A. General Considerations

Migraine is one of the most common of all human diseases. It is a chronic, often inherited disease that makes your entire nervous system more sensitive to stimuli. The disease causes headaches, but also many other symptoms. Other symptoms such as feeling sick (nausea) or being sick (vomiting) are also common. Between migraine attacks, the symptoms go completely. Its effect on daily function varies greatly. It can transform from one set of symptoms to another during a lifetime.

Migraine can affect either episodic or chronic. There are three main types of migraine (migraine without aura, migraine with aura and migraine aura without headache). Migraine occurs in about 1 in 7 people.

Episodic migraines are defined as headaches occurring less than 15 days per month.

Chronic migraines are defined as headache occurring on 15 or more days per month for more than three months with at least eight days having migraine features. About 8% of people with migraine have chronic migraine. Chronic migraine is a disabling neurological condition that affects 2% of the general population.

Migraines can be triggered by many different things, including stress, physical exertion, fatigue, lack of sleep, hunger, odors, chemicals, and certain medications and substances. In females, migraines can be triggered by the normal decrease in estrogen levels that occurs before the menstrual period each month.

B. SYMPTOMS OF MIGRAINE

The headache is usually on one side of the head, typically at the front or side. Sometimes it is on both sides of the head. Sometimes it starts on one side and then spreads all over the head. The pain is moderate or severe and is often described as throbbing or pulsating. Movements of the head may make it worse. It often begins in the morning but may begin at any time of the day or night. Typically, it gradually becomes worse and peaks after 2-12 hours, then gradually eases off. However, it can last from 4 to 72 hours.

Other migraine symptoms that are common:

• Feeling sick (nausea).
• Being sick (vomiting).
• Not liking bright lights or loud noises, so that you may just want to lie in a dark room.

Other symptoms that sometimes occur:

• Being off food.
• Blurred vision.
• Poor concentration.
• Stuffy nose.
• Tummy (abdominal) pain.
• Passing lots of urine.
• Going pale.
• Scalp tenderness.
• Sensations of heat or cold.

C. Migraine management covers the different drugs used for acute attacks.

General measures include identification and avoidance of trigger factors. A migraine diary is often helpful for this. Other therapies include relaxation therapy, biofeedback, cognitive or behavioural therapy, psychotherapy, acupuncture and hypnosis. All have their advocates but good evidence of efficacy is lacking.

Migraine prophylaxis may be used if attacks are happening at least twice a month or tend to be severe or prolonged. If medication for acute attacks is required once or twice a week then prophylaxis should certainly be considered.

For episodic migraine, approved drugs for migraine prophylaxis are effective but adverse effects may restrict their use.

C.1. Preventive – Lifestyle

There are a number of ways to reduce the triggers that set off your symptoms. A simple approach is to minimize variations in your daily routine. Here is an acronym SEEDS to remember possible lifestyle changes..

C.2. Preventive – Diet

In general, food triggers fall into three main categories:

• Byproducts of food aging and fermentation: red wine, aged cheeses, yeast and yogurt;
• Foods with ingredients that affect our nervous system: coffee, chocolate, MSG, aspartame, citrus fruits and the nitrates used as preservatives in many prepackaged foods, particularly cured meats;
• Foods you have mild or silent allergies or sensitivities to: such as milk, corn, soy and wheat (gluten). Gluten sensitivity is particularly a common issue for those with migraine;

Blood tests for food allergies may or may not identify a food trigger. The use of an elimination diet – a careful removal of specific foods over a specific time period, followed by a reintroduction of the food – is the most reliable method to identify dietary migraine triggers.

Simple rules: Buy fresh foods only – No deli or cheese

C.3. Micronutrient Supplements

Magnesium: 200-1200 mg daily (common: 400- 500mg) Higher doses are more effective. Major side effect – diarrhea (lower risk by dividing dose over day). Can lower blood pressure and interact with some heart medications, diuretic, antibiotics (aminoglycosides) and muscle relaxants.

Vitamin B2 (riboflavin): 500 mg daily.
Will turn urine bright yellow. Can interact with anticholinergics, phenobarbital and probenecid. Found in milk, meat, eggs, nuts, enriched flour and green vegetables.

Coenzyme Q10: up to 100 mg three times daily.
Side effects can include rash, poor sleep, headache, dizziness, light sensitivity, and more. May interact with blood pressure medicines (especially timolol), blood thinners, cholesterol medicines, some cancer drugs and tricyclic antidepressants. Avoid during pregnancy and breastfeeding.

Melatonin: 3 mg at bedtime
Can reduce the effectiveness of certain medication (blood pressure drugs, seizure-prevention drugs, antidepressants and birth control medications and increase blood sugar levels.

Feverfew: 6.25 mg three times daily.
Side effects include abdominal pain, diarrhea, mouth ulcers, nausea, vomiting. Avoid during pregnancy (risk of miscarriage), combining with aspirin (increases bleeding). Watch for ragweed, chamomile or yarrow cross-sensitivity. Must taper off.

Butterbur (Petasites hybridus):50-75 mg twice daily.
Recent studies have raised serious concerns about liver toxicity. To reduce this risk, use only PA-free butterbur. Avoid butterbur for children, pregnant or nursing women or people with kidney, heart or liver disease. Side effects: belching, headache, itchy eyes, asthma, fatigue. Do not combine with phenytoin, rifampin, rifabutin (Mycobutin) and carbamazepine, phenobarbital.

Ginger: Use capsules, tea or in water. Be careful not to combine ginger supplements with blood thinners because of potential drug interactions. Useful to reduce nausea.

5-HTP: 300-500 mg, taken either once daily or in divided doses Avoid in pregnancy, liver or kidney disease. Interactions with mood-elevating medications, carbidopa, trip-tans, barbiturates, chemotherapy drugs, antibiotics, tramadol.

C.4 Treatment Plan (under medical supervision) – ask your doctor for a recommended treatment plan.

• Set realistic goals: to reduce the intensity and frequency of symptoms
• Track symptoms: daily recording of symptom intensity, duration, affect on activities and triggers improves treatment planning. Use calendar or online apps to share with your doctor.
• Expect trying more than one treatment
• Don’t be afraid to try these medicines.
• Your best preventive medicine will depend on other health conditions (e.g., blood pressure, sleep, mood issues)
• Many medicines need be taken for 4-12 weeks to know if they work or not
• Most preventive medications need to be taken daily

C.5. Rescue Medicines (These are usually used at the onset of symptoms)

Comfort measures: ice packs, menthol creams, massage;

Natural Products: caffeine, ginger;

Pain relievers: acetaminophen, aspirin, ibuprofen, naproxen, flurbiprofen, diclofenac; sodium, tolfenamic acid, ketoprofen, indomethacin, piroxicam, celecoxib;

Triptans: sumatriptan, rizatriptan, zolmitriptan, eletriptan, frovatriptan, almotriptan;

Anti-nausea medicines: metoclopramide, domperidone, promethazine, trimethobenzamide, ondansetron, chlorpromazine, dimenhydrinate;

Ergot alkaloids: ergotamine, dihydroergotamine;
CGRP Blockers: ubrogepant, rimegepant, lasmiditan.

D. Associated conditions

People with chronic migraine have a significantly higher frequency of some comorbid conditions, including chronic pain, psychiatric disorders, respiratory illness, and some vascular risk factors.

E. Complications

Migraine is associated with an increased risk of depression, bipolar disorder, generalised anxiety disorder and panic disorder.

Status migrainosus – defined as a debilitating migraine that lasts for more than 72 hours.

Migrainous infarction – occurs when a cerebral infarction happens during the course of a typical attack of migraine with aura. The aura lasts over an hour and neuro-imaging shows ischaemic infarction.

Migraine is associated with increased risk of both ischaemic and haemorrhagic stroke.

F. What to do?

If You Have…

• Headaches with light or sound sensitivity,
• Headaches with nausea or vomiting,
• Temporary visual disturbances, temporary loss of vision or double vision;
• Pressure or pain across your cheeks, behind your eyes or across your forehead,
• A feeling your ears are blocked or under pressure, or have water in them,
• Very sensitive ears; bothered by wind,
• Ringing in the ears, Trouble hearing,
• Motion intolerance like difficulty reading in a car or tolerating an amusement ride,
• Dizziness or unsteadiness,
• Smell or taste sensitivity or irregularities,
• Nasal congestion or runny nose,
• Difficulty understanding what is said,
• Slurred speech,
• Jerky (unusual / uncontrollable) eye movements,
• Dental or TMJ pain,
• Family history of migraine…

Contact you Family Doctor and / or the neurologist to have a positive or differential diagnostic. There are other causes of these symptoms (such as a stroke) and these need to be ruled out before a migraine specific type can be diagnosed and a proper treatment approach recommended.

Where to ask for a physician consultation or advice: