Frequently asked questions about migraine

Here are the five most frequently asked questions that our Information and Advocacy Services have received recently

When I experience a migraine I usually feel really depressed at the beginning. I also get a headache, stomach ache and feel sick. These can last up to 48 hours; and I feel exhausted afterwards. Is this normal for a migraine?

There is no ‘typical’ migraine as everyone experiences migraine in their own way. However, a migraine attack can usually be divided into four or five stages.

The first stage is known as the premonitory or prodromal stage and usually marks the beginning of the attack. It can last from a few to several hours. During this stage people can feel a range of physical and mental changes including mood changes (from irritability and depression to euphoria), tiredness, craving certain foods and yawning.

The next stage is aura which around a third of people with migraine go through. This is followed by the headache or main attack stage. It involves head pain which can be very severe, the headache is typically throbbing and on one side of the head. People may also experience sickness and vomiting. This stage can last from four hours to three days.

The next stage is resolution – most attacks slowly fade away, but some stop suddenly. Sleep can help.

The final stage is known as the recovery or postdrome stage. It may best be described as a ‘hangover’ type feeling. It can take days to disappear and often mirrors symptoms from the premonitory stage.

I worry about the side effects I get with all the preventive medicines I have tried. Is there anything else I can take?

Preventive medicines can be very effective to control frequent, troublesome migraine. They work by reducing the severity and/or frequency of migraine symptoms and may need to be taken for several months to derive adequate benefit. However, many people find that they develop intolerable side effects (with or without benefit) which can become problematic. The goal of preventive treatment is to improve one’s quality of life and ability to function; it is not desirable to swap one set of disabling symptoms for another and as such potential side effects need to be to be balanced carefully. All medicines have the potential to produce side effects but individuals may develop these to varying degrees. Sometimes they are milder and more tolerable and resolve over a period of slow dose escalation. With all treatments, a daily headache diary should be maintained.

These are some of the non-drug options available:

  1. Supplements – Riboflavin (400mg per day), Coenzyme Q10 (400mg per day) and Magnesium (600mg/day) may be effective in reducing migraine frequency and intensity. These supplements are believed to play an important role in the production of energy in cells and a deficit of these nutrients has been suggested to have a role in generating migraine. However the reported studies were small and larger studies are needed to provide stronger evidence. There are minimal/milder side effects associated with these.
  2. Acupuncture – A recent review of the evidence (2016), concluded that adding acupuncture to acute treatments may reduce the frequency of headaches, though the effect was small.
  3. Single-pulse transcranial magnetic stimulation (sTMS) is a safe, non invasive device treatment option. It involves placing the sTMS device against the back of the head for less than a second to deliver a very brief pre-set magnetic pulse. sTMS is designed for self-administration at home and with regular treatment, it can provide acute and preventive migraine treatment with minimal side effects. There is a rental cost involved and limited NHS cover at present. It needs to be prescribed by a headache specialist doctor. Typically, the headache doctor will recommend a three-month treatment period initially, supervised by the headache clinic, to determine the effectiveness and duration required.

Alongside migraine, I am also having daily headaches and the medication I am taking isn’t working. What can I do?

Medication overuse headache (MOH) is headache that results from the frequent use of painkillers or acute relief medicines. Acute medicines, especially when taken early, can be very effective to treat and abort migraine attacks. People who are prone to headaches can develop MOH, generally those with migraine or a family history of migraine. It is not typically seen in people taking painkillers for reasons other than headaches, such as arthritis or back pain.

MOH presents as a vicious cycle and initially when the medication is stopped, worsenings occur. These will then be relieved by taking more painkillers, usually to enable people to return to function; and the cycle continues. The overuse of acute migraine drugs can also stop preventive migraine medications from working and long-term use of acute drugs may be damaging to the liver and kidneys. Treatment for this condition is stopping the medication. When stopping the overused medicines, withdrawal symptoms are common (e.g. nausea, sleep disturbance, worsened headache, agitation). The withdrawal process is very individualised and based on the types of drugs you are taking. Some people will stop the drugs immediately, others may taper them and others may even need to be hospitalised for detoxification under medical supervision. Keeping well hydrated and managing the withdrawal symptoms with your doctor’s plan and supervision is crucial. Once the withdrawal is complete, it is possible to use painkillers again, by restricting the number of days used (Table 1). The underlying migraine will also need to be addressed, for example by taking a preventive medicine for a period, to control migraine symptoms and to limit the need for painkillers.

  1. Table 1: MOH risk by medicine (criteria of the international headache society)
Medicine MOH risk

(taken ≥3months)

Simple analgesia e.g. Paracetamol, Ibuprofen, Aspirin ≥15 days per month
Triptans e.g. Sumatriptan, Zolmitriptan, Frovatriptan ≥10 days per month
Codeine and Opiods e.g. Tramadol,Dihydrocodeine ≥10 days per month
Combined painkillers e.g. Solpadeine, Cocodamol ≥10 days per month
Ergotamine ≥10 days per month

 

My friend has migraine and is struggling at work, but their employer isn’t being very helpful. Is migraine considered a disability at work? Does my friend have any rights at work?

In regards to employment, people with migraine are covered under the Equality Act 2010 if they are considered disabled. The Act defines disability as having a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on your ability to do normal daily activities. This will apply to people with migraine depending on how frequent their migraine attacks are and how they impact on the individual. Your friend’s GP/neurologist or occupational health practitioner (OH) can write about the impact of migraine on the person and whether they’re likely to be covered under the Act and recommend suitable adjustments for you.

According to the Act an employer is obliged to be flexible and provide reasonable adjustments to people who have disability at work. Reasonable adjustments can be changes to the work environment or to work practices and the way things are done which allow a person with disability to perform their job without being put at a substantial disadvantage in comparison with non-disabled people. An employer is only expected to implement what is reasonable; this is determined by factors such as size of the employer, job role, size of workforce, financial and logistical implication.

If your friend’s migraine is impacting on them in work, they can ask their employer to make workplace adjustments to help them cope better. Migraine is usually triggered by a combination of many factors so it may be helpful to consider a range of adjustments that will make your workplace migraine friendly. Examples of reasonable adjustments include flexi-time, redeployment, reduced workload, frequent breaks, disregarding sickness absence, moving her work station to access more natural light, time off for hospital appointment, changing roles, working back shortfall of hours etc.

There is more information about managing migraine at work on our website. We also have our ‘Migraine: help at work toolkit’ to provide employees and employers information on how to manage migraine at work.

Is there a risk of stroke during a migraine attack?

Understandably, some people are afraid that their migraine is a symptom of a stroke and others worry that they are more at risk of a stroke during a migraine attack. There is little evidence to suggest that a stroke is more likely to occur during a migraine attack than at another time. Migraine is common and in some people, migraine and stroke appear together but the nature of the causal relationship, if any, is difficult to establish.

Migrainous infarction is the term given to an ischaemic stroke occurring during a migraine attack. In this condition, aura symptoms are prolonged and ischaemic stroke is confirmed by being shown on a brain scan. However, research suggests that such a stroke would be independent of the migraine attack. It is also possible for a person to have a stroke but for this to have been mistaken for a migraine attack. The migraine aura can mimic transient ischaemic attacks (TIAs). Furthermore in stroke, headache similar to migraine may occur.

Brain Lesions: While there is evidence that brain scans of people with migraine will sometimes detect changes in the form of white matter lesions, a review of the literature on migraine and structural changes in the brain from 2013, indicates that these lesions are generally not associated with any neurological problems and don’t indicate any increased risk of cognitive (thinking) decline. Owing to the low risk, many experts say migraine patients who have regular normal physical examinations do not need to get regular brain scans. In fact managing the pain and associated symptoms of migraine attacks should be the treatment priority. Maintaining a migraine diary of symptoms (frequency, duration, severity) over a period, will be beneficial in getting the diagnosis and treatment right.

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