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2. What is migraine?

Migraine is a condition that can affect anyone at any time. Some people are more likely to experience migraine attacks than others but, if the right mix of conditions come together, almost anyone can experience a migraine. It is a condition that affects not just you and your quality of life but your family and friends and colleagues as well. How often have you had to miss a family party, not been able to make an important meeting, had to go to bed early or lost the first three days of your holiday just because of your migraine? By its very nature, migraine is unpredictable. We all like to feel in control of our lives but migraine can strike at any time and often at the most inopportune time. The more you, as an individual, understand about your migraine and how it affects you, the greater chance you have of being able to control your migraine. Or at least feel in control of it some of the time if not all of the time.

 2. 1 Defining migraine

 Question: I get headaches, so do I need to read a book about migraine?

Answer: Having an occasional headache is normal and is unlikely to be a sign that anything is wrong. However, recurrent headaches are not normal and are most commonly caused by migraine. Migraine may not be life-threatening, but it is a chronic (long-term) illness that causes significant suffering and disability for millions of people. This book will help you judge whether your headaches are caused by migraine, and will show you how migraine headaches can be managed.

Question: What exactly is migraine?

Answer: Migraine is a medical condition that causes intermittent attacks of headache and is associated with nausea and/or vomiting and sensitivity to light, sound, or smells. Like asthma and epilepsy, migraine is considered a chronic medical disorder. Migraine does not always receive as much attention and respect as other medical conditions, because headaches are such a common symptom. But it is important to understand that migraine is a real illness because this will help you accept that your condition deserves the same aggressive treatment as any other chronic disorder.

Question: How can something so common be so disabling?

Answer: Migraine is much more than a common headache.

Migraine is a real, and very treatable, condition that seriously affects millions of individuals worldwide. For years migraine was considered by many to be simply a reaction to stress. Now we have a better understanding of what migraine is, who suffers from migraine, and how to prevent and treat migraine attacks.

Question: How do I know if I have migraine or a “regular” headache?

Answer: You can tell you have more than a “regular” or tension (stress-related) headache by how disabling the headache is and the symptoms that are experienced with it.

In migraine, the headache can interfere with normal activities and there are typical episodes of symptoms that last for a period, then disappear. These symptoms include nausea and/or vomiting and sensitivity to bright light or loud noises. A regular or tension headache is less disabling, although it can still be severe, and is not accompanied by other symptoms. Headaches caused by stress are also more common in those who have migraine.

Question: I have bad headaches, but I can live with them. Why should I get treatment?

Answer: If your headaches are caused by migraine they are very treatable, and you are missing out on life by putting up with unnecessary pain. Yes, you can often try to ignore

the headache or take medications to dull the pain, but what you may not realize is how much your quality of life is affected. More importantly, as you push through the pain, and simply go on living with the headaches, the condition may be getting worse. Eventually, the headaches can affect your whole life, including your job, your social activities, and your relationships

Question: If I have migraine, why can I not simply take a pill for the headaches?

Answer: Migraine is a chronic (long-term) illness and cannot be successfully managed unless you have a good understanding of the condition, how it can be treated, and how you may need to change your lifestyle. Managing a chronic illness is never as simple as taking a medication and getting on with life as usual. The idea of having to live with a chronic illness may not be easy, but it is better than living with headaches

Myth or truth?

Myth “Migraine is simply a bad headache”

Truth No, there is more to migraine than just a “bad” headache. Migraine is a disorder of the brain, triggered by certain factors, such as stress, and a severe headache is only a symptom of this. Migraine is a progressive condition that is described aptly by the phrase, “a headache begets a headache.” The more frequent the migraine attacks become, the more attacks you are likely to have.

Question: Why do I have to change my life if the migraine happens only once in a while?

Answer: In many ways migraine is similar to asthma and epilepsy. In between attacks of migraine, individuals feel fine. Everyone with a chronic condition must make lifestyle changes treatment to be successful.

Chronic disorders like asthma, epilepsy, and migraine are among the most difficult for people to accept in their lives because the symptoms are so intermittent.

There is a natural tendency to want to deal with the problem when you experience the attack and ignore the condition when you are symptom-free. The major difficulty with this approach is that you are simply treating the symptoms and not the disease.

Question: Will my migraine get worse?

Answer: For some individuals with migraine, the attacks can become more severe and more frequent. However, some people have only a few attacks during their entire lifetime. The important point to understand is that you cannot gamble on this fact and ignore migraine if the attacks begin to increase in severity or frequency.

Question: Why would the migraine get worse?

Answer: Although not all headache experts and neurologists agree, migraine attacks, like epileptic seizures, may become more frequent with each attack, through a process called kindling. Many individuals with migraine go on to develop more frequent headaches. This trend has been termed the transformation of migraine into chronic migraine or chronic daily headache (more than 15 headache days a month). There are many risk factors for the development of chronic daily headache that will be discussed later. Suffice it to say at this point that life is too precious to spend one minute, let alone everyday, suffering from a treatable headache or migraine attack.

 2.2 Types of Migraine

Question: I hadn’t realised that there was more than one type of migraine. What are the main types?

Answer: There are lots of different types of migraine, the most common being migraine without aura (MOA). About 10% of migraine sufferers have migraine with aura (MA). There are even times when the aura can occur without the headache.

Then there are basilar-type migraine, retinal migraine and familial hemiplegic migraine. You could even have menstrual migraine (MM) or menstrually associated migraine (MAM); these two types are discussed later.

Question: How are common and classical migraine different?

Answer: Common migraine, which is the type that affects most migraine sufferers, is now called migraine without aura. It is what it says it is: a migraine attack without aura symptoms.

Migraine is a condition that has an impact on your quality of life (QOL).

The headache of migraine is a high-impact headache – one that stops you doing the things that you want to do or need to do. It is associated with nausea and/or vomiting, sensitivity to light and sound and possibly to smell, and with the need to keep still in the presence of these symptoms.

Classical migraine is now called migraine with aura. This affects about 1 in 10 migraine sufferers.

Aura is usually a visual disturbance, but may be associated with disturbance of sensation as well as other possible symptoms that usually occur before the headache and settle completely after 5 to 60 minutes.

The terms ‘common’ and ‘classical’ have fallen out of favor since the International Headache Society (IHS) developed a formal classification of headache disorders in 1988. Some doctors still use the terms ‘common’ and ‘classical’ but headache specialists refer to migraine by using the newer phrases of migraine with and without aura.

Question: Why is it better to avoid the phrase ‘classical’ when referring to migraine?

Answer:This is to reduce confusion as to what is meant by the term ‘classical’. Does it mean ‘straight out of the textbook’ or is it ‘a migraine attack occurring with an aura’? Using the phrase ‘migraine with aura’ is absolutely clear and avoids any potential confusion.

Question: I don’t think I get migraine because I never get any flashing lights. Am I right?

Answer: If you do not get flashing lights, all it means is that you do not get an aura. Only 10% of migraine sufferers actually get an aura, so you don’t have to experience this to have migraine. Migraine is a high impact headache that makes you feel unwell and stops you doing what you want, or need, to do.

Question: My friend’s daughter seems to have migraines at different times, with no obvious cause or trigger. What brings on a migraine attack?

Answering that question is difficult. The answer varies depending on whether we take the pragmatic holistic approach or the scientific perspective. Everyone is different and will say that X or Y causes their migraine, but not every time. The X and Y seem to be different for different people, at different times and in different circumstances. Some things cause problems for some of the people some of the time but not all of the people all of the time.

Question: I can’t figure out why I get a migraine some times and not at others. How can I find out what brings on my migraine?

Answer:You need to understand about your own migraine threshold – the point at which a migraine attack is more likely to occur – and what triggers affect your threshold. It helps to know how each trigger will tend to push your threshold down and nudge it closer to the point at which a migraine attack will inevitably occur. In any one person the combination of triggers that inevitably lead to a migraine will vary from day to day and month to month. Despite this, there are some triggers that affect people every time they are exposed to it. Very bright sunlight flickering through trees on the roadside will always trigger a migraine in some people or eating citrus fruits or particular smells in others. That’s the trouble with ‘rules’ – they are there to be broken! Most of you will already know the things that always cause a migraine for you. I am not keen on suggesting that people keep detailed diaries, as this tends to focus too much on negative detail rather than taking positive steps.

Question: The headaches I get aren’t always quite the same but they are pretty nasty. Are all my headaches migraines?

Answer: There are many different types of headaches and you can experience different headaches at different times. Migraine is a high impact headache that may or may not be associated with aura. Some people get just one sort of headache whereas others may experience several different headaches at different times. Working out exactly what headaches you get can be difficult and may take time, or several visits to your family doctor or a specialist. Deciding which sort of headache you have is about understanding where you get your headache, what sort of head pain you experience and what sort of symptoms you get with your headache. Other important features include how long the headache lasts as well as how often you get your headache. Next time you get your headache, write down what happens and how you feel. As with many unpleasant experiences, all you want to do is forget it as quickly as possible, so the best time to record what happens is while you are getting your headache or immediately after it has gone.

Question: Often my migraines last for only a few hours but they can also last for more than a day. How long does a typical migraine last?

Answer: Atypical migraine – that is, an IHS migraine – lasts from 4 to 72 hours in adults. This may vary from person to person and from attack to attack. The attack has a series of phases or stages. You may experience some of these phases some of the time, or all of the phases all of the time. The premonitory, or warning, phase is the first part of the attack. This may or may not be followed by an aura that leads to the headache phase and is followed by the recovery phase.

Question: Sometimes part of my face goes numb during a migraine. Is this normal?

Answer: This sort of symptom can occur during the aura or the headache phase of the migraine attack. It is part of the migraine, and does not cause any concern provided it settles before the headache does. If it extends beyond the headache phase, an assessment by a specialist is probably a good idea, but often it is part and parcel of the migraine rather than due to any underlying non-migraine reason.

Question: I’ve always had headaches from time to time but they seem to be getting worse. Should I be worried?

Answer: This is not an easy one to answer as it depends on what you mean by ‘worse’. Do you mean the pain is more severe or that the headache is lasting longer or that you are getting more  associated symptoms? Do you mean that the attacks are more frequent? Or do you mean that the treatment is not working as well? The severity of the pain can and does vary from attack to attack and it is impossible to predict or anticipate how it will be. As you go from childhood to teens and then adulthood the pain will often become more significant and may last longer. The pattern of symptoms and the frequency that you get your headaches can evolve and change through your life, and may vary from time to time for good reasons and sometimes for no reason at all.

There are times when you get all the symptoms associated with migraine and other times when you get very few. Again, it is impossible to anticipate how and when and why. If you have any worries or concerns, go and talk to your family doctor about them.

Question: I’m a bit worried because my headaches seem to be happening more often and I don’t know why. Can you reassure me?

Answer: The frequency of migraine attacks can vary for a wide range of reasons. A major factor is where your migraine threshold is: the higher the threshold, the less likely you are to get a migraine. The more potential triggers you expose yourself to, the lower your threshold and the more likely you are to get a migraine. Stress is often the thing that does the most to push your threshold down, but other factors can be just as important. If you feel that you are exposing yourself to a variety of triggers, there is probably no need for concern; just think about what you can do to raise your migraine threshold. If you feel there are few or no triggers in your life at the moment, and you are not getting any new or different symptoms with your migraine, it is unlikely that you should be concerned, but you might want to see your family doctor about what you can do to reduce the frequency of your attacks. If, however, you are experiencing new or different symptoms, it is probably wise to go and talk to your family doctor about them and make sure there is nothing to worry about. It may be that all you need is to think about preventative treatment, which your family doctor  can discuss with you.

Question: What is the typical number of migraines that most people have in a month or a year?

There is no ‘right’ answer to that question. The frequency can vary from time to time and from person to person. Some people can get a migraine a week, others a migraine a month and others may get only one or two a year. And some people can go for a few weeks with no attacks, followed by a week or so with several attacks. The length of an attack can vary, the attack being as short as a few hours or as long as three days. It is sometimes more helpful to think about migraine days rather than the number of attacks. This measure is useful in trying to assess the response to both acute treatment and preventative treatment. The goal in assessing a response to treatment is to reduce the total number of headache days.

Question: I’ve never had two migraines ‘set off’ by the same trigger in the same week. Does this mean that I’m briefly immune to the trigger by having the first attack?

Answer: The simple answer is ‘No’. Your migraine has occurred because your threshold dropped to the point at which a migraine became inevitable. Different factors or ‘triggers’ come together, usually in a random fashion, and push the threshold down. These factors often have different effects at different times, depending on where your threshold is and in which mix the triggers come together. This is probably why you feel that different triggers are responsible.

What is happening to me when I get a migraine attack?

Answer: Not an easy question to answer! Science is making small steps in understanding more about what is going on within the brain during a migraine attack. There are complex changes to chemicals (neurotransmitters) within the brain that affect the brain and the

blood vessels in the brain as well as the whole nervous system. These changes then lead to the symptoms that you experience during a migraine attack.

Question: I have been reading about chemicals in the brain and migraine. What is serotonin?

Answer: Serotonin is one of several neurotransmitters involved in the migraine attack. It is also referred to as 5-HT. There are two 5-HT receptor subtypes located in blood vessels in the brain: 5-HT1B and 5-HT1D. Activating these receptors causes a constriction of the blood vessel.

Question: What is CGRP and what does it do?

Answer: CGRP – calcitonin gene-related peptide – is a molecule that causes dilatation (widening) of blood vessels in the brain and also releases other chemicals (such as neurokinins) that lead to ‘sterile’ inflammation in the membrane around the brain. Any drug that mimics serotonin will block their release and hence prevent the vessel from dilating, or constrict the vessel if it has already dilated.

Question: I thought that migraines occurred mainly in women but I’ve discovered that men have them, too. Is migraine more common in men or women?

Answer: Migraine is more common in women, by about 3 to 1. This difference seems to develop during and after puberty; until then boys and girls are affected equally.

Question: Both my partner and I suffer from migraines. Does this mean that our children will be more likely to have them, too?

Answer: Yes, they are more likely to develop migraines than if neither you nor your partner suffered from them.

Question: How do I know whether I’m having an ordinary headache or a migraine?

Answer: With an ordinary headache you will usually be able to carry on with what you are doing. Migraine will make you want to keep still and, as it gets worse, you may want to lie down or retreat to a dark, quiet room.

Question: I’ve decided to see my family doctor about my headaches. How will she decide whether they are migraines or something else more serious?

Answer: Your family doctor will ask you a variety of questions about your headache and any symptoms associated with it. Deciding what sort of headache you have is about pattern recognition. If your headache fits into a specific pattern, that is the probable diagnosis. Making sure your headache is not serious or sinister means ruling out symptoms that cause concern.

Question: My family doctor said that my migraines are just that – that there are no ‘red flags’. What does he mean by ‘red flags’?

Answer: Red flags’ are the symptoms that may suggest a more serious cause for the headache. Sometimes these red flags have to be viewed in the context of your previous symptoms and sometimes they are important irrespective of your previous symptoms.

Question: Sometimes I can go several weeks without a migraine and then I have two or three in a week. Why is this?

Answer: How often you get migraine can and does vary. Migraine is, by its nature, unpredictable, and occurs now and again. ‘Now and again’ may be once a week, once a month or several times a year. If your threshold is low for any reason, it does not take much to keep pushing you over the edge into a migraine. When you say two or three in a week, do you mean separate headache days or are you getting a headache for two to three consecutive ays? The latter means your attack is lasting longer rather than occurring more frequently.

Question: The pain is always worse on the right side of my forehead. Why is this?

Answer: In migraine the pain is often, but not always, one-sided. Even if the pain starts on one side, though, it can move to the other side during an attack, or from attack to attack. If the pain affects both sides, the pain will often be worse on one side than the other. Different people have different experiences with where they get their headache – your headache just happens to be right-sided.

Question: My mother’s migraines seem to have got better lately. Will my migraines get better as I get older?

Answer: In most people, migraines tend to get better as you get older. The pain may get less severe, the associated symptoms may get less intense, and the attacks may occur less often or stop completely. In some women, attacks become more frequent around the time of the menopause. In others they occur less often and stop altogether. So it is not unreasonable to expect your migraines to get better as you get older but, unfortunately, it is by no means guaranteed. Even after the pain has gone, it still takes me another day or so to feel better.

Question: I feel absolutely washed out, tired and listless. Is this normal?

Answer: What you describe is commonly called the recovery phase, which is the final part of the migraine attack. This is the time when the brain is completing its recovery from the attack and the brain is slowly returning to normal function. The symptoms people experience during this phase vary from person to person and sometimes from attack to attack. The length of time that the symptoms last can also vary.

Question: My cousin says that her doctor told her that she probably has basilar migraine. What on earth is that?

Answer: Basilar migraine is now referred to as basilar-type migraine. This is a type of migraine that is associated with a very specific set of aura symptoms. These aura symptoms can be quite dramatic and as a result quite frightening, especially when they occur for the first time. The headache that follows fulfils the criteria for the IHS classification of migraine without aura.

The aura has to include at least two of the following symptoms:

dysarthria – the speech is slurred, and there is a difficulty saying words

vertigo – a sensation of spinning or turning

tinnitus – a ringing or buzzing in the ears

phonophobia – sensitivity to sound (also referred to as hyperacusia)

diplopia – double vision

visual symptoms - occurring at both sides of your visual field, either close to the nose or close to the temple

ataxia – anunsteadiness or clumsiness when moving your arms or legs • decreased level of consciousness

paraesthesiae – abnormal skin sensations that include tingling and numbness that are felt on both sides at the same time.

These symptoms may develop individually, in isolation, or in sequence over 5 to 60 minutes, and resolve completely before the headache starts.

Question: My son tells me that he has retinal migraine. Can you explain what that is?

Answer: Retinal migraine is a form of migraine in which the visual disturbance of the aura affects only one eye. The visual auras are ‘positive’ with flashing or zigzag lights and lines or spots, or ‘negative’ with blind spots (scotomata) or a blindness affecting part

of the field of vision in one eye such as a hemianopia or quadrantonopia (half or a quarter of the field of vision). The headache that follows fulfils the IHS criteria for migraine without aura.

Question: I have been told that I have retinal migraine. How do I know something more serious is not causing my symptoms? By ‘serious’ do you mean something wrong in the brain?

Answer: Ruling out a possibly serious cause in this situation is based on assessing the symptoms you experience and combining that with an adequate examination of your eyes and a neurological assessment. That assessment may or may not include a brain scan, which would be able to identify a specific ‘structural’, or organic, cause for your symptoms. When symptoms affect one side and particularly if they always affect the same side, a structural cause may need to be excluded before the benign nature of the symptom can be accepted. Benign ‘primary’ headaches are much more likely than a more serious ‘secondary’ headache. 

Question: I have had episodes in which I was unable to move my arm, at the same time as I had my normal migraine aura.  What sort of migraine is this?

Answer: An inability to physically move your arm suggests a true paralysis, or paresis, which is different from a feeling of heaviness. This ‘motor weakness’ is suggestive of a form of migraine known as hemiplegic migraine, which indicates paralysis down one side. If you have relatives who experience this form of migraine, it is called familial hemiplegic migraine; if not, it is referred to as sporadic hemiplegic migraine. The paralysis has to be accompanied by at least one of the following:

• fully reversible visual symptoms

• fully reversible sensory symptoms

 fully reversible speech disturbance and at least two of the following:

• at least one aura symptom develops over about 5 minutes and/or different symptoms occur in succession

• each aura symptom lasts more than about 5 minutes but less than 24 hours

• headache fulfilling the IHS criteria for migraine without aura, beginning during the aura or within 60 minutes of the aura starting

Question: My cousin has been told she has familial hemiplegic migraine. Could I develop the same sort of migraine?

Answer:  It is possible, if you have a first- or second-degree relative (parent, sibling, aunt, uncle, cousin) who has migraine with aura with ‘motor weakness’. Familial hemiplegic migraine has been linked to a specific chromosome abnormality.

Question: There are times when my arm feels heavy but I can move it. Is this a type of paralysis?

 Answer: No, it isn’t. Paralysis means being completely unable to move a part of your body, rather than a sensation of not wanting to or of it feeling heavy.

Question: Can migraine last for longer than 72 hours?

Answer: Yes, it can but, fortunately, not often. It may be as a result of the overuse of medication or the prolongation of an attack to four days from three days when using triptans that allow recurrence of headache symptoms.

Question: Is it possible to get a stroke as a result of migraine?

Answer: Yes, it is possible to have a stroke as a result of migraine; it is confirmed on brain imaging, usually a CT scan. Some studies have found that women under the age of 45 who have migraine have an increased risk of stroke. The risk is greater in women who have aura.

The important thing to remember is that the absolute risk, or the chance of a stroke occurring, is very, very low indeed. Current figures suggest that 1 to 3 per 100,000 women under the age of 35 years may have an ischaemic stroke. This increases slightly to 10 per 100,000 women over the age of 35. A three-fold increase in this risk is still very few people. If you have any concerns about the risk of stroke, think first about exercising regularly, eating a healthy diet, not smoking and having your blood pressure checked, and perhaps consider what your weight is. If you need any more advice, have a chat with your practice nurse or family doctor.

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