Migraine (severe headache)

Some people experience a ‘migraine aura’ before the headache begins, such as visual disturbances (e.g. zig-zag lines), dizziness, and pins and needles.

Treatment includes lifestyle measures and using medications for relief or in some cases as a preventive measure. See your doctor if treatments are not helping or if migraines are increasing in frequency or severity.

What causes migraine

The exact cause of migraines is still being studied but there seems to be a genetic component. People with migraines will often find that others in their wider family have also had migraines.

Migraine triggers

Trigger factors which may help start a migraine are many and varied. Try keeping a diary about when you get migraines and what may have set them off. Recognising your own trigger factors will help you to avoid these where possible.

Triggers can include one or more of the following:

• stress, anxiety or depression
• tiredness
• hunger (missing a meal or not having regular meals)
• exercise (especially heavy exercise when unfit)
• hormonal changes in women (e.g. taking contraceptive pill, having your period)
• some foods (e.g. chocolate, brown vinegar, cheese, citrus fruits, onions, MSG [monosodium glutamate])
• alcohol (especially red wine)
• changes in the weather or temperature
• strong smells, loud noise, bright or flickering lights
• some medicines used for other conditions (e.g. some angina medicines, contraceptive pill, hormone therapy)
• overuse of pain-relieving medicines (can cause ‘rebound’ headache).

Who gets migraine?

About one in 10 people get migraines, with more women being affected than men. Migraines usually first occur between 10 and 30 years of age, and may get better in middle age. If severe headache occurs for the first time in someone over 50 years, consult a doctor.

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.

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

Symptoms

Some people experience a ‘migraine aura’ before the headache starts, and this can alert them to the fact a migraine is coming. With an aura, the first sign is often a strange feeling of tiredness, being far away or having slight changes in what you see. You may feel hungry, thirsty or start yawning. You may see shimmering or flashing lights, zig-zag lines, or things will be fuzzy or blurred. This normally starts in the middle of your eye and moves to the outside.

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.

Diagnosis

The following features are common in migraines but are not normally present during 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 worried that 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.

Treatment

Migraine can't be cured but your doctor will work with you to relieve symptoms during an attack and prevent further attacks. Certain factors are commonly known to trigger migraines in some people. Management of these factors can reduce the frequency and severity of migraine attacks.

Medications

Medications for the treatment of migraines fall into two categories:

• Pain-relieving medications: are taken during migraine attacks to help stop symptoms that have already begun.
• Preventative medications: are taken regularly to reduce how often and how severe migraine are.

The type of medication you need depends on a number of factors, including how frequent, severe and disabling your migraines. Your doctor will advise you on the best course of treatment based on your particular migraine experience.

Pain-relieving medications

These medications help reduce pain and other symptoms associated with migraine. Some of these medications have been specifically developed to treat migraines, others were originally used to treat other disorders, but have been found to be effective for the treatment of migraine.

• Pain relievers (analgesics) - Most effective for migraine treatment when taken early in an attack, before severe pain and nausea has set in. If available, use liquid form as this is more rapidly absorbed. Pain relievers may not be effective once severe migraine has set in. Examples include: paracetamol, ibuprofen, aspirin and codeine.
• Anti-sickness (anti-emetics) - Relieve nausea associated with migraine and can help absorption of pain relieving medication (if taken before or at the same time as analgesics). Examples include: metoclopramide and domperidone. Seek medical advice before taking anti-emetics as they are not suitable for some people.
• Specific anti-migraine medications 
  • The triptans - Relieve pain by narrowing blood vessels in the head and blocking pain sensing nerves in the face. There are a variety of different triptans; however, sumatriptan is the only funded triptan in New Zealand. Take only as prescribed by your doctor.
  • Ergotamine - Useful in people who have recurring migraines that cannot be managed by other medications. Carries risk of toxicity and can interact with other medications. Available in New Zealand combined with caffeine as Cafergot. Use only as prescribed by your doctor.

Using migraine treatments more than twice a week can cause overuse headache and should be avoided.

Preventative medications

If you have frequent migraines - perhaps more than three times per month - there are preventative (prophylactic) drugs that can help reduce how often migraines occur. These medications need to be taken regularly, all of the time, they may take a few weeks to show any effect and need to be prescribed by your doctor.

The drugs used for prophylactic migraine prevention have for a long time had other uses as well, such as for the treatment of high blood pressure, epilepsy and depression - being offered one of these as a treatment option for migraine does not mean you have any of these other health problems.

What happens if a migraine is not treated?

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

Self care

Migraines can be painful and debilitating. When you first feel a migraine headache coming on:

• Take simple pain relief or any other migraine medication your doctor has given you, as soon as you can to prevent the headache setting in.
• Try to lie down and relax in a dark room.
• Putting a cold pack on your neck or forehead may help.

Prevention

Not all migraines have an obvious trigger, but sudden changes in daily routine, such as a missed meal, a late night or doing more strenuous exercise than you normally do are known to be common triggers. To reduce your chance of getting a migraine you may find it helpful to:

• have regular meals
• make sure you drink enough water/fluid to stay hydrated
• do relaxation and exercises for stress (e.g. meditation and yoga)
• aim for a regular sleep pattern and ensure you have enough sleep (but avoid long 'sleep-ins')
• avoid unaccustomed strenuous exercise
• massage, treatment for neck problems, improving posture or acupuncture may help.

Several factors are known to increase the likelihood of migraine in some people. These include stress, anxiety, depression, hormonal changes and head or neck trauma. If these are a concern for you, talk to your doctor. They may be able to help you work out strategies to manage these factors.

Learn more

Neurological Foundation NZ
A patient's guide to Migraine Dr Jon Simcock, Medical Adviser - Neurological Foundation of NZ
Range of topics American Migraine Foundation