Migraine is a very common condition that involves a severe headache that can also include other symptoms such as nausea, vomiting and sensitivity to light or sound. Migraines normally begin in early adulthood and are more common in women. It is thought they affect around 1 in 5 women and only around 1 in 15 men. Migraines normally gradually improve as people get older, although in some cases they can get worse.

Migraines are very individual with different people experiencing different symptoms with varying impacts on their lifestyle. At the most extreme end, migraines can occur several times a week and involve severe pain, sickness and sensitivity to light and/or sound, lasting days at a time. At the other end of the spectrum, migraines may only occur occasionally with months, or even years, between attacks that can be fairly mild and short-lived.

As you can see, migraines can have a massive impact on your quality of life and in some cases can stop you from working. It is important that you treat migraines effectively and follow preventative measures to reduce their frequency.

Migraines are thought to be caused by abnormal brain activity that affects nerve signals, chemical transmitters and blood vessels within the brain. Although it is not clear what the exact cause of the abnormal activity is, it is thought that your genes may make you more likely to experience a migraine following exposure to a specific trigger factor.

Trigger factors are stimuli that cause the changes in the brain that start a migraine. There are many proposed triggers and each migraine sufferer will have a specific trigger(s) that they are aware of that will bring on a migraine.

Migraine trigger factors can include:

• Emotional Triggers: stress, anxiety, tension, shock, depression, and excitement.
• Physical Triggers: tiredness, shift work, poor posture, neck or shoulder tension, jet lag, low blood sugar, strenuous exercise.
• Dietary Triggers: missed or irregular meals, poor diet, dehydration, alcohol, tyramine (food additive), caffeine (in coffee or tea), specific foods such as cheese, chocolate or citrus fruits.
• Environmental Triggers: bright lights, flickering lights or screens, smoking, loud noises, changes in humidity or temperature, strong smells, a stuffy atmosphere.
• Medicinal Triggers: some sleeping tablets, some oral contraceptive pills, some HRT (hormone replacement therapy).
• Hormonal Triggers: some women find that they experience migraines around the time of their period, this is possibly due to low levels of oestrogen around this time.

Stages of a migraine

To understand the symptoms of a migraine, it is also important to understand the phases of a migraine. They will normally have four distinct phases, although some people may not experience all of them. The four distinct phases of a migraine are:

1. Prodromal phase: generally involves changes in mood, behaviour, energy levels or appetite that occur from a few hours to days before a migraine attack.
2. Aura phase: the visual stage that occurs closer to the migraine attack, normally 5 minutes to 1 hour before. It usually involves flashes of light or blind spots in the vision.
3. Headache phase (Migraine attack): the phase that involves the typical migraine symptoms including throbbing headache, sensitivity to light and sound, as well as nausea and vomiting. This can last for anything from a couple of hours to 3 days depending on the severity of symptoms and the treatment used.
4. Resolution stage: as the symptoms of the headache phase leave you may be left feeling drained or tired for a number of days afterwards.

For some people the first sign that a migraine is about to occur will be the aura phase, which occurs in around one third of sufferers. This visual ‘warning’ stage usually lasts for between 5 minutes and 1 hour and can involve the following symptoms:

• Flashing lights or patterns
• Blind spots
• Tingling and numbness starting in the hand, moving up the arm to the face
• Dizziness
• Difficulty speaking
• Headache behind the eyes

The main symptom of a migraine (during the migraine attack) is a severe headache that occurs on one side or across the front of the head. It can, however, occur across the whole head and even affect the face or neck in some people. The headache experienced with a migraine is normally an intense throbbing that gets worse with movement.

Additional symptoms that may be experienced with a migraine include:

• Nausea
• Vomiting
• Sensitivity to light and sound
• Dizziness
• Feeling Drowsy
• Sweating
• Poor concentration
• Feeling very hot/cold
• Diarrhoea
• Stomach pain

Not everyone will experience all of these symptoms and they may vary with each migraine attack. It is possible to experience these additional symptoms without the typical migraine headache on some occasions.

You should seek urgent medical attention at the hospital if you have any of the following migraine symptoms:

• Paralysis/weakness of one or both arms or the face
• Slurred speech
• A sudden onset headache with agonising pain
• Fever, stiff neck, confusion, seizures, double vision, or a rash.

There is no specific way/test to diagnose migraines. A diagnosis is normally made by your GP; it is based on the pattern and severity of headaches along with the occurrence of other associated symptoms as well as your response to migraine treatments. This can take time depending on the frequency, severity and associated symptoms of your migraines.

To aid your diagnosis it is helpful to keep a migraine diary to keep an accurate record of your condition. Your migraine diary should include:

• Time and date of the migraine attack
• What you were doing at the time
• If there were any obvious or potential trigger factors
• Which migraine stages have you experienced
• What symptoms have you experienced
• Whether you took any medication and if it was effective

Based on the contents of your migraine diary, the symptoms that you experience and your response to any painkillers or migraine treatments, an accurate diagnosis can be made.

Migraines cannot be cured, although they may ease or even disappear over time. Migraine treatment aims to relieve symptoms and sometimes prevent the onset, if taken early enough. Migraine treatment can range from over-the-counter painkillers to prescription treatments depending on the symptoms and severity.

Painkillers

Simple painkillers such as paracetamol, ibuprofen or aspirin, can help to relieve the throbbing headache associated with a migraine attack if they are taken early enough. You should take them at the first onset of symptoms, do not wait until you are already experiencing a painful headache as it will be too late and they may be less effective. Soluble painkillers are absorbed into your system quicker and may be more effective at relieving migraine pain.

If simple painkillers do not relieve pain, stronger painkillers containing codeine, such as Solpadeine or Nurofen Plus, may be more effective.

Take care when using painkillers as overuse can be dangerous. Regular use of any painkillers can cause headaches and make migraines worse.

Triptans

If you have been diagnosed with migraines by your GP and they cannot be controlled with simple painkillers, you will be prescribed a Triptan. Triptans (also known as 5-HT1 agonists), which are taken alongside painkillers, cause the blood vessels in the brain to contract. As some of the changes that occur in the brain to trigger a migraine attack are believed to involve the blood vessels widening, Triptans help to reverse this process and relieve the symptoms of migraine. They may also have some effect by stabilising some of the chemical changes that occur in the brain during a migraine attack.

Each Triptan has a very similar mode of action, however each can work differently depending on the person. Although, there are slight variations in effectiveness and side effects, it is much more important to find the right drug for you. This may mean trying a few different Triptans before you find the most effective one for you. It is recommended by The British Society for the Study of Headache (BASH) that you try each individual Triptan on three separate occasions before deciding on its effectiveness. If you feel it is not effective, you should then try a different Triptan or higher strength.

When choosing the correct triptan it is worth considering the method of administration as this can help to improve the effectiveness. Tablets are the standard form of triptan that are effective in most people, however if you experience nausea or vomiting they may be difficult to take. Tablets can also take longer to have an effect than other treatments and may not be the best option if a fast onset of action is required. Tablets need to be taken early on in a migraine attack for a maximal effect as there is some evidence that the absorption of drugs may decrease during a migraine attack.

Nasal sprays or wafer melts may be a better option in cases where tablets are not suitable due to the need for a quick onset of action or where nausea/vomiting makes swallowing impractical.

The most important method of migraine prevention is to identify and avoid triggers. By keeping a migraine diary as detailed above in ‘Diagnosis’ you can start to identify triggers and then learn to avoid any triggers that bring on a migraine. Common migraine triggers are listed above in ‘Causes’. This list is only the most common triggers, you may find that there are other factors that you are sensitive to; migraine triggers are different from one individual to another.

If you experience more than 5 days of migraines in a month, you may benefit from preventative treatment from your GP. There are many medical treatments for the prevention of migraines, such as topiramate, propranolol and gabapentin, which may be effective if you have frequent, severe migraines. If you think you fall into this category you should book an appointment to discuss preventative migraine treatment with your GP and take a comprehensive migraine diary to aid diagnosis.