I experienced my first migraine at 15. It started with serious blind spots in my vision followed by grogginess, aching limbs and a dull pain deep in my head. I struggled my way onto a bus and got home before nausea, vomiting and a skull-crushingly severe headache set in. I spent several hours in bed, in total darkness, feeling horrendous. Thankfully, I only suffered this on a handful of other occasions, all in my mid-teens, and each episode was less severe than the last. One thing that never lessened, though, was the intense, totally debilitating headache that almost knocked me out, forced me to retreat to a black hole and lie still until the pain subsided.
I consider myself lucky on the ‘migraine scale’; both my mother and best friend suffer from them on a regular basis and each time they can be out of action for anything from a few hours to several days. According to the NHS website  migraines affect around 15% of adults in the UK and are more common in women than men. They can affect anyone at any age, at any time and are classed as a chronic pain condition. In order to help prevent and control recurrent attacks, the Migraine Trust suggests that the more you know about migraines the better your chances of reducing their impact on your daily life. So what are they, why do they happen and is there anything we can do to prevent their severity or even onset?
What is migraine?
The word migraine can refer to both the attack and the underlying illness causing the pain. Migraine originates from the Greek words hemi, meaning half and kranion, meaning skull. Migraine is a disorder of the brain’s circuitry and can present as an acute, episodic or chronic problem. Migraines usually occur as an intense pain in one or both sides of the head and may even swap between sides during the same episode. Attacks usually last between a few hours and a few days and are often preceded by an ‘aura’ which can be a combination of visual disturbance, dizziness, limb numbness or total lack of movement, speech and memory problems and sometimes collapse. The migraine aura often lasts around one hour and, in addition to this, many people suffer a few days of reduced mood stability leading up to an attack. Aspects of these mood changes are often mistakenly considered as triggers for migraines. Not all migraine sufferers will experience every symptom of an attack, but most feel exhausted and unable to function fully for a while after it has fully passed. Symptoms and episodes of attack usually reduce in frequency and severity with age.
It is thought that migraines are a result of incorrect activation of nerves that originate in the brainstem, particularly those responsible for detection and relaying pain signals. Nerve activation can also affect blood vessels, the gastrointestinal tract and sensory perception. Researchers believe that the ‘aura’ phase of a migraine attack occurs due to nerve suppression that spreads from the brainstem over the cortex. Whilst the cause of migraine is still largely unknown, partly due to the great variety in triggers between individuals, scientists believe ion channel function along the nerve membrane plays an important role. Errors in the ion channels’ functioning prevent the normal excitation and stimulation of the affected nerves. Serotonin levels in the brain are also thought to play a role in migraine attacks. These brain abnormalities are considered genetic, but environmental elements cause the individual attacks.
Many causes of migraine are common and simple to avoid. Most regular sufferers have a good idea of their main triggers but here are a few things to look out for:
1) Low blood sugar and energy due to missed or irregular meal patterns. This seems to be more problematic for women.
2) Water seems to be of key importance, with low ingestion being associated with both migraine onset and frequency of attacks. Increasing water intake early on in an attack and throughout your day has been shown to reduce the number of hours and intensity of an attack.
3) Irregular sleep patterns.
4) Stress, particularly when intense stress followed by a sudden cessation occurs.
5) Drops in oestrogen levels in women due to menstruation, childbirth and menopause.
In addition to these common triggers, a number of other factors can increase risk or worsen an attack: the weather, taking too many ‘over the counter’ medicines, alcohol or head injury and anything else that can lead to headaches .
The most commonly reported foods that often lead to migraine are:
Chocolate, coffee or caffeinated soft drinks, citrus fruits, fatty foods, some vegetables, alcohol (in particular red wine) and dairy products – specifically cheese, eggs and processed or preserved meats and fish. Food additives such as MSG and aspartame have also been reported.
Currently there is little firm evidence to support the role of specific dietary factors as triggers of migraine. Food seems to be more important as a trigger factor in people suffering with aura migraine versus those without aura. There is currently no confirmed link to chocolate and alcohol’s role is controversial. A small link between coffee drinking and onset of migraines, as well as caffeine withdrawal in habitual drinkers has been found in some studies. Temperature of foods may also be important with ice cold water, ice and ice cream being shown increasing chance of migraine onset in some studies.
Unfortunately there is still much to be done in order to understand the role of food in triggering migraine incidences. Most studies to date have methodological flaws and rely heavily on recall of dietary triggers, which is subject to bias. It is also very likely that migraine sufferers’ prior knowledge of potential triggers means they already modify their diet, thus reducing the potential to identify real precluding factors . Despite the lack of evidence it is widely recognised that diet plays a role in migraine onset and although the specific foods and the mechanisms that can contribute to a migraine attack are still largely misunderstood, several studies have found that migrainers who cut out commonly reported food triggers suffer fewer and less severe attacks when compared with those who make no dietary changes.
The difficulties in determining the role of food in migraine arise due to the broad differences between individual migraine sufferers. For any one migraine sufferer each migraine may be triggered by a number of different foods and the combination of foods, and other trigger factors at the time of onset are likely to be of key importance. This can lead to incorrect identification of food triggers and often results in a risk food not causing migraine each time it is consumed. The overriding message from all studies relating to food triggers is the regulation of blood sugar levels. Most of the commonly reported food triggers affect energy metabolism and promote rapid rises and falls in circulating blood levels of fuel. This may be important in isolation or in relation to low energy availability as a result of skipped meals and fasting, which is of key importance in migraine onset, as many of the trigger foods may be craved and therefore ingested as a result of low energy status.
Treatment and prevention options
Despite how well you may know your own migraine patterns and how super organised you are when it comes to keeping trigger risk to a minimum, there are still times when the inevitable happens and pain takes hold. Many people are not aware of the range of treatment and preventative therapies available to help reduce the intensity and frequency of migraines. As a result, migraine treatment is very poorly utilised by sufferers. The best starting point for effective treatment is to see your GP. According to a study carried out by the Canadian Headache Society, the choice of drugs used for migraine pain relief should be based on efficacy evidence, the potential side effects, clinical features of an individual’s migraine and other medical conditions the sufferer may have . There are a range of pharmacological agents that have been successfully used for both acute and chronic migraine and so finding one that works for you may not be too hard.
The first line of defence against migraine for everyone is likely to be ‘over the counter’ pain killers. These, when taken early enough in an attack, can considerably reduce the severity of attacks and if used correctly can help to reduce recurrence of migraines.
The NHS recommends these as a first line of defence:
- ibuprofen (for all severities of migraine)
- paracetamol (mild-to-moderate attacks)
- other non-steroidal anti-inflammatory drugs (NSAIDs)
- combination of paracetamol, aspirin, and caffeine
- combination of aspirin and metoclopramide
Rapidly absorbed forms of all drugs should be taken and dosing levels adhered to, as over-use of medication can lead to worsening of symptoms. If you experience nausea and vomiting as part of an attack, an anti-emetic in combination with pain relief (for example aspirin and metoclopramide) may be your best option for treatment. Many of the above are available over the counter but some may require prescription.
If you have tried the above and found little relief with these common pain medicines, then you may wish to discuss using triptans with your doctor. These are a class of drugs that mimic the effects of serotonin in the brain and have proven very effective in the treatment of migraine. Triptans are associated with some side effects and poor duration of pain relief and are currently not recommended for use in people with cardiovascular problems. New triptans, for example Frovatriptan, are coming onto the market and are proving more efficacious, with longer lasting relief and greater tolerance profiles than previous types, for moderate to severe migraine attacks .
In addition to pharmacotherapies, alternative preventative therapies may be considered if the severity and frequency of attacks is not reduced by standard drug use.
1) Acupuncture: a systematic review of 22 studies, with a total of over 4000 participants, carried out by the Cochrane Collaboration found that acupuncture provided a beneficial therapeutic alternative to routine or acute treatments in reducing the frequency of headaches. A considerable improvement, and fewer side effects compared with drugs, was observed as an overall outcome of the review, with acupuncture being recommended for patients willing to give it a try. Sufferers should talk to their GP before receiving acupuncture, as they may be able to refer you to the right therapist .
2) BOTOX: a good body of evidence supports the use of botulinum toxin type A in migraine sufferers as it reduces pain intensity, attack frequency and impact on functionality. Despite its effectiveness and lack of associated side effects, Botox use is only recommended in patients who meet certain, specific criteria. If you are someone who has already tried many other therapies without relief, then Botox may be available to you .
Natural and herbal help
Some good evidence is emerging into the role of certain natural and herbal supplements in helping prevent frequency and severity of migraine attacks. The following supplements and herbal products may be worth considering as part of an effective headache prevention plan.
Magnesium status of migraine suffers has been shown to be low during headache in a number of studies and the presence of deficiency is an important factor in menstrual migraine. Magnesium plays an role in a number of neuronal pathways that impact migraine occurrence, including serotonin receptor function. Daily oral supplementation of magnesium was found to be effective in two placebo controlled trials at preventing migraine attacks. Diarrhoea is a common side effect of magnesium oxide, so the source of supplementation should be considered carefully to avoid negating the positive effects.
Although evidence is scarce, results of one well designed study found that migraine frequency reduced by half in over 50% of subjects taking daily 400mg supplements of Vitamin B2 versus placebo. This is thought to be due to the important role Vitamin B2 plays in energy metabolism and membrane stability.
CoQ10 is an enzyme that plays a vital role in energy metabolism. In one study, supplements of 150mg each day for three months were found to reduce frequency of migraines by over 50% in 61% of the subjects studied. The effect was seen after 1 month of supplementation. CoQ10 may be of key importance in children with migraine, as levels have been shown to be below optimal in children with frequent headaches. Correcting low CoQ10 status in children with oral supplementation reduced headache intensity and number in a large paediatric study.
Alpha lipoic acid may be effective at relieving the severity and frequency of migraine attacks, although further studies are required to confirm the current findings.
EPA supplementation: a number of small studies have shown that daily intake of 600mg EPA may be effective at preventing headaches. This is likely due to the interaction of EPA with serotonin activity.
Tanacetum Pathenium, known as Feverfew, has previously shown poor results in studies looking at its ability to reduce the impact of migraine. Investigation of a more stable extract of feverfew, MIG-99, found a clinically significant reduction in migraine attacks with a three times daily dose, when compared with placebo. The effects of taking feverfew are thought to relate to its inhibitory actions on serotonin release and inflammation.
Butterbur a root extract of the Petasites Hybridus plant, has also been shown to reduce the number of migraines in adults, children and adolescents, without adverse effects when compared to placebo.
The clinical journal of pain in which the above results are reported and reviewed, recommends the following oral supplements, in decreasing order of preference:
- Magnesium: 400 mg daily. Chelated magnesium, magnesium oxide, and slow-release magnesium are likely to be the best absorbed.
- Petasites hybridus (Petadolex): 75 mg twice daily for 1month, then 50 mg twice daily.
- Feverfew: 100 mg daily.
- CoQ10: 300 mg daily.
- Alpha lipoic acid: 600mg daily.
Values will differ for children and pregnant or lactating women so be sure to discuss doses with a GP, pharmacist or registered nutrition professional. .
Reducing risk and impact
It is possible to reduce the incidence and severity of your migraine attacks with a few simple methods and knowing your migraines well will give you a better chance of getting the right treatment quickly if you do decide you need further help.
Keep a diary to help identify personal triggers and see if there are areas you are able to address. Staying hydrated, eating regularly and often, as well as reducing stress are a good start to protecting yourself against attacks. Keep effective painkillers, readily available to take during the early stages of an attack, to reduce length and severity of an attack when it does happen. Make sure you are using the right drugs for you and speak to a doctor if you are getting poor results or side effects with the drugs you are using. If things still don’t improve, help is available. Keep your GP up to date and go back if you are not happy with the outcomes of the treatment choices so far. It is important to read up on your options, so you have a good idea of what’s available to you, before you see your doctor.
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Sophie Tully– a nutrition, fitness and health scientist – started her consultancy business thanks to the help and support of many inspiring and thought-provoking people. Her passion for fitness and nutrition, deepened by her biomedical science and cancer research background, led to the creation of Sophie Tully – Total Health Consulting, to promote ‘Total Health’ to the public. Sophie’s mission is to show people that ‘optimal health’ is not just being disease-free. It is about living a long and happy life without reliance on medication, or suffering ongoing illness. ‘Health’ results from a delicate balance of nutrition, physical fitness and mental wellbeing, specific to each of us. Each aspect is equally important and reliant on the other two. One element alone can shift the balance and impact on health. Using simple and effective, hands-on methods, Sophie Tully – Total Health Consulting will help clients discover their unique ‘health’ profile and provide simple solutions to achieve vitality.