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Migraine

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 Understand and Prevent Migrain

 

People who suffer from intermittent attacks of migraine know the symptoms all too well, the inconvenience of unexpected attacks, the frustration of “cures” that have not worked, and the expense of lost work and healthcare.

Understanding migraine – the different types, the symptoms, and the possible causes -gives you the knowledge to deal more effectively with your condition.


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.

 

(35) Migraine

 Cefaly - Anti-Migraine, Anti-Stress

 Migraine35

Preventative Drug Treatment for Tension – Type Headache

 How can I stop my tension-type headaches from becoming migraines?

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(36) Migraine

Stop Overusing Painkillers

Painkiller Infographic Reduced

Tackling medication overuse headache

Medication overuse headache (MOH) is challenging to treat because, first and foremost, it is about stopping taking the painkillers. Doing this successfully means finding the strategy relevant to you, as an individual; what works for one person may not necessarily work for another.

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(37) Migraine

Stop Overusing Painkillers

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COPING WITHOUT PAINKILLERS

I get a headache every day and the last time I tried to stop the painkillers the headache got so bad I had to start taking them again. I have to go to work and the only way to get through the day is to take the tablets. I just don’t think I can stop; what can I do?

Stopping painkillers is never easy. If your headache started off as migraine, the ‘rebound’ symptoms can be quite severe and be similar to the severity of migraine attacks themselves. The only way to completely break the medication overuse headache cycle is to stop using painkillers completely, no matter how bad your headache gets.

To be successful you need support. This can come from your friends, your family, or your work colleagues or it can come from medication that is not a painkiller but can help the pain from your headache. Your doctor or nurse will encourage you to seek help from those around you. It is about putting a strategy in place that can help you not only now but also in the future.

You need to consider all the options and decide exactly what you must do to reduce the chance of a headache developing. Finding a way of not taking the painkiller is about changing how you react and respond to pain or finding a way of stopping the pain happening in the first place.

I have young children and there are times when the headache gets so bad that I have to take something for it. Even though it does not get rid of the pain, it means I can look after the children until my husband gets home. What can I do if I can’t take the painkillers?

The challenge you have is that with medication overuse headache you must break the cycle. To break the cycle you have to stop taking the painkillers completely during the washout phase. To do that you have to do away with all the circumstances or situations that will provoke you into taking a tablet. You have to find a way of doing this, whatever it takes.

If the barrier to stopping the painkillers is ‘who’s going to look after the children?’ you need to find a time when it won’t be a barrier. This could mean arranging for a friend or family member to look after the children, so that you can concentrate on stopping the painkillers. You might need only a short period of time (a few days) or it could take a little longer (a week or two); there is no way of knowing just how long this it will be. It is one of those times when you really do have to take each day as it comes. To stop successfully, you need to plan carefully and ask for help and support from people around you.

The nurse at the clinic has been talking to me about different drugs I can use during the washout phase. How do I decide which one to take?

Choosing which drug to use is not an easy or straightforward decision. Some are automatically ruled out if you have specific medical conditions, such as asthma, so this is a ‘negative choice’. Some are automatically chosen because you have another medical condition that would benefit from a particular drug, so a ‘positive choice’. Some are chosen because of their possible side effects: sedation if you need to sleep, weight loss if you could do with losing some weight.

When the nurse sees you she will talk to you about the different drugs available and deciding which best meets your needs or suits you. There is no way of predicting which choice is the right one; there is the one that works for you but it is not always possible to choose the right one first time. Sometimes trial and error is the only way to move things forward.

The nurse has said that there are tablets I can take to help the pain that are not painkillers. She said that they are antidepressants but I am not depressed. Why should I take antidepressants?

Medication overuse headache can be seen as a form of chronic pain, and there is range of drugs that are used to help chronic pain that are not painkillers. One of these is a group of drugs called tricyclic antidepressants. Stopping this headache is about stopping the painkillers, and if taking a tricyclic antidepressant will help you do that, it is worth thinking about. It is another one of those ‘nothing ventured, nothing gained’ situations.

It could make the difference between taking back control and just not getting there, so why not give it a try? Why can’t I just take prophylaxis to make the headaches go away?

Prophylaxis can help, but if you have medication overuse headache you have to stop the painkillers as well. Understanding why this is essential is often difficult. It just doesn’t seem to make sense that tablets designed to stop pain should apparently cause it. Perhaps I can explain it here. Pain is felt when a receptor in the brain is stimulated.

What happens with medication overuse headache is that the receptors get reset and, instead of being ‘switched off’ by the painkiller, are actually kept ‘switched on’.

Pain is a response to a stimulus or irritant. When you have medication overuse headache, the receptor is so sensitive that it takes very little to produce a pain response. The only way to reset the receptor is to stop the painkiller. Painkillers and triptans seem to wind things up, making the nerves ‘irritable’, whereas preventative drugs help calm this response down and stabilise the nerve so that pain is felt less often and the response is at a lower and more normal threshold.

How can I make sure I succeed? I have tried to stop painkillers before but it just got too hard.

Success is about how badly you want to succeed and who else you get to help and support you while you go through the washout phase. It may be that you need to arrange some time off work, or get help with the children. Think about what will be happening during the washout period. Take positive steps and make positive choices and decisions. If you couldn’t do it on your own before, ask for help and support this time. People will help if they know you need it and why.

The nurse has said that I cannot take any painkillers during my ‘washout’. Why not?

The receptors in the brain have been reset by your taking regular painkillers, and as a result it takes very little to stimulate the receptor to send signals telling that you are in pain. The receptors have to learn to respond correctly rather than over-enthusiastically.

The washout means exactly that, it is a washing out of the receptors so that they respond more appropriately in the future.

My nurse at the clinic has said that I can call her any time. Will that really make a difference?

Yes, it can. Changing what you do is always difficult. It is easier to change if you have someone to help you. In some ways stopping your painkiller is like trying to deal with an addiction to anything, such as nicotine or alcohol. You need all the help you can get, so grab the opportunity with both hands! If you feel the need to take a painkiller, phone the nurse and talk to her instead.

Is there a good time to stop taking painkillers? I really want my headache to get better but it just seems so hard.

There is a good time to stop, and that is the time when you feel that you can do it successfully. This may take a little planning and thinking about. It means making sure that you have all the help and support in place that you feel you need.

I’m not getting a headache every day now, but I’m still getting some bad days when I have to go to bed. When are the headaches going to stop?

It is always difficult to know exactly what will happen when you stop the painkillers. The background headache should improve slowly with time. This means that you will shift slowly from a daily or near-daily headache to an episodic headache. The episodic headache is the one that you started with before your headache increased in frequency as a result of your use of painkillers.

If this headache is bad enough to send you to bed, it is probably migraine. But you still need to complete your washout because the longer you can keep going the better. Eventually all that you will be left with is the occasional bad headache, probably migraine, which you can then treat.

 What happens if the headaches don’t get better when I stop taking the painkillers?

 It would be unusual for the headaches to not change at all. You should notice a reduction in the total number of headache days that you get. There will be a gradual shift from daily headache, to fewer headache days, to no dull aching background headache to just the occasional migraine. It is unlikely that the headaches will stop completely but they should significantly reduce in frequency so that they become manageable and treatable.

If your headaches do not improve, you should continue not taking painkillers but think about taking a preventative drug. This would help control your headache and make it easier to stay off the painkillers. It may be that you need the preventative drug to ‘switch off ’ the nerve response completely.

 I have done really well and have stopped all my painkillers. That nagging background headache has gone but I still need to treat the migraine. I am worried that if I start treating the migraine my daily headache will come back. What should I do?

There is always a chance that your daily headache might return. Your migraine is a high-impact headache that needs treating. The best thing to do is to find the most effective acute treatment that gets rid of your migraine attack and makes sure that it stays away. This is called a ‘sustained pain-free response’. What you need to look out for are shifts in how your attack responds to your acute treatment. If your migraine seems to become less responsive, takes longer to settle and recurs more often, you need to be aware that the medication overuse headache may be coming back. If the number of headache days starts to increase, you may need to think about prophylaxis. Prophylaxis, or prevention, is about reducing the total number of headache days so that you don’t have too many days taking acute treatments.

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(38) Migraine

 Migraine Mechanism

Attitude

 

STOPPING TAKING TRIPTANS

My doctor says I have to stop taking my triptan every day but he wants me to take another tablet every day instead. I’m happy taking my sumatriptan when I need it, as it takes away my pain and allows me to get on with my life. I think what my doctor is suggesting could lead to lots of side effects and my headache will get worse. What do you think?

It is my opinion that, if you have to take sumatriptan every day, you have a medication overuse headache – that is, a triptan rebound headache. The headache develops as the effect of the triptan wears off, stimulating you to take another dose of the triptan; it does work but in this case is actually responsible for the headache developing the next day even though it seems to ‘fix’ the problem in the short term.

The only way to stop this rebound headache from happening is to stop the triptan. Yes, your symptoms will get worse in the short term but you will then go back to an episodic migraine rather than a daily migraine-like headache. I encourage you to take a preventative drug in the short term to reduce the severity and impact of the withdrawal

symptoms and possibly even in the medium term to minimize the number of headache days that you get, reducing the chance of developing rebound headache symptoms again in the future.

I use a triptan to treat my migraine. My doctor says that I am taking too many but I have to take the triptan or the migraine doesn’t settle. Is my doctor right?

Your doctor is probably right. The threshold for what is called ‘triptan rebound’ is about 8 to 10 triptans a month and this applies to any triptan. If you are taking more than 10, it is almost certain that your triptan is contributing to your headache. Headache recurrence when treating migraine is not unusual and occurs in 25–50% of attacks.

Repeating the dose is the right thing to do provided you get migraines only every now and again. The more frequent your migraines, the more headache days you have and the more days you take an acute treatment. The shift from episodic headache to medication overuse headache occurs with remarkable ease in some individuals!

Why does my migraine seem to come back? I am taking a triptan every day now. If I don’t take it early the headache just gets worse instead of better.

It sounds as if you have a triptan rebound headache. The headache often comes back at the same time every day. The brain’s pain receptors stop working properly, the headache creeps back and you feel you have to take another triptan – it becomes a vicious circle. It is just the same as getting medication overuse headache when taking ordinary painkillers.

COPING WITHOUT TRIPTANS

 I only take my triptan because the headache gets really bad. I just don’t know how I am going to avoid taking one for at least six weeks. What else can I do?

 Stopping triptans is never easy because the rebound headaches tend to be quite significant. Careful planning as to when you stop is as crucial to success as the how. Using preventative drugs as a routine measure is recommended, which, as always, is a balance between effectiveness, side effects, and possible risks.

Is there anything I can do to make it easier to stop taking my triptan?

Everyone is different in how they set about making such a significant change. You need to think carefully about potential triggers and stresses that contribute to your migraines. Also, make sure that you are in the best possible situation with all the support you need in place.

The specialist nurse has suggested that I may need to be admitted to hospital to stop my triptan. Why might this happen?

 The nurse has probably suggested this so that you are given the best possible chance of success. In hospital you will have none of the sorts of stresses and hassles that would occur at home. It also means that there will be people around who can help with any rebound symptoms you get and offer appropriate drug treatment if needed.

The specialist nurse has suggested that I take some beta blockers when I stop taking my triptan. Can they help?

I have found that beta-blockers seem to work well in relieving or easing the rebound symptoms when triptans are stopped. I usually recommend a 160 mg dose of propranolol as a slow-release preparation, which is taken just once a day.

However, if you have asthma or a history of asthma, beta-blockers are not an option for you. If that is the case, the nurse will discuss other preventative drugs with you.

I have been told to expect nausea and vomiting as well as the chance that the headache may get worse before it gets better. Is there any way to ease those symptoms?

 Research offers a variety of options, although none of them gives an absolute guarantee of success. The suggestions that I offer are based on the published evidence base and the experience we have built up at the headache clinic in York.

I suggest using metoclopramide or domperidone to ease the nausea and vomiting, and often suggest using diazepam as well. The diazepam is optional, but I usually encourage patients who have been overusing triptans for months, rather than days and weeks, to consider it. Diazepam is helpful if you are likely to get mood swings, irritability or sleep disturbance when stopping your medication – which in my experience is most likely when stopping triptans.

I would normally suggest using this mix of drugs for seven to ten days to ease the most severe ‘rebound’ symptoms.

I have stopped my triptans and feel that the propranolol has helped. How long should I take the propranolol after stopping my triptan?

Well done for having successfully stopped your triptans – not an easy thing to do. If the propranolol is helping to ease your symptoms, I suggest continuing to take it for a minimum of eight weeks. There is no absolute rule to help you decide how much longer after that you should carry on taking the propranolol. There are times when it is a good idea to take the propranolol for three months; sometimes it may be longer. The decision has to be taken on a day-by-day or week-by-week basis.

I had a lot of rebound symptoms when I stopped taking my triptan and was given diazepam and metoclopramide. The nurse has said I should stop taking them now. Are my symptoms likely to return?

Diazepam and metoclopramide should be used only in the very short term and I tend to suggest using them for no longer than the first seven to ten days. This provides cover for the most severe symptoms experienced in the first few days after the triptans have been stopped. The most severe symptoms should not return, and are most commonly associated with stopping triptans. Your headache symptoms will take longer to settle and this is why you will be encouraged to take preventative medication. If you are already on a preventative drug, it makes sense to carry on taking it in the short term and possibly in the medium term.

A friend of mine was given steroids when she stopped taking her triptans. It has not been suggested to me. Why not?

It is difficult to give you a simple answer to that question. There has been some research looking at what drugs offer the best way of easing or completely alleviating the symptoms associated with triptan withdrawal. One piece of research looked at using high-dose oral steroids, at a dose of 60 to 80 mg taken over the first three days that no triptans are taken. The results of the published trials were not very conclusive, so it is an option that tends not to be used as much now.

I can’t take beta-blockers because I have asthma. What are my options to try to ease my withdrawal symptoms?

You can try any of the standard migraine-preventative drugs, including tricyclic antidepressants and anti-epilepsy drugs. There is no ‘right’ choice.

 

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(39) Migraine

Kids Migraines- What a Pain!

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Children and headaches

Children can get the same sorts of headaches as adults. There are times when diagnosing the problem is harder but patience and listening to the parents and the child are usually rewarded. The criteria for making a diagnosis have been changed and modified over time to better reflect the reality of headache in childhood.

Non-drug treatments are often underrated as a way of improving headache in childhood: relatively simple changes can have a dramatic effect on the frequency of headaches. Choosing drugs to treat the acute headache can also be difficult because of drug licensing rules. The same range of drugs can be used for children but there must be careful discussion resulting in informed consent involving the parents or guardian or other responsible adult and the child. Similar choices and decisions have to be made with preventative drugs as well.

 Diagnosing Headache in Children

How will the doctor be able to tell that my child has migraine?

The diagnosis of migraine in children, as in adults, is made on the basis of the International Headache Society (IHS) classification, which uses a set of criteria that need to be met. Diagnosis can be more difficult in children, as the symptoms may be short-lasting and may not always occur every time. The child may not associate the symptoms

with the headache, or have the ability to describe them. The symptoms must be sensitive enough and specific enough to make the diagnosis of migraine. Sensitivity is about choosing the symptoms that discriminate and separate the different types of headaches accurately enough. Specificity is about choosing the symptoms that are precise and limited enough to separate the different types of headache. The higher the sensitivity and specificity of a set of symptoms, the more accurate, and reliable the diagnosis of migraine compared with any other headache.

The IHS criteria for diagnosing migraine in a child are:

• The headache attack lasts from 2 to 48 hours

• The headache has at least two of the following:

 - It is one-sided

- Has a throbbing quality

- Is of moderate to severe intensity

- Is aggravated by routine physical activity

• The child has at least one of the following:

 - Nausea and/or vomiting

- Sensitivity to light or sound gets migraine and finds it hard enough to describe my symptoms.

 How can I get my daughter, who is eight, to explain hers to our doctor?

 It is difficult to describe symptoms that you are experiencing to someone else, but do the best you can with prompting from the doctor. Your doctor will, with time and patience, be able to get a feel for what is happening to your daughter. You can help by describing what you see happening when your daughter is having her attack or you could ask your daughter to draw a picture to show how it affects her. There are some points your doctor needs to be aware of, because migraine in children can be quite different from that experienced by adults. The headache, if present, is often much shorter than in adults.

Nausea and vomiting may be more dominant than the headache. Migraine sufferers are often very pale and quiet during an attack. This may be the best clue, rather than a description of what is happening. I’m worried about my grandson. He doesn’t complain of headache but every now and again goes really pale and just curls up on the sofa rocking back and forth. He’s like this for a few hours and then bounces back, right as rain.

I remember his mum having similar problems and now she has migraine. Could this be the start of migraine in him?

Yes, it could. What effect or impact the symptoms have is often the best guide to what is happening. Going pale and looking ill may be the only symptom of migraine in young children. How he seems looks or behaves may be the only clue you have that he might be having a migraine. Headache does not always occur, or if it does may not be particularly severe.

The diagnosis of migraine is made on the basis that the same sequence of events recurs over time, and follows the same pattern on each occasion. This is called ‘being stereotypical’.

I think my son has migraine but my doctor says it doesn’t last long enough. Is he right?

Migraine headache in children tends to be shorter than in adults, and generally tends to be shorter the younger the child. The headache may last as little as 1 or 2 hours and perhaps no longer than 24 to 48 hours. Making the diagnosis is not just about how long the headache lasts but also the other associated symptoms of migraine such as being sensitive to light or feeling sick. An accurate diagnosis is about getting a feel for the balance of different symptoms and how they come together - the need for high sensitivity and specificity.

My son keeps having bouts of gastroenteritis, or at least that’s what I thought they were. I took him to see our doctor because he often has two or three days off school with diarrhea and vomiting. The doctor has suggested that it could be migraine. Could it?

It is certainly a possibility, especially if no other cause can be found. Children experience migraine in different ways and this sort of episodic bouts of illness is consistent with a possible diagnosis of migraine, especially if he looks pale, has some abdominal pain and is very quiet and withdrawn. If your doctor has ruled out any infective or other cause then migraine is quite possible. I thought the pain of migraine had to be one-sided and not on both sides.

I am sure my daughter has migraine but she gets pain on both sides of her head. Could it still be migraine?

One-sided pain is only one possible symptom in the diagnosis of migraine. The pain can occur on both sides, the diagnosis depending on what the pain feels like, and some or all of the other associated symptoms. So it could still be migraine despite the fact that pain occurs on both sides of your daughter’s head. Remember that migraine does not follow all of the rules all of the time, and headaches in children are the most unpredictable of all.

I think my daughter has migraine but when we went to the doctor she found it difficult to describe her pain. How important is that in deciding what sort of headache she has?

Describing pain is never easy but the severity or impact of the pain tends to offer a better clue to the diagnosis. Making the diagnosis of migraine is not just about describing the pain but asking about all the symptoms that are associated with migraine as well.

I took my son to see a specialist and she said that he has a migraine variant. What does that mean?

A migraine variant tends to be a form of migraine in which the headache tends to be less significant and the other migraines symptoms more prominent.

There are three different types currently within the International Headache Society classification:

• Cyclical vomiting

• Abdominal migraine

• Benign paroxysmal vertigo of childhood

 It is felt that although these types are not migraine they do occur in childhood and may herald the  development of migraine in later years.

What is cyclical vomiting?

I was reading about it on a website and wondered if that is what my grandchild has. She has been admitted to hospital twice now with dehydration. Cyclical vomiting is a condition that is associated with intense nausea and vomiting, lasting for at least one hour and up to five days. The vomiting will occur several times an hour, for at least an hour. The child is often very pale and lethargic during an attack, and completely well between attacks.

Our doctor says that my daughter has ‘abdominal migraine’. I thought you had to have headache to have migraine, so what does she mean?

No, you don’t have to have a headache to have migraine. In abdominal migraine there is abdominal pain that tends to last from 1 hour to 72 hours. I would expect your daughter to look pale, feel nauseated, or vomit, and she would choose to avoid bright lights. These last symptoms are similar to those of migraine, which is why the condition is called abdominal migraine. The abdominal pain is a substitute for the head pain and tends to be moderate or severe in intensity. It can be dull or the child will describe it as ‘sore’. The pain can be quite generalized or might be around the belly button (umbilicus).

I was told that I had abdominal migraine when I was a child but as I got older I seemed to get more and more headaches. Is that normal?

Yes, it is, or at least it can be. The consensus seems to be that, if you get abdominal migraine, you are likely to develop more typical migraine as you get older. There will be a shift from abdominal pain to headache with time.

I know what vertigo is like, but how can it be ‘benign’ when the symptoms are so horrid?

It is not particularly benign as an experience, but is benign in that there is no underlying ‘sinister’ or pathological cause. It affects young children and they become unsteady quite suddenly, grabbing on to any nearby object to stop them from falling over. They vomit, often profusely. If you look closely at the eyes you may see nystagmus - a jerking, side-to-side or up-and-down movement. The attacks occur repeatedly over several days before settling for a few weeks before recurring.

I used to get travel sickness as a child and now I have migraine. My son has started to get problems with travel sickness. Do you think he could develop migraine, too?

Yes, it is possible. Up to 40% of children with migraine have travel sickness. Migraine being triggered by travel may be a result of many different factors, including changed eating patterns, dehydration and flickering bright lights, to name a few.

How on earth can my young son have a tension headache? He’s only a child.

Anyone can get a tension-type headache, be it child or adult. The term is used to describe the particular mix of symptoms involved, not necessarily the cause. A tension-type headache can be similar to migraine in some children because the migraine headache is often not as severe as in an adult. Tension-type headache is not associated with nausea or sensitivity to light and sound whereas migraine is. Moreover, the headache is more likely to occur on both sides, and to be of mild to moderate intensity rather than severe. It is more likely to be felt as a tightness or pressure than pulsing or throbbing. The headache can last for as little as half an hour or for several days.

My neighbor’s teenage son has headaches that sound very like my cluster headache. Can children get cluster headache?

 Yes, they can. Cluster headache is rare under the age of 10, but can occur for the first time at any age. It most commonly occursfor the first time between the ages of 20 and 40, with more men being affected than women.

My daughter seems to be getting a headache most days. She does not often have time off school but she always seems to have a headache by the time she gets home. What sort of headache could she have?

It is difficult to be sure, but daily headache is not migraine. It may be a tension-type headache or possibly a chronic daily headache or even a chronic tension-type headache. If she has been taking regular painkillers, it could also be a medication overuse headache. From what you have described so far, it is not possible to be sure. I would look out for the usual diet and lifestyle things initially, such as regular meal patterns and a sensible fluid intake. It might be worth having a word with the teacher to see if there is anything your daughter is having problems with that she is not telling you. What should I do if I am worried about my daughter’s headaches? She seems to be getting them more often than ever before.

If you are worried about your daughter’s headache, it would be sensible to go and have a chat to your doctor. If your doctor feels that your daughter’s headaches fit neatly into a particular ‘diagnostic box’, he will offer appropriate advice for that type of headache. If he feels that your daughter’s headache does not neatly fit into any ‘box’, she may be referred to a paediatrician or paediatric neurologist. Headaches can be difficult to assess, especially in children, even though they can get the same sorts of headaches as adults.

One of my friends at school seems to be taking lots of paracetamol. She says that she has to take them to stop her headache getting worse. Should I get her to talk to someone about it?

Yes, you should - the challenge will be to convince her that she needs to. The regular use of any painkiller to treat headache has the potential to cause a shift from occasional headache to daily headache that becomes less and less responsive to the treatment. If she is using paracetamol that often, it is quite possible that she has a medication overuse headache and needs to see her doctor for help in stopping the paracetamol.

My son is getting what I thought were migraines but they seemed to be happening more often. At what point should I take him to our doctor?

You should take him if you are worried or concerned in any way. If you feel that there has been a significant change in how often he gets his migraine, an assessment by his doctor will help rule out a potentially serious (or ‘sinister’) cause.

Your doctor will want to know:

• If there are any new symptoms associated with his migraine

• If the symptoms have become more intense or dramatic

• If the headache is always on the same side or changes and swaps sides

The sorts of symptoms that cause concern are basically anything that is out of the ordinary and is different from anything that has been experienced before. If you are worried about it, do ask.

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