Migraine - some questions and answers

What is migraine?

Migraine is an intermittently occurring headache that may be accompanied by nausea and vomiting and/or sensitivity to light and sound. In addition, a minority of people experience neurological disturbances called migraine aura. These arise in the visual cortex of the brain rather than in the eyes – i.e. they are hallucinations, which is confirmed by the fact that they can occur in blind people. Some people experience other forms of ‘aura’ which affect speech and movement. When aura is present, the condition is sometimes called ‘classical migraine’; when it is absent, ‘common migraine’. It needs to be distinguished from other headache syndromes such as cluster and tension-type headache.

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Did migraine exist before the modern era?

Migraine is one of the oldest disorders known to mankind. Migraine-like conditions are described in writings from ancient Babylon in around 3000 BC. They are described even more accurately in an ancient papyrus dating from around 1550 BC, said to have been found buried with a mummy in Thebes, Egypt. This appears to be a copy of earlier manuscripts, because it refers to remedies prepared for an Egyptian king who reigned in about 2700 BC. Conditions that are clearly migraine are also described by Hippocrates in 460 BC, and Aretaeus of Cappodocia in 80 AD.

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What are the symptoms of migraine?

Premonitory symptoms, which are thought to be the first signs of an impending migraine, may be noticed up to 24 hours before the onset of headache. These may take the form of changes in mood (irritation or depression), alertness (drowsiness, excitability or yawning), the senses (visual disturbances, aversion to light, noise or smells), or craving for or withdrawal from food or drink. They only occur in about one-third of people with migraine; the remainder have no warning. It is important for migraineurs to learn to recognise their premonitory signs so that they can take action or medication to abort the attack.

In migraine with aura, visual aura usually precede the onset of the headache, though a minority experience aura alone which does not progress to a headache.

In both migraine with and without aura, headache is the dominant symptom, but it can be very variable in location, severity and nature, or even absent in a few people. The word migraine comes from the Greek ‘hemicrania’ – meaning literally ‘half the head’, although headaches on one side of the head apply to only about 40 per cent of sufferers. Another 40 per cent have two-sided headache from the outset, while the remaining 20 per cent have an initial one-sided headache that then spreads to both sides of the head.

Migraine headache usually has a throbbing nature, severe enough to disrupt normal activity, and is made worse by activity. In some people, the pain is focused deeply behind the eye or at the inner angle of the eye. More often, it centres in the frontal lobe of the brain behind the forehead and may radiate back as far as the neck. In some people, the pain is facial and can be confused with cluster headaches. During the headache phase, patients commonly feel sick or actually vomit (around 10 per cent), experience increased sensitivity to light, sound or occasionally smell, and have various forms of gastric discomfort.

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What are the visual hallucinations like?

About 10 per cent of people experience so-called ‘fortification figures’ because they resemble the zigzags of medieval castle walls and battlements as if viewed from above. These are most often white in colour, shimmer as they drift across the field of sight (called scintillation scotomas) and leave an area of temporary blindness behind them as they pass. This may show as gaps in a page of typescript, for example. Another 25 per cent experience light flashes or stars in one or both visual fields.

On this section Migraine, Oliver Sacks emphasised two important aspects of aura experiences. Firstly, they can vary considerably between attacks in the same patient. Secondly, they have a very definite sequence which changes with time during the attack. In particular, he points out the endless variations found in aura experiences: ’...migraine aura ...is put together from a variety of components or modules arranged in innumerable different patterns’.

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Are there different kinds of migraine?

Because of the wide range of signs and symptoms, it is true to say there are almost as many forms of migraine as there are people with it. From a clinical point of view, it can be divided into migraine with aura, which affects about 15 per cent of migraine sufferers, and migraine without aura, which affects about 85 per cent.

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How common is migraine?

Estimates vary slightly, because up to one-third of people with migraine do not go to their doctor. Generally, it is thought to affect 1 in 10 people in the UK at some time in their lives – 5 to 6 million in total. The total number of cases in the population has doubled in the past 15 years, probably reflecting a greater awareness and willingness to report the illness.

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Can migraine affect anyone?

Migraine can affect both sexes and is known at all ages. However, population studies have shown that after maturity it is two to four times as common in women as men, varying slightly with age. Over a complete lifespan, about 15 per cent of females get migraines, compared to about 8 per cent of males. In a quarter of people, the attacks begin under the age of 10, while about three-quarters develop the illness before the age of 30. Migraine is most prevalent during people’s most productive years, between the ages of 20 and 50.

Incidence declines with advancing age and onset is uncommon over the age of 50, though it is possibly under-diagnosed in the elderly because of confusion with transient ischaemic attacks (‘mini-strokes’).

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What is menstrual migraine?

Some women experience headaches several days before their periods (i.e. they are an aspect of pre-menstrual tension). These have to be differentiated from menstrual migraines, which are defined as ‘attacks of migraine without aura which occur regularly on day one of menstruation (plus or minus two days) and at no other time’. These attacks are thought to relate to the fall in oestrogen levels and the release of substances called prostaglandins into the blood stream at this time. In many women these attacks can be treated by the use of oestrogen skin patches, for example.

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Can children suffer from migraine?

It was not until the 1960s that the regular diagnosis of migraine in children began. Childhood migraine commonly appears in the first three years of life, and the attacks can differ quite dramatically from adult migraine. They tend to be shorter – sometimes only lasting an hour – and end abruptly after one to 48 hours. The headache phase is often less pronounced and this can lead to underdiagnosis. They are also characterised by abdominal pains accompanied by nausea and vomiting, which require active treatment to prevent dehydration and the build-up of certain types of acids in the body. These effects are self-limiting and give way at puberty to more conventional ‘head-centred’ migraine attacks. Fortunately, many children grow out of their migraine completely. Childhood migraine can be treated in most cases with pizotifen, propranolol, the pink and yellow tablet combination Migraleve, or with analgesics specially formulated for children.

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What are migraine trigger factors?

There is a generally held view that we all have a threshold for migraine attacks. In non-migraineurs the threshold is high, but in migraine sufferers it is low. This is supported by the observation that most people experience migraine-like episodes at some time in their lives, but mostly only on the odd occasion, perhaps at times of great stress or personal instability. People with a low threshold are perhaps more susceptible to triggering by everyday events which may be psychological or material (i.e. certain types of food, etc.) and become migraineurs. It is important to note that in many people, several triggers may have to be present to cause an attack, while in others there may be sensitivity to a specific food ingredient such as tyramine, found in cheese and chocolate. People who suffer from migraine may need to make adjustments to their lifestyle to avoid the things that trigger their attacks.

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What are the commonest trigger factors?

Almost anything can act as a trigger. But there are common and well-recognised factors which often act either alone or in combination, such as:

• chocolate
• alcohol
• cheese and other dairy produce
• Coffee and tea (caffeine)
• citrus fruits and fruit juices
• sea food
• onions
• pork
• Marmite
• citric acid
• monosodium glutamate
• aspartame sweetener

Citric acid and monosodium glutamate provide flavour or stability and are added to many foods such as soups during processing, so they may occur in products where you would not expect them. Keeping a personal diary is a good way to keep track of your own trigger factors and then eliminate them. Identifying trigger factors can take some time and a lot of personal experimentation, but it is worth it if attacks can be reduced or avoided as a result. A craving for certain food does not necessarily imply that it is a trigger – such symptoms may be part of the early phase of a migraine attack.

Not all migraine sufferers are food-sensitive. In some people, lack of food and low blood sugar can act as a trigger. In others, the important factors can be hormonal, emotional, environmental (e.g. light, loud noise or strong smells), or fatigue. Finally, it must be recognised that this is a complex area and if you have migraines, you should obtain more detailed information on trigger factors. Helpful information is available from your GP or migraine support groups.

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Does migraine have an impact on the rest of the family?

Migraine has a major impact on the individual through diminishing the quality of life. But it also has a direct effect on the husband/wife and on the children. This was shown clearly in a large American study first published in a medical journal called Headache in 1996. Social, sexual, and business activities of the parents can suffer. Children may become more withdrawn, be disturbed by apparent parental irritability or disinterest, and their schooling may be affected.

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What causes migraine?

While the exact cause of migraine is still under study, the attacks seem to follow a sequence consisting of:

• a premonitary (prodromal) phase,
• aura (in migraine with aura only),
• pre-headache symptoms such as yawning, avoidance of food and drink, light, and sound, and nausea, which merge into
• headache with continued nausea and possibly vomiting,
• a resolution phase when there is often deep sleep, and lastly
• a recovery period when there may be limited food tolerance, mood changes and tiredness.

To some extent, these phases can now be related to changes that occur in the nerves and blood vessels in the brain. An originating centre deep in the brain results in electrical signals travelling to other parts of the head. This causes changes in nerve cell activity and reduces blood flow that, in turn, gives rise to the pre-headache symptoms. Release of further chemicals causes blood vessels to enlarge (called dilatation), leading to the inflammation of surrounding tissue. This irritates the trigeminal nerve, resulting in throbbing and pain. This simplified account is discussed in greater detail in a later section.

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Is migraine inherited?

It has become clear in the past few years that genetic factors play a part in migraine, probably by lowering the trigger threshold. For example, close relatives of people with migraine carry an increased risk, and identical twins carry a higher risk than non-identical twins. Studies of the genes carried by migraineurs have revealed at least 10 common genetic variations associated with migraine. The pharmaceutical company Glaxo Wellcome reported in 1999 that it had located a number of these variations in the human gene pool that appear to increase the likelihood of a person experiencing migraine. Understanding these will provide new avenues for medicines development.

Valuable genetic evidence has also arisen from studies into a rare form of family migraine with aura called familial hemiplegic migraine. In this form, there is weakness on one side of the body during an attack, accompanied by sickness and headache with light and sound sensitivity. The weakness may last for just a few minutes or persist for weeks, but there is always full recovery. Studies of these families suggests that the culprit genes lie on chromosome 19 and/or chromosome 1 and possibly involve the way calcium is taken up into cells. This is an element that is essential for the health of all cells, including those in the brain. In the past few years calcium uptake and chromosome 19 have also been implicated in both types of migraine, as well as in epilepsy.

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Are there any serious consequences of migraine?

For the great majority of people with migraine (more than 98 per cent), there are no serious long-term physical consequences and life expectancy is normal. However, in January 1999, a study published in the British Medical Journal showed that women of child-bearing age with migraine had an increased, but still very small risk of ischaemic stroke compared to a similar age group who did not have migraine. Risk was increased by high blood pressure, smoking and the use of the contraceptive pill. Women in this category should have their blood pressure checked regularly, consider giving up smoking, and may wish to seek advice about continued use of oral contraceptives.

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Can migraine be adequately treated?

There are now effective medicines to treat migraine which are suitable for the large majority of people. So it is a pity that many people with migraine still do not visit their doctors to seek advice and treatment. This is either because they are unaware that good treatments exist and persist in self-medication, or they believe there is a stigma associated with admitting to getting migraine attacks.

Attitudes to migraine have changed a lot in recent years and everyone with this condition should get proper medical advice. At first, the doctor may suggest non-medical approaches such as the avoidance of trigger factors and relaxation training. If this fails, subsequent steps will depend on factors such as the impact of the illness on the everyday life of the individual, attack frequency, whether they are constant or rising in frequency, and finally whether there are other medical conditions that are triggering the headaches. In especially ambiguous cases or when symptoms persist or do not respond adequately to treatment, the individual may be referred to a migraine clinic (about one in 20). A list of such clinics in the UK and a leaflet giving information about what to do before you attend is available from the Migraine Action Association and the Migraine Trust.

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What are the main types of medicines used in migraine?

The medicines available today for migraine can be grouped according to their uses into those that:

• relieve pain – e.g. non-steroidal anti-inflammatory agents (NSAIDs) and analgesics such as ibuprofen or tolfenamic acid, and products containing aspirin, paracetamol or codeine alone, or in various combinations,
• control other symptoms such as nausea – e.g. prochlorperazine, metoclopramide, buclizine, domperidone, sometimes in combination with analgesics,
• are preventive and have long-term use – e.g. some beta-blockers such as metoprolol, nadolol and timolol, as well as clonidine, pizotifen – a serotonin antagonist, and some anti-epileptics,
• offer acute relief of an attack already started, e.g. ergotamine, isometheptine, and the triptans, and
• other agents – e.g. antihistamines and minor tranquillisers which seem to benefit a few people whose migraine is food-related or who are anxious.

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Are there alternative treatments for migraine?

Many more people are now more prepared than in the past to try alternative medicines or treatments. One is a plant called feverfew, a member of the daisy family. This has been shown to have some beneficial action in a majority of people with migraine without aura. It contains an active substance called parthenolide which can block the release of a substance called serotonin, also known as 5-HT. Other people derive benefit from physiotherapy, acupuncture, hypnosis and various forms of relaxation. The place of relaxation in the control of migraine seems well established and many of these practices may well contribute to quietness and aid recovery.

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What are the effects of migraine on people’s quality of life?

For many migraineurs, in addition to the pain, distress, disruption and disability that migraine attacks cause, the unpredictability of the attacks can have more far-reaching effects on their quality of life. Although they obviously wish to avoid the personal pain and trauma of attacks, this is compounded by guilt at possibly having to cancel plans at short notice or causing problems for family, friends and colleagues. Psychological disturbance is not necessarily linked to the frequency of attacks, but to how disabling they are, how long they last, their unpredictability and their impact on the life of the individual. This fear of when the next attack may strike can result in migraineurs adopting a significantly modified lifestyle at work, at home and in their social life and can damage relationships, career prospects and the ability to enjoy life.

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What kind of general information and support is available for people with migraine and their families?

For anyone suffering from migraine, the need for complete support from their doctor, employers, work colleagues and family and friends cannot be over-emphasised. If there is a lack of understanding or a mistaken view that migraine is trivial, the problem will be all the harder to live with. Sympathy and tolerance are vital: understanding the condition, its causes and effects and the needs of the individual are very important. This may also come from the relationship with the doctor or from migraine charities and patient support groups. The addresses and telephone numbers of some of these organisations are listed at the back cover of this booklet. Many, such as the Migraine Action Association and the Migraine Trust, publish a range of useful booklets and can provide helpful support and information. These cover many aspects of migraine, from general information to more specific guidance on issues such as migraine and the menopause, migraine in children, and keeping a migraine diary.

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