Migraine and headache treatment

Migraine is a recurrent headache associated with increased sensitivity in the brain to sound and light, sometimes with nausea and vomiting. Some patients experience aura, a visual disturbance on one side of their visual field, or abnormal sensation on one side of their body for typically 20-60 minutes before the headache.

Migraine is more common in women and may be affected by the menstrual cycle. Migraine tends to be better in pregnancy and after the menopause.

The precise cause of migraine is not known, but the tendency often runs in families and genes for some types of severe migraine (familial hemiplegic migraine) are now known. It is thought that in the first stage of migraine there is activation of nerve centres within the brain that control the sensations we receive from the blood vessels around the brain.

These nerve centres then release inflammatory proteins causing inflammation and dilation of the blood vessels. The inflammation increases the pain further, and soon a vicious circle builds up with activation of the pain sensitive structures in the brain, and dilation and inflammation of blood vessels, causing the patients to become sensitive to light, sound, and movement for up to several days.

Some patients can detect the first stage of this process as the 'premonitory phase' several hours before the headache starts with symptoms such as neck ache, yawning and food cravings.

The first stage is always to look for triggering factors such as irregular sleep, meals, exercise, but foods such as cheese and chocolate are rarely the cause. Migraines just with the menstrual cycles can sometimes be treated with hormonal treatments such as changing the contraceptive pill.

If the migraines are happening infrequently then treatment taken just as the pain starts may be sufficient, starting with a non-steroidal anti-inflammatory drugs combined with an anti-sickness drug such as domperidone. If this is insufficient then migraine specific medication known as triptans can be used. If the patient vomits within one to two hours of taking medication then it may not be absorbed and injectable medication or suppositories may be needed.

If migraines are occurring frequently then preventative treatment on a daily basis for a several months may be necessary. Patients should avoid taking pain-killers such as paracetamol and codeine based drugs frequently as these may make the headache worse (medication overuse headache). Preventative treatments include amitriptyline, beta-blockers, topiramate and valproate: the option depends on many factors and should be discussed with your doctor. If these treatments do not work and the patient is suffering headaches most days then treatments such as occipital nerve injection can be done as outpatient procedures.

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Circle Health Group, 1st Floor, 30 Cannon Street, London, EC4M 6XH