Migraine (severe headache)

Key points

1. About one in 10 people get migraines, with more women affected than men.
2. Migraines usually first occur between 10 and 30 years of age, and may get better in middle age.
3. If you are over 50 and a severe headache occurs for the first time, see your doctor.
4. Some people have a ‘migraine aura’ before the headache begins. This could be problems with your eyes (eg, seeing zig-zag lines), dizziness or pins and needles.
5. Treatment includes lifestyle changes and using medications for relief or, in some cases, to stop a migraine from happening.
6. See your doctor if treatments are not helping or if your migraines are happening more often or getting more severe.

What causes migraine?

The exact cause of migraines is still being studied but it could be partly genetic. People with migraines often find that others in their wider family have also had migraines.

What are the triggers for migraines? 

Triggers are the things that can cause migraine. Learning what triggers your migraine and finding ways to avoid or reduce these triggers is an important part of managing your migraine.

There are many different trigger factors that may start a migraine. Keeping a diary about when you get migraines and what may have started them is a useful way to work out your triggers.

Some foods such as chocolate, brown vinegar, cheese, citrus fruits, onions and MSG (monosodium glutamate) can be a trigger for some people. Food may be considered a trigger for migraine if an attack occurs within 6 hours of eating and you don't get migraines when you don't eat that food. 

Women and migraine

Female hormone fluctuations, the oral contraceptive, menopause and pregnancy may affect migraine.

• Migraine often happens around menstruation or at other regular times of the menstrual cycle (menstrual migraine).
• Many women find migraine disappears during pregnancy.
• Oral contraceptives containing oestrogen may change migraine frequency.
• Some women get migraines during menopause.

Non-migraine headache is also a common feature of pre-menstrual syndrome.

What are the symptoms of migraine?

Some people notice a migraine aura before the headache starts, and this can alert them that a migraine is coming. The symptoms of an aura may be different for everyone. Examples include:

• feeling tired, fatigue
• repetitive yawning
• restless or irritability
• anxiety
• food cravings, feeling hungry or thirsty
• difficulty concentrating
• sensitivity to light or sound
• problems with vision (seeing zig-zag lines)
• dizziness 
• tingling or numbing feelings in your body.

When the headache starts, it is a strong pain, usually on one side of your head. You may feel sick or vomit, get tingling around your mouth, have trouble talking or feel dizzy or weak.

How are migraines diagnosed?

The following are common with migraines and don't usually happen during a tension headache:

• aura
• headache on one side
• high sensitivity to light and noise
• nausea or vomiting.

These symptoms are very particular to migraines. Your doctor may do other tests if they are concerned the headaches may have another cause. However, migraines are not a sign of a stroke or a tumour, and your doctor will reassure you of this.

How are migraines treated?

Migraine can't be cured but you can relieve symptoms during an attack and prevent further attacks. Migraines vary between people and so does the treatment. Some things are commonly known to trigger migraines in some people. Avoiding these triggers can reduce how often and how severe your migraines are. 

Medicines

Medicines for the treatment of migraines fall into a few categories:

• Pain-relieving medicines, which are taken during the migraine attack to help stop symptoms that have already begun.
• Medicines for nausea (feeling sick) or vomiting (being sick).
• Medicines to prevent migraines, which are taken regularly to reduce how often and how severe migraine are.

The type of medicine you need depends on many things, including how often, severe and disabling your migraines are. Your doctor will advise you on the best treatment based on your symptoms and experience. The usual approach has 3 steps:

• Step 1: Pain relievers such as paracetamol and NSAIDs such as ibuprofen, diclofenac, naproxen.
• Step 2: Triptans.
• Step 3: Combination treatment with a triptan and an NSAID.

Anti-sickness medicines may be used at any step to relieve nausea associated with migraine and can help the absorption of pain-relieving medicines (if taken before or at the same time). Examples of anti-sickness medicines include metoclopramide, domperidone and prochlorperazine. Read more in-depth about medicines for migraine.

Caution – medication overuse headache

Medication overuse (or rebound) headache can happen from using too many pain relievers to treat headaches and migraines. It may feel like a tension-type headache or migraine-like attack.

Headaches often improve within 2 to 4 weeks of withdrawal of the overused medicine but can feel worse before improvement is seen. To avoid this:

• triptans should not be used for more than 10 days per month
• paracetamol and NSAIDs should not be taken for headache on more than 15 days per month.

What self-care can I do when I have a migraine?

Here are some simple measures that you can try to ease your symptoms.

• Lie in a quiet, cool, dark room.
• Avoid moving around too much.
• Put a cold flannel on your neck or forehead.
• Avoid drinking tea, coffee or orange juice.
• Try to relax by listening to music or through meditation.
• Don't read, watch TV or drive.
• Sleep through the attack.

How can I prevent migraines?

Not all migraines have an obvious trigger, but sudden changes in daily routine can be a trigger. This includes a missed meal, a late night or doing more strenuous exercise than you normally do.

To reduce your chance of getting a migraine you may find it helpful to make the following lifestyle changes:

• have regular meals
• make sure you drink enough water/fluid to stay hydrated
• do relaxation and exercises for stress (eg, meditation and yoga)
• aim for a regular sleep pattern and ensure you have enough sleep (but avoid long sleep-ins)
• avoid sudden strenuous exercise
• limit caffeine intake, such as no more than 2 cups of coffee a day.

Addressing other conditions that may be causing your migraines is also important. These include stress, anxiety, depression, hormonal changes and head or neck trauma. If these are problems, talk to your doctor. They may be able to help you work out how to manage these things.

Cognitive behavioural therapy (CBT), coping strategies and relaxation training are helpful for many people with migraine especially if they are associated with anxiety or stress. 

Preventive medicines

Preventive medicines are taken daily to prevent migraines from happening. They are not used to treat a migraine attack. Medicines to prevent migraines are an option if you:

• have at least 2 migraine attacks a month
• have significant disability despite suitable treatment for migraine attacks
• cannot take suitable treatment for migraine attacks.

Preventative medicines aim to reduce how long and severe your migraines are and how often you get them. They can help to reduce disruption to your daily activities that happens with migraine, and reduce overuse of pain relief medications. They must be taken every day to work well. They may take a few weeks to start working. Read more about preventive medicines for migraine.

What happens if a migraine is not treated?

You will keep having headaches but will not come to any harm. Migraines are likely to happen again and again.

Support

Migraine Down Under Blog with New Zealand-specific support and resources.

Learn more

The following links provide further information about migraine. Be aware that websites from other countries may have information that differs from New Zealand recommendations.

Migraine Neurological Foundation, NZ
A patient's guide to Migraine Dr Jon Simcock, Medical Adviser, Neurological Foundation, NZ
Living with migraine The Migraine Trust, UK
Range of topics American Migraine Foundation

References

1. Cafergot tablets to be prohibited 1 May 2020 Medsafe, NZ, 2019
2. The role of triptans in the treatment of migraine in adults BPAC, Z, 2014
3. Medication-overuse headache BPAC, NZ, 2008

Reviewed by

	Angela is a pharmacist in the Quality Use of Medicines Team at Waitematā District Health Board. She has experience in hospital pharmacy in New Zealand and in the UK, and was previously a medical writer for Elsevier in The Netherlands. Angela is interested in promoting the safe use of medicines, particularly high-risk medicines.