When it hurts more than a headache

By Dr. Harsha Gunasekara

Everyone has had a headache at some time or other. The pain is usually mild and a couple of pain killers will have done the trick and you'll have felt better again quite quickly. A migraine attack is quite different. It is so painful that you may have to stop what you're doing. Everything becomes an effort and you feel weak. The only way that you can cope is to draw the curtains and go to bed. Tablets don't seem to help at all.

What is migraine?

Migraine is a complex condition but is not life-threatening. Migraine is only one of many different types of headaches and comes in different forms. In general, it is a recurring headache which lasts from 4 hours up to three days.

Migraine affects as many as 20% of the population. Women are three times more likely to have migraine than men. The first attack usually happens when you are a child or a teenager. It is rare for a first attack of migraine to happen after the age of 40 although there may be a gap of many years between attacks.

Many people try to struggle through an attack thinking that little can be done to help them. Certainly in the past, it was considered something that you had to 'live with' and very little was known about the condition. As more research has been done, there has been a rapid increase in our knowledge, although the picture is by no means complete. Nowadays, more can be done to help the migraine sufferer to make the attacks less severe and occur less often.

How does migraine differ from 'ordinary' headache?

Migraine is more than just a headache. There are other associated features occurring before, during and after the headache .

What causes an attack ?

Most people have read that certain foods such as cheese and chocolate can trigger an attack. This is certainly true for some people but it is usually much more complicated than that. You may have wondered why the same triggers do not always result in an attack. This is because it is necessary for more than one trigger to be present to cross the 'threshold', resulting in the attack. It is usually the final trigger that is most obvious but those underlying triggers are equally important.

Dealing with any of your triggers may help you have fewer attacks.

The most common triggers are:

• Lack of food - missing meals (especially breakfast), snack lunches or sugary snacks instead of a proper meal can all result in an eventual drop in blood sugar which can lead to an attack. This is particularly important for children who use up a lot of energy and are growing quickly.
• Specific foods - a few people notice that if they eat certain foods, a migraine quickly follows. But missed meals are a much more important trigger.
• Changes in sleeping pattern - too much and too little sleep - a Saturday morning 'lie- in' or a run of late nights
• Hormonal changes in women - migraine attacks may be made worse by the oral contraceptive pill although some women do notice an improvement when they are taking it. It is wise to stop the 'pill' if attacks become more frequent or more severe. It should not be taken if you have attacks with an 'aura'.
• Head and neck pain - muscle tension affecting the neck and shoulder muscles may be a trigger, particularly if you are hunched over a desk or in front of a computer all day, or do a lot of driving. Simple neck exercises and awareness of the way you sit and stand can help considerably, or even regular massage if you wish. In a few cases, migraine can be aggravated by specific dental problems.
• Environmental changes - bright lights, loud noise, strong smells, travelling etc. can all trigger attacks in some people. If you are particularly sensitive to bright lights then it may worth buying a good pair of sunglasses or glasses with photochromic lenses.
• Exercise - regular exercise, without overdoing it, can help prevent migraine attacks but exercise done once in a while when you are unfit can trigger an attack.
• Travel - a long journey or flight, especially if it involves a change in meal and sleep patterns.
• Stress - often in the period of time after the stress (including the weekend after a stressful week or the first few days of a holiday).

What are the symptoms of a typical attack of migraine?

A typical attack of migraine can actually be divided into five distinct stages. The first two stages may be present before the headache. However you may go through an attack of migraine without noticing all the stages.

• Prodrome: Before an actual attack starts, you may notice that you feel very tired and yawn a lot more. Before other attacks you may have had the opposite feelings - lots of energy and getting all your work done in half the normal time. Some women find that they recognise the start of a migraine attack when they approach housework with great enthusiasm! Others crave certain foods - often sweet.
  These sorts of feelings are noticed by about two thirds of sufferers and may only be apparent when you look back on an attack. Relatives and friends may be more aware of these subtle changes in mood or behaviour than you are. The symptoms usually start several hours or the day before the attack.
• Aura: A warning 'aura' consisting of visual disturbances (flashing lights, blind spots in the vision, zigzag patterns which move across in front of your eyes etc.) is seen in about 10% of migraine sufferers. Difficulty in talking or finding the right words, and feeling weak or numb in some parts of the body, are other symptoms that you can experience during the 'aura'. It lasts from a few minutes up to an hour. There may or may not be a gap between the end of the aura and the start of the headache.
• Headache : The headache may only affect one side of the head but can be all over. The pain is often throbbing and made worse by movement. The headache can last up to two to three days but you may still feel washed out for a couple more days. The most common accompanying symptoms are dislike of light (photophobia), dislike of sound (phonophobia) and nausea/vomiting. Some people become more sensitive to certain smells (osmophobia) and strong smells may even trigger an attack. Most are off their food, but some are extra hungry in spite of the nausea.
• Resolution and Recovery (Postdrome): After the headache has gone, feelings of lethargy and generally being 'washed-out' remain. It can take a couple of days to get over this. Some people are more lucky and find they have extra energy immediately after an attack - it may have something to do with the feeling of relief!

If you are a migraine sufferer…..

• Identify prodromal symptoms
  Ask friends and relatives if they notice any changes in you before the migraine attack starts. Look out for any differences in mood or behaviour in the 24 hours before the headache.
• Identify triggers
  You can divide the triggers into two groups - those which you can do some-thing about (missing meals, drinking red wine) and those which are out of your control (menstrual cycle, travelling). Try dealing with the triggers within your control. Cut out any specific triggers that you suspect, one at time. If you try to deal with too many all at once, you can't be certain which are most relevant to you. If you know that you have a particularly difficult period at work, be extra careful to make sure you don't miss meals or have too many late nights. Most people find it difficult to 'relax', but an active hobby (playing sports, cycling to work, walking) can help to relieve stress. Attacks triggered during menstruation may be helped by eating small, frequent meals, avoiding sugary snacks and alcohol, getting adequate sleep etc. in the week or ten days before your menstrual period.
• Take treatment early
  During a migraine attack, the body systems shut down and drugs are not easily absorbed. It is important to take migraine treatment without delay as early as possible in a migraine attack. This means that simple treatment can be effective.
• Carry a dose of treatment about with you
  Drugs can be taken without delay if you have them on you. Ideally keep a couple of biscuits and a small carton of drink with you so that you are not taking the tablets on an empty stomach.

What treatment is available?

Treatment falls into two main groups, 'acute' treatment and 'preventative' treatment.

• Acute treatment
  This includes drugs which are taken only when you have an attack. Simple pain relieving drugs may be enough to abort an attack if taken early. If this is not effective, your doctor will prescribe an anti-sickness drug to be taken in addition which can help the drugs to be absorbed. Your doctor can also prescribe stronger and more specific drugs for migraine if necessary.
• Preventive (Prophylactic)
  treatment:
  If you are having frequent attacks of migraine which interfere with your work or social life, your doctor may prescribe a short course of tablets which you take every day to prevent the attacks. Prophylactic drugs can help to break the cycle of frequent attacks and minimize the use of pain killers which can cause serious side effects with long term use. There are many different drugs available for prevention of migraine from your doctor.

(The writer is the Consultant Neurologist at Sri Jayawardenepura General Hospital)