headaches during pregnancy.

Preventing migraines

It’s important to maintain a generally healthy lifestyle, including:

• regular exercise, sleep and meals
• ensuring you stay well hydrated
• limiting your intake of caffeine
• limiting your intake of alcohol

One of the best ways of preventing migraines is recognising the things that trigger an attack and trying to avoid them. 

Preventative medication

Medication is available to help prevent migraines. These medicines are usually used if your migraines remain frequent (more than 1 migraine per week) following a period of avoiding possible triggers.

The following medications can be prescribed by your GP. If they’re not effective, you’ll be referred to a neurologist. The neurologist will consider what advanced therapies might be best to try next.

Medications used to prevent migraines are taken every day to reduce the severity and frequency of headaches. It takes a few weeks to reach the right dose and you might need to take it for several weeks (usually 8 weeks once the right dose is reached) to find out if it works.

Propranolol

Propranolol is a medication used to treat angina and high blood pressure. It’s also effective in preventing migraines. It is taken every day in tablet form, regardless of whether you have a headache or not.

Propranolol is not suitable for people with asthma, chronic obstructive pulmonary disease (COPD) and some heart problems. It should be used with caution in people with diabetes.

Side effects of propranolol can include:

• cold hands and feet
• pins and needles
• problems sleeping
• tiredness
• light headedness

Tricyclic antidepressants

You might be prescribed tricyclic antidepressants like amitriptyline or nortriptyline. This is a type of medication used for depression but at lower doses can also help prevent migraines.

The side effects can include:

• drowsiness
• a dry mouth
• weight gain
• difficulty passing urine

Topiramate

Topiramate is a type of medication originally developed to prevent seizures in people with epilepsy. It’s now much more commonly used in migraine. It’s been shown to help prevent migraines. It is taken every day in tablet form regardless of whether you have a headache or not.

Topiramate should be used with caution in people with kidney stones, liver problems or glaucoma.

You should not take topiramate during pregnancy as it can harm your unborn baby. You must be on an effective form of contraception when taking topiramate. Topiramate can reduce the effectiveness of hormonal contraceptives. Your GP should discuss alternative methods of contraception if you’re prescribed topiramate.

Side effects of topiramate can include:

• decreased appetite and weight loss
• nausea and vomiting
• constipation or diarrhoea
• tingling sensation
• memory problems and difficulty finding words
• problems sleeping

Candesartan

You might be prescribed Candesartan. Candesartan is a medication used for high blood pressure.

Candesartan can cause lightheadedness due to low blood pressure, tiredness and cough. It should not be used if you’re pregnant or trying for a baby.

Other oral preventive medications

Other less common options of oral preventative medications for migraine include:

• pizotifen
• flunarizine

Complementary therapies and supplements

There are some complementary therapies and supplements which might help to prevent your migraine symptoms. These include:

• magnesium
• vitamin B2 (rivoflavin)
• coenzyme Q10
• acupuncture

You should discuss any complementary therapies you’d like to try with your GP.

Medical devices

There are some devices that have been developed that might help treat migraines. These include:

• transcranial magnetic stimulation
• external trigeminal nerve stimulator
• non-invasive vagus nerve stimulation

Advanced therapies for migraine

The following medicines are advanced therapies for migraine that can only be prescribed by a neurologist.

Botulinum toxin type A

Botulinum toxin type A is used to prevent headaches in some adults with chronic migraines. Chronic migraines mean you have headaches more than 15 days per month and at least half of them are migraines, over a period of 3 months.

Botulinum toxin type A is a type of neurotoxin (nerve toxin) that paralyses muscles. It’s not exactly clear why this treatment can be effective for migraine.

SIGN recommend this treatment as an option for people who have chronic migraine that hasn’t responded to at least three previous preventative medical treatments.

Botulinum toxin type A should be injected to between 31 and 39 sites around the head and back of the neck. A new course of treatment can be given every 12 weeks.

Calcitonin Gene-Related Peptide (CGRP) monoclonal antibodies

CGRP might be prescribed if other medication has not prevented your migraines.

This medication has been created specifically for migraines.

CGRP monoclonal antibodies are given by an injection into the skin on your thigh or abdomen (tummy) once per month. You’ll have to self administer this treatment meaning you’ll need to learn how to deliver the injection yourself.

Preventing menstrual-related migraines

Menstrual-related migraines usually occur between 2 days before the start of your period to 3 days after. They can be preventable using either non-hormonal or hormonal treatments.

Non-hormonal treatments

The non-hormonal treatments that are recommended are:

• non-steroidal anti-inflammatory drugs (NSAIDs) – a common type of painkiller (usually naproxen)
• triptans – a type of medication used to treat a migraine attack (usually naratriptan or frovatriptan)

These medications are taken as tablets 2 to 4 times a day from either the start of your period or 2 days before, until the last day of bleeding.

Hormonal treatments

Hormonal treatments that may be recommended include:

• combined hormonal contraceptives, like the combined contraceptive pill, patch or vaginal ring (usually taken continuously for at least 3 months)
• progesterone-only contraceptives, such as progesterone-only pills, implants or injections
• oestrogen patches or gels, which can be used from 3 days before the start of your period and continued for 7 days

Hormonal contraceptives like the combined contraceptive pill or vaginal ring are not used if you have migraines with aura symptoms. This is because this can increase your risk of having a stroke. 

Migraine clinic

If the treatments above aren’t controlling your migraines, you might be referred to a specialist migraine clinic for further investigation and treatment.

A specialist might recommend other treatments like transcranial magnetic stimulation devices or greater occipital nerve blocks.

Complications of migraines

Migraines are linked to a very small increased risk of mental health problems. Migraines with aura are associated with a small increased risk of ischaemic strokes.

Stroke

An ischaemic stroke occurs when the blood supply to the brain is blocked by a blood clot or fatty material in the arteries.

People who experience migraines with aura have about twice the risk of having an ischaemic stroke compared to people without migraines. However, this risk is still small. The risk increases significantly if you smoke and take the combined contraceptive pill.

It’s unclear why ischaemic strokes are linked to migraine.

Contraceptive pill

The risk of having an ischaemic stroke is increased by the use of the combined contraceptive pill. Medical professionals generally advise women who experience migraine with aura not to use the combined contraceptive pill.

Women who have migraine without aura can usually take the combined contraceptive pill safely, unless they have other stroke risk factors like high blood pressure or a family history of cardiovascular disease.

Talk to your GP about alternative forms of contraception if you experience aura symptoms and are taking the combined contraceptive pill.

Mental health problems

Migraine is associated with a very small increased risk of mental health problems, including:

• depression
• bipolar disorder
• anxiety disorder
• panic disorder