Migraine

• What is migraine?
• Statistics on migraine
• Risk factors for migraine
• Progression of migraine
• Symptoms of migraine
• Clinical examination of migraine
• How is migraine diagnosed?
• Prognosis of migraine
• How is migraine treated?
• Migraine prevention
• References

What is migraine?

Migraine is a recurring type of primary headache. It is characterised by unilateral pain (pain which occurs on only one side of the body), which is typically moderate-severe and has a pulsating quality. Migraine may occur with or without aura, which refers to focal neurological symptoms (neurological disturbances affecting a distinct area of the body, such as the eyes) which precede the migraine headache. They may be categorised in terms of the frequency with which they are experienced as:

• Intermittent or episodic- when headaches occur on
• Chronic- when headaches occur on ≥15 days per month.

Migraine is the most common type of severe, recurring headache. However, it often goes undiagnosed, as the individuals who experience them fail to consult a health professional to discuss their migraines and obtain a prescription for medicine. Instead they self-medicate using medicines available over the counter.

Migraine headaches can be further categorised as:

• Migraine with aura;
• Migraine without aura;
• Migraine sine headache (aura without headache);
• Rare type migraine, including:
  • Basilar migraine characterised by accompanying neurological symptoms;
  • Familiar hemiplegic migraine, characterised by migraine with aura and with weakness and/or temporary paralysis on one side of the body.

The pathophysiology of migraine is not well understood; however, migraine headaches are understood to arise as a result of neurological (nervous system) rather than vascular (blood vessel) pathologies. The visual symptoms (aura) many patients experience with a migraine arises from vasospasm (spasms of the blood vessels) due to neural inhibition of the nervous system. However, it is not well understood how these changes result in migraine or the way in which medicines commonly used to treat migraine work.

Statistics on migraine

The World Health Organisation ranks migraine 19^thamongst the disability-causing diseases worldwide. It is a common and under diagnosed syndrome which effects up to 12% of the population. Incidence and prevalence of migraine is similar around the world. Onset is typically before age 40 and often occurs during childhood or adolescence. Acute episodes of migraine occur most commonly between 10 and 40 years of age.

The frequency of acute attacks and type of migraines differs between individuals. A study of people presenting to Australian doctors with migraine reported that the majority (77%) experience migraines ≤1 per month, 11% experienced an average of two migraines per month and 12% experienced at least three migraines per month. Individuals experiencing acute episodes of migraine >15 days per month may be diagnosed with chronic migraine, a separate condition associated with over use of migraine medications.

Two-thirds of migraine sufferers experience common migraine (without aura); the remaining one-third experience classic migraine (with aura). Lifetime prevalence of migraine with aura is 5% compared to 8% for migraine without aura. Women have a three-fold increased risk of experiencing migraine compared to men; some 18% of women experience migraines compared to 6% of men. Women are twice as likely as men to experience migraine with aura and seven times more likely to experience migraine without aura. However, the pattern is reversed in adolescence, at which time boys are more likely to experience migraine compared to girls.

Risk factors for migraine

Hemiplegic migraine is a rare type of migraine associated with genetic abnormalities which mean that the condition is hereditary. Other types of migraine also appear to have a hereditary component. Food is often thought to trigger migraine; however, the types of food triggers differ between individuals.

Progression of migraine

Migraine headaches occur intermittently; however, different people experience migraines more or less frequently.

Migraine phases

There are several phases of a migraine headache: prodrome, aura, headache and postdrome; however, individuals may not experience all phases.

Prodrome

The prodrome phase occurs first and is characterised by the individual’s experience of premonitory migraine symptoms. Prodrome is experienced by approximately 30% of migraine sufferers, and premonitory symptoms typically persist for 7–10 hours (however, considerable proportions of people experience very short or very long prodrome duration). Tiredness, mood changes, gastrointestinal problems or a combination of the three are the most common symptoms of the prodrome phase.

Between people who do and do not experience prodrome, there are marked differences in terms of migraine triggers, presence of aura and its timing in relationship to headache and experience of postdrome. Individuals who experience prodrome are more likely to respond to triggers including alcohol, hormones, odours, stress, weather changes, and not eating. The duration of aura in individuals who experience prodrome is longer than in those who do not, as is the duration between aura and headache. Headache duration, duration of peak pain and duration of postdrome are also extended in individuals who experience prodrome. They are also more likely to experience symptoms such as nausea and teary eyes than individuals who do not experience prodrome.

Aura

Aura, the experience of focal neurological disturbance, is the second phase of migraine. It affects approximately one-third of individuals who experience migraine and typically precedes headache symptoms (phase three) by ≤1 hour. The most common symptoms of aura are visual disturbances including photopsia (light sensitivity) and distorted vision, which are experienced by 90% of individuals who have migraine with aura. Sensory (e.g. numbness, vertigo), motor (e.g. weakness) and cognitive (e.g. speech disturbance) symptoms may also occur in the aura phase, usually alongside visual symptoms.

Headache

The third, or headache phase of migraine is characterised by head pain which is typically moderate-severe, unilateral (one-sided) and pulsating. It is often aggravated by moderate physical exertion and accompanied by nausea, vomiting, photophobia (sensitivity to bright light) and/or phonophobia (sensitivity to loud sounds). Pain persists for 4–72 hours. The majority of migraine sufferers experience headache; however, some experience aura without headache.

Recovery/postdrome

The recovery or postdrome phase of migraine refers to symptoms experienced after the migraine headache has subsided. It is experienced by the majority of migraine sufferers, and it has been reported that 69% of females and 57% of males studied experienced the postdrome phase. Average postdrome duration was 25 hours, with 12% of individuals experiencing postdrome which persisted for > 24 hours. The majority (72%) experienced tiredness. Other commonly reported symptoms of the postdrome
include:

• Head pain (33%);
• Cognitive impairment (12%);
• Hangover (11%);
• Gastrointestinal symptoms (8%);
• Mood changes (7%); and
• Weakness (6%).

Migraine triggers

For many individuals specific triggers, particularly certain types of food but also stress, are associated with the onset of migraine headaches. However, triggers vary from person to person. Multiple triggers which lead to headaches of varying severity are common.

Menstrual migraines

In women, migraines are often more severe at the time of menstrual bleeding. Some 15% of females who experience migraine do so exclusively at the time of menstrual bleeding. In these circumstances the condition is referred to as true menstrual migraines.

Symptoms of migraine

If you experience frequent headaches be aware that migraine is substantially under diagnosed. In a US-based study 52% of respondents who met the criteria for migraine had not had their condition diagnosed by a health professional. Consulting a doctor about frequent headaches is important to ensure the condition is managed appropriately. Without proper management individuals who experience migraine may also experience secondary headache syndromes and/or medication-overuse headache. Because migraine headaches sometimes transform into other headache types, the doctor may wish to re-assess your symptoms if you have already been diagnosed with migraines.

To diagnose an individual with migraines, a doctor will ask about the nature, frequency and duration of their headaches. This helps to exclude other headache types from the diagnosis. It is particularly important for the doctor to exclude life-threatening causes of secondary headaches such as subarachnoid haemorrhage (bleeding in the brain) and meningitis (brain infection). Information about the headache characteristics also assists the doctor to differentiate migraines from other types of primary headaches when making the diagnosis. Other differential diagnoses which the doctor must consider before making a migraine diagnosis include:

• Benign intracranial hypertension;
• Infrequent episodic tension headache (with vomiting);
• Thunderclap headaches;
• Hemicranias (short lasting headaches which produce unilateral pain);
• Secondary headache syndromes (headaches which occur as a result of illness or injury); or
• Medication overuse headaches.

Diagnosis of migraine headaches is made using the International Headache Society criteria, and the diagnosis is based on an individual’s description of their headaches. To exclude other headache types the doctor will ask about comorbid conditions or other factors (e.g. medication use) which may influence the medications which can be used to treat the headache. For example, beta blockers should not be used to treat asthmatic individuals with migraines, while valproate (for example, sold as Valpro and Epilim) may be inappropriate for an individual who is attempting to lose weight.

Once a diagnosis of migraine is made, headache characteristics are used to assess the quality of the migraine headache (e.g. with or without aura) and identify factors which trigger migraines. Important clinical features which may assist the doctor in distinguishing migraines from other types of headaches or in determining the best course of management include:

• Lifetime history of headache: Including the pattern of headaches in relation to changes in lifestyle, with particular attention to psychosocial factors which may be stressors, and disability associated with headaches;
• Frequency of headache: Which may assist in determining need for prophylaxis (preventative treatment) and/or determining the medicine of choice for treatment of acute attacks;
• Pattern of onset: Aura symptoms of a migraine (when experienced) precede headache and typically develop over 5–20 minutes, and other premonitory symptoms may occur 7–10 hours before headache onset. Experiencing these symptoms makes the diagnosis of migraine more likely and also influences the course of management;
• Duration of headache: Migraine with aura headaches typically persist for 20–60 minutes, while migraine without aura may persist from 4–72 hours;
• Need for bed rest: When a migraine occurs the affected person typically needs to rest;
• Psychological health: As stress is a common trigger for migraine, while headache often accompanies depression;
• Medication use: With a particular focus on recent changes to existing medication or commencement of new medications. The doctor will also enquire about use of over-the-counter medicines to treat migraine and the frequency with which they are used. Medications which may contraindicate particular treatments will also be assessed, including:
  • Antibiotics;
  • HIV protease inhibitors;
  • Reverse transcriptase inhibitors (medications used in the treatment of HIV);
  • Antifungals;
• Use of herbal and alternative therapies;
• Premonitory symptoms: Which typically include mood changes, hyperactivity and/or fatigue, yawning, neck pain, smell dysfunction, food craving and water retention;
• Family history of migraine;
• Migraine medication effectiveness: To determine which medications have been trialled and the effectiveness of these treatments, as well as how frequently the medications are used. These enquiries can be particularly useful for identifying medication overuse headaches, which commonly develop in individuals who experience migraines.

Identifying factors which trigger migraine headaches is an important part of the diagnosis, as avoiding these triggers is a primary component of preventing migraines. However, many migraines occur without an identifiable trigger. Allodynia, that is; pain occurring in response to stimuli which do not normally provoke pain (e.g. brushing hair), may trigger acute migraine symptoms. Recurring episodes of allodynia confirm the diagnosis of migraine. Food is also a frequent trigger of migraine. Caffeinated beverages are commonly implicated; however, food triggers vary from person to person.

Hormonal changes in women which occur throughout the menstrual cycle or due to menopause may cause migraine. The doctor may ask you to keep a symptom diary, which plots menses over several months and headache symptoms occurring at different stages of the menstrual cycle. Severity and frequency of symptoms should be recorded on a daily basis. A 3-month record is usually sufficient to guide migraine management if you experience at least two migraines per month. The symptom diary is an essential tool for assessing the role of hormonal changes in triggering migraine. It is also used to establish a baseline frequency of headaches (how often headaches occur in the absence of treatment) against which the effectiveness of the treatment can be assessed.

Without aura

To be diagnosed with migraine headache (without aura) the individual must fulfil the following criteria:

• Headaches not attributable to other causes (e.g. illness or medication overuse);
• Have experienced > 5 migraine episodes, occurring on < 15 days per month, fulfilling the following criteria:
  • Duration of 4–72 hours, with or without treatment;
  • Headache pain characterised by at least two of the
    following pain traits:
    • Unilateral;
    • Pulsating;
    • Moderate or severe;
    • Aggravated by, or causing you to avoid, routine physical activity;
• At least one of the following comorbidities occur with migraine:
  • Nausea;
  • Vomiting;
  • Photophobia (light sensitivity);
  • Phonophobia (noise sensitivity).

An individual who has experienced less than five attacks in the past but fulfils all the other diagnostic criteria for migraine is likely to receive a diagnosis of “probable migraine”, rather than a definitive diagnosis. Infrequent tension-type headache is also a possible diagnosis for these individuals. Those who experience ≥ 15 headaches per month may be diagnosed with chronic migraine or medication overuse headache.

With aura

A diagnosis of migraine with aura is made in an individual who has experienced two or more episodes of migraine (as described above, without aura) following an episode of focal neurological disturbance (most typically visual disturbances). In migraine with aura, headache symptoms occur within 1 hour of focal neurological disturbances. Common visual symptoms include:

• Flickering light spots in vision (Photopsia);
• Lines of varying complexity – either zigzagging (teichopsia) or jagged (fortification spectra) lines in the visual field; and
• Distorted vision – shimmering, pixilation.

Other neurological symptoms which occur during migraine aura include:

• Sensory – paralysis, numbness and/or vertigo;
• Motor – ophthalmoplegia (paralysis of the eye muscles) and/or limb and facial weakness;
• Cognitive-speech disturbance.

Sensory changes may occur as a ‘sensory march’ in which altered sensations spread, for example, up the arm, to the shoulder and then the face. This pattern of sensory change is a strong indicator of migraine.

Visual aura may occur without migraine headache symptoms. Individuals who experience aura but not headache will probably be diagnosed with aura with non-migraine headache. Those who experience visual symptoms affecting only one eye during migraine attacks may be diagnosed with retinal migraine.

Acute presentations

During an acute attack, individuals with migraine may present to an emergency department if simple pain killers fail to relieve their symptoms. By this stage they are usually tired due to lack of sleep, dehydrated due to vomiting and may also be incapacitated by pain.

Chronic migraine/medication-overuse headache

Headaches occurring secondary to overuse of migraine relief medications, known as chronic migraine or medication overuse headache, are common. If you use medications to treat migraine attacks on ≥10 days per month it is likely that medication overuse headaches will occur. If you experience worsening of migraines and require increased doses of medication to relieve your symptoms it is also likely that you have developed medication overuse headaches. It is important to consult a doctor to discuss treatment options urgently, as continuing to treat migraines with the same medication is likely to make the headaches worse.

Clinical examination of migraine

When diagnosing migraine headaches the doctor often also conducts a physical examination to check for symptoms of secondary conditions which may cause the headaches. Examination usually includes:

• Blood pressure;
• Eye examination;
• Temporal arteries (primary artery of the brain);
• Temporomandibular joints (the jointwhich forms the jaw);
• Neck.

How is migraine diagnosed?

Tests are not necessary to diagnose migraine. The doctor will only conduct tests if there is a possibility that headaches result from another cause.

Prognosis of migraine

Migraine cannot be cured. However, some 80% of migraine without aura cases are transient and resolve spontaneously within 15 years. Prophylactic medications and avoiding triggers (such as caffeine and stress) can prevent or reduce the frequency of migraines or increase the effectiveness of treatment when migraines occur. However, only 8% of individuals affected by migraine use prophylaxis at any given time and only 15% do so in their lifetime.

Recent advances have made treatment more effective, however many people fail to treat their condition and suffer unnecessarily from migraine associated pain. While the condition is not life threatening, it causes significantly disruption and disability. For example, a US study reported that 24% of individuals with migraine had been absent from work due to migraine on at least 1 day in the 3 months prior to the study and 45% had experience reduced productivity due to migraine for at least 1 day in the period.

Migraine with aura

Individuals who experience migraine with aura have a 1.2 times increased risk of all-cause mortality and a 1.3 times increased risk of mortality from cardiovascular disease. The risk of coronary heart disease is increased 1.3 times and the risk of stroke is 1.4 times more likely in migraine with aura patients compared to those who do not experience migraine or who experience migraine without aura. Females who experience migraine with aura also have an increased risk of non-cardiovascular mortality.

How is migraine treated?

Migraine management is a long-term process which requires cooperation between migraine sufferer and their doctor. The majority of individuals with migraine go undiagnosed and some 57% use only over-the-counter medicines to treat their symptoms which may result in inadequate symptom relief or medication overuse headaches. A good relationship with your doctor is an essential component of effective migraine management, which has numerous components:

• Education;
• Lifestyle and dietary modifications to ensure migraine triggers are avoided;
• Prophylactic medications;
• Treatment of acute migraine episodes;
• Avoiding medication overuse;
• Referral.

The doctor will work with you to develop an individual management plan. Where migraine triggers are identifiable, strategies for avoiding the triggers should be incorporated into the management plan. The frequency and characteristics (particularly the experience of vomiting) of headache symptoms should be considered when determining the most appropriate medications, as should your track record using medications for migraine management (e.g. which medicines were and were not effective). Your financial situation may also be relevant as the use of some medications is limited due to cost.

Education

Education regarding the aims of treatment and your expectations is vital to devising an effective management plan. Be aware that migraine is not curable and that treatment aims to reduce the duration and severity of acute migraine and ideally to abort an acute migraine before it reaches its peak and causes disability. Your role in managing the condition is particularly important as effective management depends on monitoring symptoms and their response to treatment (e.g. in a diary), and instituting appropriate and early treatment when migraine symptoms occur. While early treatment is essential for optimising pain relief, you must also be aware of the risks associated with overuse of medication. Talk to your doctor about medication overuse headache and precautions you need to take (e.g. ensuring you use prophylactic medicationssmokingand oral contraceptive use on migraine with your doctor.

Lifestyle and dietary modifications

Lifestyle and dietary modifications are a particularly important component of the management plan if you experience migraines in response to food or psychological triggers.

See Prevention for a full discussion of this topic.

Prophylactic medications and natural remedies

Prophylactic medications and natural remedies are also an important consideration in managing migraines. Numerous medications and several natural remedies have demonstrated efficacy in migraine prophylaxis.

See Prevention for a full discussion of this topic.

Acute treatment

Acute episodes of migraine may be treated with simple analgesics (e.g. paracetamol), potent analgesics (e.g. ergotamines) or a combination of the two. Opioids should be avoided as they are addictive and over time typically result in a need for increased doses due to tolerance. This heightens the risk of medication overuse headaches. When discussing possible medicines with your doctor, be sure to speak openly about your previous experiences using medicines to treat migraine. You may be able to identify the best medicine to use based on your past treatment experience.

Oral, intravenous and other routes may be used for administering the medications. During a migraine attack the pylorus (a section of the stomach) closes, limiting the absorption of oral medication. Oral medications are more effective when taken early in the attack. Non-oral administration routes (e.g. anal suppositories, where the tablet is inserted into the rectum) may be more appropriate if treatment is administered during an acute attack.

Rest

Resting during an acute attack is an important component of effectively managing migraine. Sleep has a therapeutic effect and one study reported sleeping for several hours during the acute phase of a migraine shortened its duration.

Oral simple analgesics

Effective management of migraine depends on recognition of early migraine symptoms and administration of medication (usually with simple analgesics) early in the attack. Failure to institute early treatment may increase the severity of the migraine. Simple analgesics which may be used in acute treatment include soluble aspirin, paracetamol and NSAIDs. The choice of drug is made largely based on your preference and the best regimen is one that gives you confidence that your symptoms will resolve. However, the potential for habituation (where the medication becomes less effective after repeated use) or addiction with regular codeine use should be considered when determining an appropriate regimen, as codeine-containing medications are more likely to result in habituation.

Soluble aspirin

Soluble aspirin (600 mg) is often effective when used early in the course of a migraine. It may be dissolved in ice water to aid absorption (although this recommendation is made based on doctor’s opinion rather than evidence from clinical studies). Alternatively a preparation taken without water and absorbed through the oral mucosa (sucking aspirin tablets) may be appropriate.

Paracetamol

Paracetamol is effective for some individuals with migraines. The recommended dose for early treatment of mild-moderate symptoms is 1,000 mg to start and again every 4 hours, to a maximum of 4,000 mg daily (4 times daily). This regimen is also suitable for women who experience migraine in pregnancy.

Non-steroidal anti-inflammatory drugs

NSAIDs including ibuprofen, tolfenamic acid, naproxen, diclofenac potassium, and piroxicam have
demonstrated efficacy in the treatment of migraine. Diclofenac potassium has been demonstrated superior to ergotamine. Indomethacin suppository (inserted into the rectum) may be recommended if you experience vomiting early in a migraine attack.

Oral NSAIDs are an appropriate first-line choice for mild-moderate attacks, or for individuals with a severe migraine who have previously achieved adequate relief with NSAIDs. NSAIDs should be used with caution in the elderly, volume depleted patients (those with low levels of salt and water in the body) and those with kidney dysfunction or a history of peptic ulcer.

Most individuals with migraines choose to self-medicate with NSAIDs, which may be combined with codeine, depending on preference. In the case of combined use, an appropriate regimen would be ibuprofen (200 mg) plus codeine (8–30 mg): Two tablets at headache onset and a further two tablets if the headache has not resolved within 2 hours.

Gastric protection

Simple analgesics can cause gastrointestinal disturbances. Individuals who have difficulty tolerating simple analgesics may benefit from antiemetics (medications to inhibit vomiting). Those who experience vomiting as a symptom of migraine may also benefit from antiemetics. Oral antiemetics include metoclopramide (e.g. Maxolon and Anagraine), domperidone (e.g. Motilium), or prochlorperazine (e.g. Nausetil, Stemetil). Rectal or intravenous administration of prochlorperazine is a further option for individuals who cannot swallow or hold oral medications in their stomach due to severe vomiting. Alternatively the metoclopramide dose may be administered intravenously (into a vein) or intramuscularly (into a muscle). Gastric protection with a proton pump inhibitor or histamine blocker is also an option for individuals using NSAIDs.

Other oral medications

Oral opioids

Oral opioids are highly effective analgesics, however due to the high risk of habituation which may cause medication overuse headache, they are rarely used. Opioids are recommended only for use on rare occasions and are unsuitable for individuals requiring frequent medication.

The use of pethidine is not recommended as it is short acting and offers no benefit over other agents with less serious side effects. The addition of codeine to a paracetamol regimen increases efficacy marginally, but the combined regimen offers no benefit over aspirin alone. There is no evidence to support the use of other opioid agents in the management of migraine.

Oral ergotamines

Oral ergotamines have a well-established role in the treatment of migraine. While ergotamines are less expensive than triptans (discussed below), they are associated with numerous adverse effects and many people fail to tolerate their side effects. Triptans are typically better tolerated and, where cost is not an issue, the doctor will usually recommend a trial of triptans before oral ergotamines are prescribed. However, ergotamines are effective in individuals who can tolerate the side effects.

The recommended dose is 2 mg ergotamine tartrate orally, with caffeine at onset. A maximum of 6-daily and 10-weekly doses is recommended to avoid medication overuse complications. Suppository formulas are also available and the recommended maximum dose is 3 per day or 5 per week. Ergotamines must not be used at the same time as triptans.

Triptans

Triptans are effective treatments in most migraine cases and their use is associated with few side effects, which in most cases makes them a more appropriate treatment option compared to ergotamines. Triptans may be added to, or used as an alternative to simple analgesics in individuals who do not achieve adequate pain relief with simple analgesics. It is generally recommended that triptans be used early in the course of migraine (preferably at the aura stage, before headache begins) for maximum effectiveness. However, some evidence is contradictory and suggests they may not be effective if taken in the aura phase of migraine, before headache onset.

Note that triptans must not be used by individuals with coronary disease or Prinzmetal angina (cyclical
chest pain) or those who have used ergotamines in the past 24 hours or MAOIs in the past 2 weeks. Ergotamines should not be administered within 6 hours of a dose of triptans. They appear to be less effective in individuals who experience allodynia.

It is typical to begin using oral triptans, which in Australia are available in the following oral formulations:

• Imigran- sumatriptan (tablets 50 mg, 100 mg): Maximum dose 300 mg/24 hours;
• Suvalan- sumatriptan (tablets 50 mg, 100 mg): Maximum dose 300 mg/24 hours;
• Sumatab- sumatriptan (tablets 50 mg, 100 mg): Maximum dose 300 mg/24 hours;
• Zomig- zolmitriptan (tablets 2.5 mg): Maximum dose is 10 mg/24 hours.Zolmitriptan is more potent and absorbed more rapidly than other triptans; and
• Naramig- naratriptan (tablets 2.5 mg): Maximum dose 5 mg/24 hours. Naratriptan has the most favourable side effect profile.

Sumatriptan is also available in preparations for nasal spray and subcutaneous injection and these may be most appropriate for individuals with a tendency to vomit early in their migraine attack. Sumatriptan injection comes as a 0.6 mg/0.5 ml injection and is fast acting but is associated with more side effects compared to other sumatriptan preparations. Sumatriptan nasal spray is available in two strengths (10 mg/1ml and 20 mg/1ml) and may be absorbed better than oral formulas; however, it takes 15–45 minutes to exert its pain relief effects. The maximum dose is 40 mg/24 hours.

Your preference, the effectiveness of various formulations and their cost should be considered when determining the most appropriate triptan. If you fail to respond adequately to one triptan, you may achieve the desired response with another type. With the exception of sumatriptan subcutaneous injection (discussed below), these medications are subsidised by the PBS for individuals who:

• Have tried and failed to achieve an adequate response with prophylactic migraine medications;
• Have failed to respond to oral ergotamine therapy during past acute attacks; or
• Cannot take other migraine medications due to contraindications such as comorbid conditions or pregnancy.

Sedation

Sedating a person to allow them to sleep-off the migraine is another treatment option.

Injectable NSAIDS

NSAIDs formulated for intramuscular injection may be an appropriate choice for individuals who are unable to tolerate oral medications.

Parenteral medications for rescue

Occasionally severe migraines fail to respond to oral medication and parenteral (intravenous) therapy is required. If you experience severe vomitingearly in the course of your migraines you may require parenteral therapy.

In some instances parenteral therapy may be administered in the home if you have sufficient support to assist you with administration of the parenteral therapy. Parenteral treatment typically includes rehydration with saline solution and some individuals will respond to this alone. In other cases parenteral medication is required. Parenteral antiemetics should be trialled first. If you fail to achieve an adequate response with rehydration and antiemetics, you may need to go to an emergency department for treatment with opioids or other drugs.

Rehydration, anti-emetics and neuroepileptics

Parenteral antiemetics or neuroepileptics have proven efficacy, and when administered in combination with rehydration fluids are the mainstay of parenteral treatment of migraine. They should be trialled before other parenteral therapies. The doctor will probably want to monitor your response during and for several hours after treatment. If you fail to achieve adequate relief using these agents, you may be referred to a neurologist for further assessment.

Dihydroergotamine

Dihydroergotamine is an ergotamine which may be administered intravenously, intramuscularly or subcutaneously (under the skin). If you are prescribed this agent, the doctor can teach you to self-administer the medicine during a migraine. This medicine is perceived by doctors to be an effective migraine treatment; however, there have been few clinical studies to assess its effectiveness. Side effects associated with dihydroergotamine are similar to oral ergotamines.

In the hospital setting dihydroergotamine should only be instituted for individuals who fail to respond to rehydration and antiemetic agents, and who have had brain images taken to exclude ischaemic stroke. Intravenous rehydration and antiemetic therapy is usually continued while dihydroergotamine is administered.

Opiates

Opiates are effective when administered intravenously but are inappropriate for frequent use and should be reserved for infrequent migraines which fail to respond to other treatments. However, during an acute attack you may present to a doctor who is unfamiliar with your history (e.g. in the emergency department) of opiate use. This makes it difficult for the doctor to assess the frequency of intravenous opiate use, and means that doctors who are unfamiliar with your migraine history are not authorised to prescribe you opioids. If your doctor believes use of intravenous opiates on rare occasions is an appropriate component of your management plan, they may provide you a letter informing other doctors that you can be prescribed oral opiates. In this case the prescription will be reported to the doctor who manages your migraines on an ongoing basis so that they can monitor your use of opiates.

Amongst opiates, morphine is the recommended agent and occasional treatment of severe migraine with a single dose of intravenous morphine is warranted. Pethidine should not be used due to the risk of toxicity and addiction.

Steroids

Intravenous steroids are an option for migraine individuals who fail to respond to intravenous dihydroergotamine. Dexamethasone is the recommended agent and should be administered at a maximum dose of 20 mg daily. The dose is typically reduced gradually as the migraine responds to treatment.

Sumatriptan

Subcutaneous injection of sumatriptan acts rapidly and can be self-administered. However, its use is limited due to expense. It is not available through the PBS and each injection costs around $70.

Lignocaine

Lignocaine (e.g. Xylocard and Oraqix) is only used as a last resort for individuals who fail to respond to other intravenous treatments. Electrocardiogram (ECG) monitoring is essential in individuals being administered this medicine. Lignocaine should only be administered by a neurologist with lignocaine experience in a hospital.

Natural therapies

There is no evidence to support the use of natural therapies in acute migraine treatment. The use of acupuncture in acute treatment has not been studied.

Medication for migraine complications

Complications including restlessness, akathisia (restlessness or constant movement of the leg), dystonia (involuntary muscles contractions, orofacial dyskinesia (involuntary contraction of facial muscles) and oculogyric crisis (involuntary rotation of eyeballs) occur rarely with the medications used to treat migraine. Treatment with intravenous benztropine or antihistamine injection is effective in resolving these complications in most cases.

Habituation

Many of the drugs used in the acute treatment of migraine are potentially habit forming, particularly opiates, ergotamines and triptans, but also simple analgesics such as paracetamol. Individuals who require frequent medication for migraines are particularly vulnerable. Intermittent migraine headaches may transform to chronic daily migraines, also known as medication overuse headaches, with over-medication. This is a common outcome which may be difficult for a doctor to diagnose and treat. Once habituation/medication overuse occurs the effect of the medication is reduced and increasing doses are needed to produce an effect. A withdrawal period, in which medications are avoided and headaches are typically experienced daily, is necessary before new medications are trialled in treatment.

To minimise the risk of habituation, the doctor may recommend a two-step medication regime for managing migraine episodes. This usually involves administering a simple analgesic at the first sign of migraine headache. A more potent analgesic should only be taken if the headache has not resolved within 2 hours. You will probably learn to predict which headaches will progress to migraines, and with experience may be able to recognise the need for more potent analgesics and implement them earlier in the course of a migraine.

Referral

Individuals who fail to respond to the treatments outlined above represent complex cases, best managed by a specialist headache clinic. However, such clinics are rare in Australia and management at a specialist pain clinic may be a more feasible option. In practice, most individuals who experience difficult to manage headaches are referred to neurologists. If you use an opioid and notice that you require more frequent or higher doses, this could be a sign that opioid overuse is developing. Advise your doctor as you may require specialist consultation with a neurologist.

If you also experience psychological conditions you may be referred for consultation with a psychiatrist. If you are pregnant or breastfeeding and are concerned about the effects of migraine medication you may also be referred for specialist consultation.

For more information about the different types of primary and secondary headaches and how they can be treated, see Headache.

 

Headache Australia is the only Australian charity that aims to support the more than 5 million Australians affected by headache and migraine. Headache Australia is an initiative of the Brain Foundation – a national charity raising funds for research from community donations.

For more information, see Headache Australia.

 

Migraine prevention

Future migraine attacks may be prevented by making dietary and lifestyle modifications and/or using prophylactic medications. Migraine prophylaxis can reduce the frequency and severity of migraines; however, prophylaxis is only used by a small minority of patients (8% at any time; 15% in their lifetime).

Lifestyle and dietary modifications

Lifestyle and dietary modifications should be instituted with the aim of avoiding factors which trigger migraines. Common triggers include dietary factors (e.g. caffeine-containing food and drinks), hormonal factors (e.g. hormonal changes in the menstrual cycle or at menopause), lifestyle factors (e.g. stress) and neck trauma.

Stress is a common trigger for migraines and daily relaxation is typically implemented before prophylactic medications are prescribed. The simplest form of relaxation therapy is listening to a relaxation CD combining soothing music with voice-over relaxation instructions such as advice on controlled breathing. Other options include meditation, and supervised programs such as cognitive behavioural therapy.

Many people will experience migraine triggered by dietary factors and adhering to a pro-forma diet which excludes common triggers (including cheese, chocolate, wine, citrus and nuts) may be useful for these individuals. A pro-forma diet is not necessary for individuals with no history of food-triggered migraine. However, caffeinated beverages should be avoided by all people who experience migraines.

Prophylactic medications

Prophylactic medication may be prescribed for individuals with frequent, severe migraines which interfere with their lifestyle, and which do not resolve with lifestyle measures such as relaxation therapy. Individuals who fail to respond to acute treatments (treatments instituted during the migraine headache) are also good candidates for migraine prophylaxis. Other therapeutic options which may prevent the need for prophylaxis should be trialled before commencing prophylactic medications.

Establishing the pattern and frequency of migraines, current treatment strategies and the individual’s expectations is essential for determining the appropriateness of prophylaxis. You should also compare your symptoms to baseline while prophylaxis is being administered to determine whether or not, and to what extent, prophylactic medications reduce headache frequency and/or severity. It is important to be aware that migraine has no cure and the goal of prophylaxis is to reduce the frequency and severity of acute attacks, not to cure the condition.

Frequency, severity and the degree of disability experienced, along with the individual’s preference, will be considered by the doctor when assessing the need for prophylactic medication. Some people may be willing to experience, for example, weekly headaches if they are able to control an acute attack while others may prefer prophylaxis. Typically, individuals who experience migraines less than monthly do not use prophylactic medicines but in cases of less frequent but very severe migraines (e.g. an attack every 2–3 months which causes severe disability), prophylactic medicine may be appropriate. Thorough discussion of the reasons for commencing prophylaxis and the dangers of medication overuse are essential for ensuring that you take your medicines at the correct times. Ask your doctor if you are unsure about how often or when you should use prophylactic medicines.

The timing of migraines is often unpredictable and therefore daily prophylaxis is often required. However, if the timing of migraines can be predicted (e.g. in a woman who experiences migraines only during menstruation), prophylaxis may be taken only during the period of the person’s vulnerability.

Several medications are used in migraine prophylaxis and the medicine of choice varies from person to person. Trial and error is usually required to determine a suitable prophylactic regimen. However, it is important to discuss comorbid conditions (particularly psychological conditions) before commencing prophylaxis, as comorbidities may influence the choice of medicine. Use of acute agents (medicines used to treat acute migraine attacks) for prophylaxis is associated with an increased risk of medication overuse headache. While these agents are not typically recommended for regular prophylactic use, some 9% of Australians with migraine who are treated by general practitioners use them for prophylaxis.

Different prophylactic medications should generally not be administered at the same time; however, this may be appropriate in some difficult cases who fail to respond to a single medication. The initial choice of medicine should be made after a discussion of the likely side effects. Be aware that if you try one medicine and find it unsuitable (e.g. because it does not prevent headaches or causes too many side effects) there are other medicines which can be trialled. Whatever medication is chosen, simple analgesics (e.g. paracetamol, aspirin) should ideally be used on a maximum of 15 days per month and other prophylactic medicines (discussed below) on no more than 10 days per month.

Beta blockers

Beta blockers are the mainstay of migraine prophylaxis. Evidence suggests selective beta blockers are less effective than broad spectrum beta blockers. Sustained release formulas enable once-daily dosing and may be prescribed to make it easier for you to take your medications according to the correct schedule. Amongst beta blocking agents the best evidence is for propranolol (e.g. Deralin, Inderal) although there is no evidence regarding the long term use of this drug in migraine prophylaxis. Metoprolol (e.g. Minax or Lopresor) or atenolol (e.g. Tensig or Noten) are other beta blockers which may be used to treat migraine. Always take the dose of medication prescribed by your doctor at the correct time each day to optimise the effectiveness in preventing migraine.

Beta blockers may be a good choice of medicine if you have hypertension, as they will also improve hypertension. However, they should be used with caution in individuals with depression and should not be used by people with asthma. Be sure to inform your doctor if you have any of these conditions. Be aware that using beta blockers can sometimes cause vivid dreams and hair loss (females) as side effects. As they reduce the heart rate they may cause cardiovascular effects which are unacceptable for individuals who participate in active sports. Talk to your doctor if you are concerned about the side effects which may occur with beta blockers.

Antidepressants

Antidepressants may be used for migraine prophylaxis; however the doses prescribed are much lower than when these medicines are used to treat depression. The best evidence is for amitriptyline (e.g. Endep, Tryptanol). There is also some evidence that nortriptyline is effective and it may be trialled if amitriptyline is not tolerated. The doctor will determine the correct dose and advise you how and when to take the medication. The doctor may change the dose over time. Always take the dose prescribed by your doctor. If you think the dose is too high or too low, talk to your doctor before changing the dose.

Individuals using amitriptyline all experience dry mouth. Other common side effects include drowsiness, urinary retention (inability to urinate), constipation, and weight gain (with higher doses). Individuals who cannot use amitriptyline include those using medications called monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs) and tramadol as well as those who have experienced a recent seizure, or cardiac arrhythmia. If you have a psychological condition, be sure to inform your doctor as precautions need to be taken before prescribing amitriptyline to individuals with psychological conditions.

Anticonvulsants

Anticonvulsants (anti-seizure medications) may also be used for migraine prophylaxis and evidence suggests sodium valproate or topiramate as the best choices. Topiramate is now available on the pharmaceutical benefits scheme (PBS); however, only those individuals who have used and failed to achieve migraine prevention with beta blockers and other medicines are eligible for the PBS subsidy. Gabapentin (e.g. Nupentin and Gabahexal) is also used in migraine prophylaxis although evidence for its effectiveness is limited. Lamotrigine (e.g. Lamotrust and lamogine) and levetiracetam (e.g. Keppra) may also be used although their effectiveness has not been proven and they are not subsidised by PBS for the prevention of migraine.

The dose varies depending on the medicine used and may be adjusted over the course of treatment. Always take the dose prescribed by the doctor according to the recommended schedule.

All anticonvulsants are contraindicated for pregnant women and women intending to become pregnant; they are associated with foetal malformation. All sexually active women using anticonvulsants should use contraception to prevent pregnancy during treatment. If you require contraception your doctor can provide advice about methods which may be suitable for you.

Ergotamines

Ergotamines are a class of medications used to treat individuals with migraine who do not respond to simple pain killers like paracetamol and aspirin. They work by narrowing the blood vessels which feed the head, subsequently reducing blood flow to the head. For ergotamine use in migraine prophylaxis, the best evidence exists for pizotifen. The doctor will determine the correct doses and times at which you should take the medicine. Side effects include sedative effects and drowsiness, dizziness, oedema, muscle pain, erectile dysfunction, paraesthesia, hallucinations and weight gain.

There is also strong evidence that the ergotamine methysergide is an effective prophylactic agent for migraine; however, its use is associated with cardiovascular side effects. If you are using this medicine your doctor will need to monitor your heart to ensure cardiovascular changes, which may cause problems, are identified. Methysergide should be taken for a maximum period of 6 months, after which a 1 month rest period is necessary. Other side effects include nausea and vomiting, insomnia, vertigo, skin reactions and mood disturbances. You should not use methysergide if you have any of the following conditions:

• Hemiplegic migraine (pain on one side of the head);
• Basilar type migraine (affecting blood vessels that supply the brain);
• Ischaemic heart disease;
• Peripheral vascular disease (reduced blood circulation in the extremities);
• Uncontrolled hypertension (high blood pressure);
• Pulmonary heart disease;
• Kidney or liver conditions;
• Use of some antibiotics.

Triptans

Triptans are another class of medicines reserved for individuals who fail to achieve migraine relief using simple pain killers. The mechanism by which they work to prevent migraine is not well understood. Frovatriptan, a long-acting triptan which is not currently approved for use in Australia, has demonstrated efficacy for women who experience menstrual migraines. For this type of medication, the doctor will likely prescribe the medication to be taken immediately prior to (e.g. for several days before) the onset, and for the duration, of menstrual bleeding.

Other prophylactic medicines

Other medicines which may be used for migraine prophylaxis include:

• Serotonin blockers (e.g. Sandomigran, Periactin) are sometimes used in migraine prophylaxis, however there is limited evidence regarding their efficacy;
• Calcium channel blockers, including verapamil (e.g. Anpec and Isoptin) and diltiazem (e.g. Dilzem and Coras) have demonstrated efficacy but they are not recommended as the initial choice for preventing migraine. Verapamil may be used as additional therapy in individuals with severe migraines which cannot be managed using a single medication. The drugs are associated with hypotension (abnormally low blood pressure) and pedal oedema (accumulation of fluid in the foot), however, they are otherwise well tolerated;
• Other anti-hypertensives (e.g. Catapres, Atacand). Due to lack of evidence these agents are not recommended as the first choice of medicine, however candesartan (Atacand) is becoming more widely used in Australia;
• Oestrogen- there is some evidence to support the use of topical oestradiol gel (1.5 mg) for prophylaxis of menstrual migraine. Application should commence 2 days prior to expected menses-associated migraine. Changing or ceasing oral contraceptives may also reduce migraine symptoms;
• Magnesium salts may be trialled, however are not recommended as the first choice of drug as evidence for their effectiveness is contradictory;
• NSAIDs (e.g. ibuprofen, aspirin) may be useful in cases of menstrual migraine and should be commenced 4 days before the expected onset of menses-associated migraine;
• MAOIs (e.g. phenelzine, sold as Nardil);
• Botulinum toxin should be reserved for cases which fail to respond to other treatments due to its expense;
• The serotonin blocker Deseril (Methysergide) may also be used in cases that fail to respond to all other treatments.

Children

There is limited experience with prophylaxis for preventing migraine in children. Beta blockers may be of value.

Prophylactic natural remedies

There is evidence to support the use of several natural remedies in migraine prophylaxis and these may be most suitable for individuals who wish to avoid regular use of pharmaceuticals. They include:

• Butterbur (Petasites hybridus) was shown in one study to reduce the frequency of migraine attacks by >50%. However, improperly processed leaves have potential carcinogenic effects. If you wish to use this treatment, talk to your doctor for advice about obtaining it from a reputable source;
• Co-enzyme Q10 has been shown to reduce the frequency, but not severity, of acute attacks;
• Magnesium oxide has been shown to reduce the frequency of migraine;
• Riboflavin (vitamin B2) has been shown to reduce the frequency of migraine;
• Ginger.

There is no evidence to support the use of feverfew (tanacetum parthenium) in migraine prophylaxis.

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