Managing migraine

Migraine is not just another word for ‘bad headache’. They have specific characteristics that distinguish them from tension-type headaches. Migraines affect about 1 in 10 people, particularly women. Minimising potential migraine triggers plays an important role in managing migraine. In addition, different medicines can be used as preventive therapy for migraine.


Signs and symptoms of migraine headache

Doctors have identified two types of migraine:

  • migraine without aura
  • migraine with aura (which present as altered vision, speech, sensation or, more rarely, movement).

Both types of migraine:

  • are associated with a severe throbbing or ‘pounding’ pain, usually only on one side of the head, although the affected side may change between, or even during, attacks
  • usually last from 4 hours up to 3 days
  • are often accompanied by other symptoms such as nausea and vomiting, and a sensitivity to bright lights or noise — many people feel the need retreat to a quiet, dark room when they have a migraine
  • are so painful and distressing that normal everyday activities become impossible during an attack
  • can leave the person feeling drained and exhausted afterwards
  • can be aggravated by physical activity such as walking or climbing stairs.

You may also experience a range of characteristic symptoms — such as fatigue, difficulty concentrating, neck stiffness, food cravings and a sensitivity to light or sound — up to a day or so before a migraine attack.

Migraine affects everyone differently. Some people have migraines only once a year while others have migraines several times a week or even daily. Overall, the average is one to two attacks per month.

Causes of migraine

Various triggers are known to set off migraine. These include:

  • missing meals
  • altered sleep patterns
  • bright lights and loud noise
  • alcohol, chocolate and certain cheeses (although most migraine sufferers can eat what they like)
  • strenuous exercise in someone who isn’t accustomed to it (although regular exercise may help prevent migraine attacks)
  • menstruation.

Altered sleep patterns

Both too much and too little sleep may trigger attacks; a common time for migraine is Saturday morning as you adjust from your weekday routine to a weekend routine. If this appears to be a problem for you, try setting your alarm on the weekend for the same time as during the week.

Foods that can trigger a migraine

A food is classed as a trigger when:

  • a migraine develops within 6 hours of consuming a particular food or drink
  • the effect can be reproduced (although not necessarily on all occasions)
  • withdrawal of the food or drink leads to improvement in migraines.

Common triggers include chocolate, cheese, wine, citrus fruits and food additives such as flavour enhancers used in Asian or processed foods. However, food triggers are much less common than was previously thought and there is no reason to routinely avoid all cheeses and chocolate.

Treating migraine without medicine

The following non-medicine treatments may help you to prevent frequent or troublesome migraines — you can use them either instead of, or as well as, medicine treatments:

  • physical therapies (eg, physiotherapy or chiropractic treatment), especially if neck problems are thought to be contributing to your migraines — it’s essential to seek out a therapist with specialist training in this area, however, as there have been very rare reports of stroke after spinal manipulation of the neck
  • physical exercise
  • relaxation training (eg, yoga, meditation), which can help manage underlying problems with stress
  • cognitive behavioural therapy (CBT), a psychological therapy that teaches you to identify and challenge stress generating thoughts
  • acupuncture.

Medicines for an acute migraine attack

Doctors recommend a stepped approach to treatment for acute migraine attack; that is, trying the simplest remedy first. If this fails to manage your pain — as a general rule on 3 consecutive occasions — then you should try the next treatment.

Step 1. Simple pain relief medicine alone

Most simple pain relief medicines are available to buy over-the-counter in pharmacies and supermarkets.

Take pain relief medicine at the first sign of migraine symptoms. As a migraine progresses, your stomach emptying can slow and this can affect the absorption of pain relievers into your bloodstream, making them less effective. This is especially important if you experience nausea and vomiting with migraine.

Step 2. Simple pain reliever and medicine for nausea and vomiting

If nausea is a problem, or if a pain reliever alone does not relieve your migraine pain, you can take the pain reliever with medicine to treat nausea and vomiting.

Step 3. Anti-migraine medicine: the triptans

Triptans work differently to pain relievers. They cause the blood vessels around your brain to contract (narrow). There are a number of different triptans available in Australia and you will need to get a prescription from your doctor.

Step 4. Preventive therapy

If you are experiencing two or more severe migraine attacks a month, you could be a candidate for preventive therapy. Preventive therapy is used in addition to treatments for acute attack, not in place of it.

Children and migraine

Fortunately, migraine attacks in children are often short-lived and generally resolve with a few hours of sleep.

Migraines in children often respond to simple pain relievers. The recommended medicines are:

  • ibuprofen (Nurofen for children)
  • paracetamol (Children’s Panadol).

Aspirin (Disprin, Aspro Clear) is not recommended for children under the age of 12 years because its use in children is linked to the rare but potentially fatal condition, Reye’s syndrome. For children aged 12–16 years, consult your doctor or pharmacist before giving aspirin.

Medicines for nausea and vomiting should be used with caution because movement-related side effects are more common in children.

Triptans are not suitable for use in children aged 12 years and under, although sumatriptan nasal spray can be used in the 12–17 years age group.

Children who suffer frequent and severe migraine attacks may require specialist (neurologist) intervention. Preventive therapy can prove helpful, but management is more complicated than for adults.

Find out important information about giving medicines to children.

Preventing migraine

The aim of migraine preventive therapy is to reduce the number of attacks to a manageable level, either because:

  • the medicines used to treat attacks don’t control your symptoms adequately, or
  • migraine attacks, even though well controlled, are happening far too often, placing you at risk of developing medication overuse headache.

Note that it may take some months for the full effect of preventive therapy to be seen.

In general, medicines used as preventive therapy are more commonly prescribed for the treatment of other conditions (eg, high blood pressure or depression) but have unrelated anti-migraine effects — for example:

  • beta-blockers — Propranolol (Deralin), atenolol (Noten, Anselol), metoprolol (Betaloc, Lopressor)
  • amitriptyline (Endep).

Other medicines occasionally used to prevent migraines include antiepileptic medicines (especially sodium valproate [Epilim, Valpro] and topiramate [Epiramax, Tamate]), methysergide (Deseril) and botulinum toxin (botox). 

Treatment can be complicated and is best managed by a specialist (neurologist).

Medicines to avoid in migraine attacks

Morphine and related opioid pain relievers — such as pethidine, codeine, oxycodone and buprenorphine — should rarely, if ever, be used in the treatment of migraine, and even then only under specialist supervision. This is because they can aggravate nausea and vomiting and are potentially addictive.

Complementary medicines for migraine

Complementary medicines can have side effects and interact with prescription medicines. Remember to tell your doctor if you decide to take complementary medicines for migraine.

Of the herbal medicines, feverfew and butterbur have been promoted as a preventive treatment for migraine.

  • Butterbur may prove helpful for some people.
  • Some studies have found feverfew to be effective, but an equal number have not. There are also concerns over the long-term safety of feverfew. For this reason, it is particularly unsuitable for children.

Riboflavin (vitamin B2) and co-enzyme Q10 supplements have shown some promise as preventive treatments for migraine. Riboflavin must be taken at very high doses (200 mg twice a day) to be effective.