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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.


(40) Migraine

 Migraine Mechanism



Our doctor says that my daughter’s headaches might be caused by stress. Can children really get stressed?

Anyone can get or feel stressed, and children are no exception. The causes of stress can be different in children, potentially more complex and sometimes difficult to identify or recognise. Life can affect different people in different ways. The effect or impact of life

events should never be ignored or underestimated. Finding out what might be causing stress is often quite difficult and challenging. The only way is to ask around, seeing what friends and family members think or feel about what is going on. Worry about exams, being bullied at school, getting homework finished on time or even the illness of friends or family members may all cause problems that are not readily identified by you or your child. We all react and cope differently to life events. We all cope with and talk about our feelings in different ways and sometimes not at all.

My daughter is keen to go to drama class and chess club. Do you think kids can do too many things after school?

Getting the balance right between things we want to do, need to do and have to do is always difficult. Homework and chores have to be done, eating, and sleeping need to be done, after-school clubs and hobbies are things we want to do. Doing too much of everything is not a good idea and may cause stress but doing enough of the good things helps relieve stress.

I am always reluctant to be dogmatic but if she is getting a lot of headaches already, she will need to reflect on how full her days are. It is all about balance. By all means let her try to go to drama and chess club but remember there will still be homework and chores to do.

My son, who is at primary school, often gets his migraines in the afternoon. I am not convinced he eats his lunch. Could that be a trigger?

Yes, it could. If he skips, misses, or delays lunch, this may drop his migraine threshold and increase the chance of a migraine developing later in the afternoon. It might be worth having a chat to the staff at the school to see whether he is eating his lunch. If he isn’t, you will need to try to find out why. Children can be notoriously faddy and difficult when it comes to food these days. It may be that he will do better with a packed lunch, with a mix of healthy options and the occasional treat.

How hard should I try to get my daughter to have breakfast every morning? Is it really worth the effort?

Changing patterns of behavior is always challenging but often worth the effort! Eating regularly and drinking enough of the right sort of fluids are important. Breakfast is often referred to as the most important meal of the day because it ends the overnight fast, and the right sort of breakfast will set her up for the morning. It is all about keeping her migraine threshold as high as possible. The higher the threshold, the less likely that a migraine attack will happen.

The specialist nurse has said that if my son stops drinking so much cola he will get fewer headaches. Will it make that much difference?

Cola contains caffeine and sugar or artificial sweeteners. Caffeine can cause headache in its own right, as can artificial sweeteners. Drinking lots of fizzy drinks, especially if they are his sole source of fluid, means that he is less likely to drink enough water and so he

could become dehydrated to some degree. Dehydration has the potential to lower his migraine threshold, so drinking plenty of water but little or no cola can raise his headache threshold and make it less likely that he’ll have an attack.

How do I get my son to stop drinking fizzy drinks and have water instead?

Your son will have to want to do that for himself. Motivation and ownership of an idea are the best way to encourage the change to happen. Your son must decide for himself that he needs to do whatever it takes to reduce the number of headaches he gets. You can, of course, support him in that process. Only if he makes that decision for himself, though, will he be able to find the motivation to make the change from fizzy drinks to water.

The nurse has said breakfast, lunch, and dinner every day. That’s easy enough to say but how do you cut down on the junk food?

Changing diet and lifestyle is all about desire and motivation with a hefty dose of insight. Recognizing and accepting that avoiding junk food will make your headaches better is the first step to initiating change. Change comes from within and it is never easy to seem to be different. Peer pressure is a powerful force but if the desire for fewer headaches is strong enough, diet changes do happen. Once an improvement occurs, the change becomes the norm and accepted. Improvement will also encourage further changes in behavior.

My daughter has a part-time job after school, which means that she is up quite late sometimes doing her homework. Will all those late nights mean more migraines?

Too little sleep, as well as too much sleep, can lead to more migraines. Late nights along with early mornings can also lead to more migraines. A regular sleep pattern is the ideal, and a change in sleep patterns – for whatever reason – can cause a shift in the migraine threshold. Regular food and fluid intake may help but won’t completely prevent this, and anything that causes a fall in the migraine threshold has the potential to lead to more migraines.

Exams are coming up and I’m wondering what I can do to help my daughter get through without getting any migraines. Have you any suggestions?

Exams are a stressful time and there are a variety of approaches that may work for her. Stress in this situation can be both good and bad. It is about finding ways to spread the stress as much as possible, or use the stress in a positive and constructive way.

Try to plan regular breaks into the day and the revision. Encourage regular fluid intake and healthy snacks with regular meal breaks. Think about the range of potential triggers that come into play to push her migraine threshold down, and control the ones that can be modified so that the rest become less of an issue. Everyone is different and different triggers have differing effects at different times.

My son seems to spend most of his spare time in front of our PC playing games. Can computer games cause migraines?

Flickering lights can cause migraines and playing computer games in a dark room may trigger a migraine attack. Any computer screen, if used for significant periods in poor lighting conditions, could push the migraine threshold down and lead to a higher probability of a migraine developing. Posture may also be a factor in triggering headache symptoms in this situation.

Should I be discouraging my kids from playing computer games?

This is a difficult one, as things forbidden will often become much more desirable! A little bit of the things we enjoy doing is good for us, but too much of some things may not be quite such a good idea. As well as the lighting factor (see the previous answer), posture can have an effect in generating headache symptoms. So spending too much time crouched over a computer game could lead to headache symptoms. If there seems to be a direct cause and effect in any of your children, playing fewer computer games may be the answer. Triggers are rarely relevant in total isolation so think about other factors that may come into play at the same time, as these may need to be reviewed or modified as well. It is always difficult to know the best way to tackle things. All things in moderation are usually a sensible starting point. Banning something is rarely helpful, but restricting the amount of time spent is a reasonable compromise; also, not playing games in the 30 minutes before bedtime might help.



(41) Migraine

What is migraine?

British Association for the Study of Headache (BASH: UK)

Membership enquiries: Professor Peter Goadsby



What should I use for my daughter’s migraine attacks?

It depends on what sort of migraine and what symptoms she gets. If she has aura, taking something such as ibuprofen as soon as the aura starts is a good option. Even if she does not feel nauseated, taking something to encourage the stomach to empty will tend to make the ibuprofen work faster.

If she does not get aura but her attack starts with a headache, the same mix should work well if it is taken early enough.

Should I try ibuprofen or paracetamol to ease the migraine headache my daughter gets?

Either has the potential to work, provided a high enough dose is taken and it is taken early enough. Migraine is an inflammatory process, so ibuprofen should work better than paracetamol. Taking both together may work better than either one alone. Everyone is different, and the best treatment is the one that works best for your daughter – and you won’t know which until she tries them both.

My son gets quite bad nausea and vomiting. What can he try to help relieve these symptoms?

The best option is what is referred to as a gastric-emptying antiemetic - it helps the stomach to empty and should reduce the chance of vomiting. There are two drugs that can be used but domperidone is the one preferred in children. The dose is calculated on the basis of body weight and can be given as a ‘suspension’ (a liquid) as well as a tablet.

The alternative is metoclopramide, but this is best avoided if your son is under the age of 20 years unless no other option is effective. It can be given in the form of tablets, suspension or injection and, as with domperidone, the dose is calculated according to his body weight.

I would describe my son as being large for his age. Is there a right or wrong dose of ibuprofen to treat his migraine?

The right dose of ibuprofen is the one that works and relieves the headache quickly and completely. There are, of course, dosage guidelines for children in different age groups:

• In 1- to 2-year-olds: 50 mg, three, or four times a day

• In 3- to 7-year-olds: 100 mg, three, or four times a day

• In 8- to 12-year-olds: 200 mg, three, or four times a day. If he is large for his age, I would be inclined to calculate the dose on the basis of his body weight - if you know how much he weighs. The dose is 20–30 mg per kg, split into three or four doses in the day.

Remember that you can use ibuprofen in children under the age of 16, but not aspirin. If ibuprofen does not work, try paracetamol or go back to your doctor for more advice.

I have found that my daughter’s headache gets better with the first dose of ibuprofen but always comes back. Can I repeat the dose?

Yes, you can. She can take a dose every four to six hours, depending on how much she takes each time. The first dose should be the highest, and each subsequent dose could be slightly lower. The total dose that can be taken over any 24-hour period depends on her age and weight, and this total dose can help you calculate the best dose mix.

I use paracetamol for my child’s headache – is there a right dose? Can I give her too much?

As with ibuprofen you need to use the right dose of paracetamol soon enough in the headache phase of a migraine attack. The correct dose is decided on the basis of age, or body weight if under the age of 3 months, taking no more than four doses in each 24-hour period:

• 3 months to 1 year: 60 to 120 mg every 4 to 6 hours

• 1 to 5 years: 120 to 250 mg every 4 to 6 hours

• 6 to 12 years: 250 to 500 mg every 4 to 6 hours

If the child is under 3 months, the dose is calculated using the formula of 10 mg per kg body weight.

How can I tell that my son has the best treatment for his migraine?

That rather depends on how you define ‘best treatment’. The ‘best’ is usually the one that works the quickest, takes the headache away completely, does not allow the headache to come back during the next 24 to 48 hours, and causes few or no side effects.

There is no ‘best’ option to fulfill all these parameters but a suitable compromise should exist if you seek it out. Different people respond to different drugs and drug combinations and the best is the one that gives your son the best compromise.

My son’s treatment seems to work better at the weekend, rather than if an attack occurs at school. Why is that?

This is a difficult question to answer absolutely but treating migraine effectively is all about getting the medication on board quickly. It is generally felt that it may be easier to get treatment on board quickly at home than at school. Access in a school environment may be delayed by needing to get at the medication and also getting water with which to take it. It may also be harder at school to find a quiet place for a short period to allow the medication to take hold.

Why do the pills seem to work better for some attacks rather than others?

Timing is everything when it comes to taking treatment for migraine. ‘If I take my tablets quickly enough’ is a frequently heard phrase. The earlier pills are taken, the more effective they are in treating the attack. Early treatment tends to get rid of the headache more quickly and means it is less likely to recur in the next 24 to 48 hours.

There are other factors that come into play, and they tend to vary from person to person. The relevant factors may well reflect where the person’s migraine threshold is at the time that the attack is triggered. Another difficulty with youngsters is that the attack may be much shorter than is seen in adults, so the criteria used to assess the response may well not be valid or relevant. If the attack is shorter on occasion, the perception is that the treatment worked better, whereas the attack was settling anyway, regardless of the treatment.

Are there any right or wrong tablets for my son to take for his migraine?

The ‘right’ tablet is the one that works well in relieving all the symptoms of the migraine attack and stops it from coming back. The ‘wrong’ tablet is the one that does not relieve the symptoms of the attack or causes unacceptable side effects. Trial and error will discover the ones that help and the ones that don’t.

My doctor said that triptans are not licensed for use in children. What does that mean?

Drugs have to go through a formal approval process before they can be prescribed to treat specified conditions. This occurs after their effectiveness and safety have been assessed in drug trials. The process looks at what conditions a drug can be used to treat and for what age groups it can be prescribed.

Drugs can also be prescribed in an ‘unlicensed’ way, or ‘off licence’. This means that experience and common usage have led to a drug being used for other conditions or age groups. Triptans were originally tested only with adults, and are used safely and effectively by them. Recently, however, two triptans have been licensed for use in 12- to

18-year-olds and this would tend to suggest that all of them can probably be used safely in this age group.

How can I decide which triptan to give to my daughter when only two of them are licensed for children?

The triptan to use is the one that works the best. Sumatriptan adolescent nasal spray and zolmitriptan are currently licensed for use in 12- to 18-year-olds, so try those first. If they do not work as well as expected or hoped for, try the others in turn. You will then find one that works in the way you are looking for.

Is it safe to use something that is not licensed?

Using drugs that are not licensed is possible, and in fact may not be that uncommon. It will depend on what aspect of the licence is actually being ‘ignored’. With triptans, using a drug ‘off licence’ usually relates to the age of the person taking the drug. This is the only area where it is reasonable to consider using a triptan in someone under the age of 12 for sumatriptan adolescent nasal spray and zolmitriptan, and under the age of 18 for the other triptans.

It is felt that these rules of age can be broken, provided that the responsible adult, be this a parent or guardian, gives informed consent. There is a need to balance the theoretical risk of using a triptan in these age groups against the benefit in terms of improved quality of life and reduced time off school or work.

 How old do you have to be to take triptans?

Age is a relative thing but according to the licence you should be over the age of 12 to take sumatriptan adolescent nasal spray and zolmitriptan, and over the age of 18 for the other triptans. I take sumatriptan nasal spray and I noticed that the strength is 20 mg but the nasal spray my teenage daughter has been given is only 10 mg. Will hers work as well?

The form of sumatriptan licensed for teens is the ‘adolescent nasal spray’, which is a dose of 10 mg, whereas the adult dose for the nasal spray is 20 mg. The research evidence suggests it should work as well. If you and your daughter feel that it does not offer the necessary benefit, it is reasonable to ask her doctor if she can try the adult version to see if it is any better.

I use zolmitriptan for my migraines. Why can’t my kids use the same if they get migraine?

They can now, if they are 12 or over, because zolmitriptan is one of the two triptans that have been licensed for use between the ages of 12 and 18. Your doctor will probably want to check this out, and can do so by looking it up in a reference book known as the BNF. The BNF is the British National Formulary, which lists all the drugs available in the UK to treat any condition.

If sumatriptan adolescent nasal spray and zolmitriptan don’t work for my daughter, and they are the only triptans that are licensed for adolescents, can we try one of the other triptans?

Yes, you could but you need to talk to your doctor or specialist so that you can discuss the alternatives available and choose which one your daughter wants to try next. They are all worth trying but she will need to treat three consecutive attacks with any given triptan to assess how effective each one is. It is about informed decision-making and making you, as the parent or guardian, aware of the relevant safety issues and concerns.

My doctor has given me lots of information about sumatriptan and zolmitriptan. What other triptans are there?

There are seven different triptans in all, the other five being almotriptan, eletriptan, frovatriptan, naratriptan and rizatriptan; they come in a variety of forms: tablets, wafers or ‘melts’, nasal sprays and injections. There are pros and cons to each and they each work differently in different people. Trial and error is the only way to find out which one works for your child.

If the triptan eases the headache but doesn’t take it away, what else can my daughter try to get rid of her migraine?

She could try the same triptan at a higher dose, if one is available, or a different triptan. All triptans react differently in different people, so all are worth trying to find which works best. If the various triptan options do not work on their own, it is worth your daughter trying taking an anti-inflammatory such as ibuprofen or a simple painkiller such as paracetamol at the same time as the triptan.

It may be that taking an anti-nausea drug such as domperidone (in preference to metoclopramide) may make the triptan more effective. If this is not enough, a mix of triptan, ibuprofen, and domperidone may be needed. It is all about looking at the full range of options out there and ringing the changes until you find what works. Your doctor paediatrician or specialist nurse will be able to provide the necessary advice, information and support needed.

If there are seven triptans, is any one better than the others?

Not really - they all have the ability to work well if taken at the right time at the right dose. Different drugs are ‘best’ in different people, and what is best for one person may not be best for another. The choice is complex and based on a variety of factors, including speed of onset (how quickly the treatment works), sustained pain-free response (the headache going away and staying away) and low side effects (not making you feel any worse than you do already).


(42) Migraine

What is migraine?

Everyday Health - Headache & Migraine - Home Remedies for Headache Treatment

WebMD - Migraines & Headaches Health Center



  When is it time to think about preventative treatment for my son rather than acute treatment?

Preventative treatment is not a substitute for acute treatment because it will not stop all attacks happening. Deciding that prevention is a good idea and finding the motivation to take a tablet every day needs careful thought, as all drugs are potentially associated with side effects and although reducing the total number of headache days will not stop them all.

The point at which preventative medications are tried usually depends on the total number of headache days experienced in each month, balanced against the effectiveness of acute treatments and concerns about the overuse of medications with continued usage.

Deciding when preventative treatment is the right thing to do is about balancing a series of factors until a point or ‘threshold’ is reached; that threshold is different for everyone, adult or child, when it is decided that taking a tablet every day is worth it.

What drugs can be used to prevent migraine in children?

The same drugs used to treat adult migraine can be used in children, the dose depending on the child’s weight and age. Drugs include beta-blockers, anti-epileptic drugs, tricyclic antidepressants and pizotifen. All have been shown, in a range of trials, to have some effect in reducing the frequency of migraine attacks.

Is there a preventative drug that works best in children?

The best drug is the one that stops the most number of headache days and causes the least side effects. As with adults, any one child will react differently to each of the drugs available. There is a case to be made to try different drugs in the same class or group, as the effect may vary significantly from one to the next. A drug has to be taken for long enough at the right dose to have its effect.

I am not too sure I want my child to take a tablet every day to stop migraines. Do preventative drugs stop all migraine attacks?

No, they don’t. Preventative drugs will only reduce the number of headache days by up to 50% in up to 50% of people. Taking a tablet every day can be a chore and nobody wants to take a tablet every day without good reason. However, the advantages will outweigh the disadvantages if drugs are used for a limited period to break the cycle of frequent headache and return to an infrequent pattern of migraine attacks.

How can I know that my daughter is taking the right dose of the drug?

To minimise the risk of side effects I would suggest starting her at a low dose and then slowly increasing it to an initial ‘target dose’. This target dose tends to be the lowest dose at which that drug can be expected to have an effect.

The right dose is the one that reduces the total number of headache days by at least 50%. The number of headache days at each dosing phase needs to be monitored before a further dose increase is considered, assuming that side effects are not a problem. The doctor will review your daughter’s response to the drug at three monthly intervals.

If we decide that my son should take a preventative drug, how long will he need to take it?

He needs to take it for long enough to produce an effect: this is assessed by using diary cards (see Chapter 12) and counting the total number of headache days. Preventative drugs should not be taken permanently but for long enough to break the current cycle of attacks. There is rarely a need to take the drugs for more than six to twelve months.

Assuming that the preventative drugs work for my daughter, what is the best way to stop taking them?

Slowly! A gradual stepped reduction over a few weeks is the safest way to prevent a ‘rebound’ effect. During this step-down phase it is wise to pay particular attention to diet and lifestyle factors to support the process and keep the migraine threshold as high as possible


The nurse keeps talking about my menstrual cycle. What is my menstrual cycle?

A menstrual cycle is the length of time between the first day of one period and the first day of the next period. It can vary by up to seven days, but is usually fairly regular within a day or two. A simple diary recording exactly when you have your period allows you to calculate the length of your menstrual cycle. If you look at the diary, recorded in the months of March, April and May, you can see that the cycle from March to April is 29 days. You can work this out by counting the number of days from the first day of the period on 8 March, to the first day of your period on 5 April. If you count the days in the same way the April to May cycle is 32 days.

My cousin tells me that she has menstrual migraine and she reckons that I have it, too. What exactly is it?

Menstrual migraine, which affects about 10% of women, has a very precise definition. The attack must start no more than two days before the first day of your period and two days after the first day of your period, inclusive, and you cannot have attacks at any other time in your cycle. This must occur and be recorded in two out of three cycles.

If you record a period diary and then mark in the days that you have headache, you and your doctor can see if there is an association between your headaches and your periods. In the diary the areas marked ‘H’ denote headache days, and as you can see there are no headaches at other times of the cycle. This is menstrual migraine.

I think my migraines are something to do with my periods but how can I prove it?

The best way to prove it is to keep a diary that shows when your period is and when your migraine is. It is a good idea to keep the diary for at least six months, as you may not get a migraine with every period. If you don’t record things for long enough, the link may well be missed. The diary card shows that one attack (in March) may be menstrual migraine but the vast majority of headaches fall outside the definition of menstrual migraine. It is important to remember that some headaches may be migraine but some may be a tension-type headache; you need to understand more about associated symptoms in order to make this distinction.

Why do I get attacks around the time of my period?

Migraine can occur at any time and may be associated with your period just by chance. Migraine attacks happen when your threshold is low. A variety of factors have the ability to push down your threshold. One of these could be falling oestrogen levels along with dehydration and fluctuating blood sugar levels. Around the time of your period you tend to get food cravings, often for sweet things. If you reach for the cakes, sweets and biscuits, this tends to produce peaks and troughs in your sugar levels.

It is easy to get stressed and bad tempered around the time of your period. This may lead you to skipping or delaying meals or to having unsettled sleep, all of which could push your migraine threshold down.

My migraines tend to occur around my period. Is there anything I can do to stop them happening?

It rather depends on how you want to tackle it. The first step -which doesn’t involve taking tablets – is to think about diet and lifestyle changes. Try to keep your blood sugar levels as stable as possible with low glycaemic index (low GI) foods, eat regularly and drink plenty of water. Try to keep your caffeine intake – tea, coffee and colas – low, too.

The nurse at the clinic says I don’t have menstrual migraine. I can get attacks at any time but I always get an attack when I start my period. If it’s not menstrual migraine, what is it?

It sounds as if you have menstrually associated migraine. This term allows for the attack of true menstrual migraine to be accompanied by attacks at other times in the cycle as well as at the start of your period.

As you can see from the diary, the severe headaches are almost certainly migraine and the moderate headaches are probably migraine, but the mild headaches are probably not. The episode of headache at the start of the August period is a severe headache that is probably migraine, but the headaches during the rest of the cycle are mild. The attack before the June period is associated with the period, but there are other episodes of moderate headache (which may be migraine) in that cycle, making the diagnosis menstrually associated migraine rather than menstrual migraine.

I know that I have menstrual migraine. It has been suggested that using hormones might help. How is this?

The hormone concerned is oestrogen rather than progestogen, both being female sex hormones. Research has suggested that it is the size and speed of the fall of oestrogen levels that occurs at the start of the period that have the potential to trigger a migraine.

Hormone treatments are thought to help by slowing down the speed of the fall of oestrogen and thereby reducing the chance of a migraine attack being triggered. The important thing is to get the timing right, and that means starting the oestrogen two days before you expect the attack to happen and using it for seven days. The oestrogen is most effective in the form of a patch or gel, because this delivers steady and even levels of hormone into the bloodstream. The main drawback with this approach is that your periods must be regular: you have to be able to predict when the period will start so that you can begin the treatment two days before.

As you can see from the diary each cycle is of 29 days. The migraine attack starts on a different day in each cycle, so you will need to start your oestrogen four days before the start of your period to anticipate the onset of your migraine. As you can appreciate, your periods really do need to be regular to be able to use this approach.

I am happy to try oestrogen to stop my menstrual attacks happening but why do I have to use a patch rather than a tablet?

Hormone-dependent attacks are triggered by fluctuating oestrogen levels and the degree and rate of change are the factors that need to be modified to prevent attacks from happening. A patch allows a steady, even level of hormone to develop in the bloodstream.

A tablet, however, has to go through the stomach and intestine to be absorbed, and many factors may affect how well it is absorbed. Varying rates of absorption of oestrogen lead to fluctuations in hormone levels that are less than ideal for the task.

I have tried several different patches but am sensitive to the adhesive. Using the oestrogen seems to work really well, though, so is there anything else I can try?

One trick, if you have not tried it yet, is to wave the patch in the air before applying it. Sometimes it is the alcohol that causes a reaction rather than the adhesive itself. If that does not work, you could try an oestrogen gel instead. The gel gives a steady level of oestrogen in the same way the patch does.

My doctor has suggested that I take naproxen regularly to stop my menstrual attack happening. Is it really going to work?

Naproxen is a non-steroidal anti-inflammatory drug (NSAID) that works by targeting a particular chemical called prostaglandin. Prostaglandin levels are known to rise during a period and have been shown to trigger a migraine-like headache. Anything that can stop the rise in prostaglandin levels should reduce the chance of a migraine being triggered.

If you get painful periods, you could continue to take the naproxen to the end of your period to relieve these symptoms. If you start the naproxen two days before you expect the migraine to happen and take it for seven days, there is a fair chance that the attack will not be triggered. You have to be able to predict exactly when your period is going to be for this option to be viable.

I have painful periods and always get a migraine on the first or second day of my period. My doctor has suggested I take a non-steroidal anti-inflammatory. Why will this help me?

Prostaglandins are chemicals released by the lining of the womb, causing the pain of painful periods. They are also associated with the triggering of migraine attacks. Using a non-steroidal anti-inflammatory drug (NSAID) such as naproxen or ibuprofen can suppress the level of prostaglandins in the blood and thus reduce the chance of a migraine happening as well as helping the pain of your period.

Are all non-steroidal anti-inflammatories the same? I know the names are different but if one doesn’t work, is it worth trying another?

Each NSAID does seem to work differently in different people at different times. If one doesn’t seem to work for you, it is certainly worth trying a different one. There can also be a ‘dose response’ aspect as well, so, if the lower dose does not work, try a higher one.

Remember that the drug has to be taken regularly to be effective in preventing an attack from developing.

My menstrual attacks are really hard to treat. What is the best way of getting rid of the migraine?

It is not clear why menstrual attacks are often difficult to treat. If you usually use a triptan to treat your migraine, you need to think about using the top dose of whichever one you take.

For example:

• Sumatriptan: try 100 mg instead of 50 mg, or the nasal spray instead of the tablets.

• Zolmitriptan: try the 5 mg dose rather than 2.5 mg, or the nasal spray instead of tablets.

• Eletriptan: think about using 80 mg rather than 40 mg or 20 mg.

If the triptan you use has only a single dose option or if the maximum dose doesn’t allow you to be headache-free or does not prevent headache recurrence, think about using a mix of drugs to do the job.

This may mean using a triptan and an NSAID along with an antinausea drug such as domperidone or metoclopramide. You need to use what is called a pro-kinetic anti-nausea drug to promote emptying of the stomach and thus help all the drugs be absorbed.

If this mix gets rid of the headache but it tends to recur, you may have to repeat the dose of the NSAID through the course of the next 24 to 36 hours to be sure of hitting the attack on its head.

Zolmitriptan works quite well for most of my attacks but my menstrual attacks just don’t seem to settle as well. Any suggestions?

I suggest that you try zolmitriptan, either the 5 mg Rapimelt, or two 2.5 mg tablets or the nasal spray. If that is not enough, add in naproxen or ibuprofen. Naproxen should be used in a dose of 500 mg, and you can repeat the dose in about 12 hours. Ibuprofen can be used in a dose of 400 mg, 600 mg or even 800 mg. The dose can be repeated in six to eight hours but you must not take more than 2,400 mg in any 24-hour period.

I have found that naproxen seems to work better than ibuprofen for my menstrual attacks. Why is this?

Different drugs do work differently in different people, and it may be that naproxen is the one that suits you. There is a suggestion that naproxen may target just the right prostaglandin that is released during your period and is involved in triggering migraine.

I want to try to prevent some of my migraines. Some are around my period and some occur at any time. What can I do?

There are lots of options and any one of them might help you. It may be that you need to think about all the options, but try each one alone before trying different combinations until you find what works for you.

Diet and lifestyle changes are always a good start. Eating regularly, drinking lots of water, trying low glycaemic index (GI) foods and having regular breaks to de-stress through the day can all help. If making these changes helps a little but you want to try something else, you need to decide whether you want to try a preventative drug. This means taking something every day to try to reduce the number of headache days you get throughout the month.

Alternatively, you might want to try a targeted option – taking the preventative drug just prior to your menstrual attack – but it won’t help attacks at other times of the cycle.

The choices are yours and yours alone but your doctor, specialist or specialist nurse are there to support you through the decision-making.

I don’t really want to take a tablet every day to stop my migraines. Is there anything else I can do?

If you do not want to take preventative drugs, you will need to focus on diet and lifestyle changes or consider ‘targeted’ treatment focused on your menstrual attacks. If neither of these has enough of an effect, though, you will need to think about preventative drugs, but to work they will have to be taken every day.

If you have attacks throughout your cycle, intermittent treatment around your period isn’t going to have a significant impact on the total number of headache days. It is a trade-off because, if your menstrual attacks are stopped and these are hardest to treat, stopping them may be the best option for you.



(43) Migraine

Managing Headache During Pregnancy

Migraine Action UK - The national advisory and support charity for people affected by migraine


Migraine & Headache Center



 I’m expecting our first baby. Am I more or less likely to get migraine while I am pregnant? 

If you get menstrual migraine, there is a 60-70% chance that you will have few or no migraines while pregnant. This is even more likely if you normally get migraine without aura. Up to 25% of women get no change in migraine frequency while they are pregnant but, unfortunately, 4-8% finds that their attacks get worse. They are more likely to get worse if you normally get migraine with aura.

My sister did not get any migraines while she was pregnant but I do. Why are we different?

It would be fair to say that no one really knows why but it is assumed that it is something to do with the steady level of oestrogen that occurs during pregnancy. Pregnancy is divided into three ‘trimesters’ and migraine might get worse in the first trimester and then improve in the second and third trimesters.

Your situation is more likely to improve if you have migraine without aura. You are more likely to get migraine with aura for the first time during pregnancy and it is more likely to get worse during pregnancy.

I have always had migraines around the time of my period. Will they get better or worse while I am pregnant?

Migraine around the time of your period, especially if it is true menstrual migraine, is normally migraine without aura. The expectation would be that the migraine will get better, especially in the second and third trimesters.

Are there any headaches that occur during pregnancy that I should be worried about?

A serious (or ‘sinister’) headache can occur at any time, not just during pregnancy. The main concern in pregnancy is a headache that is associated with pre-eclampsia or eclampsia. Pre-eclampsia is a condition that can occur at any stage in pregnancy and is associated with a rise in blood pressure, swelling of your feet and/or fingers and protein in your urine.

Eclampsia is the next step and much more serious. The headache will often become much more severe, the blood pressure higher and may be associated with changes in the level of consciousness and, occasionally, fits. If you are worried about your headaches, talk to your doctor or midwife about them.

I am six months pregnant and occasionally get blurred vision with a bad headache. Should I go and see my doctor or midwife?

Any change in your vision should not really be ignored. It could be related to your blood pressure or possibly a rise in the pressure in your eye. The latter, called glaucoma, can be associated with eye pain or headache.

Blurring of your vision is not usually a feature of migraine aura unless it is what is referred to as stereotypical – meaning that the pattern is consistent and blurring is more of a visual distortion rather than just a slight loss of focus.

If you get new symptoms or a change in symptoms, it is always important to seek advice. If you don’t want to bother your doctor in the first instance, you could see your optometrist and, if this assessment seems normal, see your doctor or midwife.

I am a little concerned as I got these horrible flashing lights in the middle of my vision when I was pregnant. I never got a headache to follow. What was this all about?

Migraine with aura can occur for the first time in pregnancy, although it is not clear why. The flashing lights might have been a migraine aura. As is the case when you are not pregnant, it is possible to get an aura but not have a headache follow it.

My mother got her first migraine when she was pregnant with me. My sister and aunt get migraine, but I have never had one. I have just got pregnant and wonder what my chances of getting a migraine while pregnant are?

The optimistic view would be low, the pessimistic view would be high and the realistic view is ‘who knows’. If you have a family history of migraine, you have an above average chance of developing migraine at some time. Migraine can develop at any time and pregnancy is as good a time as any.

I have never had migraine before but I developed migraine with aura during the early part of my pregnancy. Should I be concerned, and will I always get them now?

Not easy questions to answer! If you have a family history of migraine, you could develop migraine at any time, and migraine with aura is more likely to occur for the first time during pregnancy.  It is important that you ask your doctor for a full assessment in order to confirm that there are no symptoms, or ‘red flags’, to cause concern, and make sure that on examination there are no abnormalities to be found to suggest a structural cause.

Aura tends to follow a typical pattern and, provided that what you experience fits with what is regarded as normal, there is little cause for concern. If the aura symptoms are not typical, your doctor might refer you to a neurologist, to exclude any possible ‘sinister’ cause, especially when they occur for the first time.

I’m afraid it is impossible to say whether your migraine will continue after the baby is born. Only time will tell. My migraines have settled while I have been pregnant but what’s going to happen when my baby arrives?

If you are lucky, you may not get a ‘rebound’ effect immediately after the baby arrives. Unfortunately, the evidence suggests that as many as 40% of women who have migraine get their migraines back after the baby is born.

What can I take to treat my migraine while I am pregnant?

Hopefully, you won’t get many migraines while you are pregnant, because your options are limited in real terms to paracetamol. If you get significant symptoms and their severity justifies using other drugs to aid the nausea and vomiting, you could take an anti-nausea drug, but this may be discouraged in the way that the use of any drug during pregnancy is discouraged. See the next few answers for more information. Some people have found that ginger in its various forms - biscuits, tea, cordial - may help some of your nausea symptoms.

I have been told that all I can take for my migraine while I am pregnant is paracetamol. Why can’t I take anything else?

As I am sure you know, no drug is encouraged during pregnancy other than iron supplements and folic acid. The reason for this is that at any stage in the pregnancy a drug might have an effect on the growth and development of the baby. Different drugs tend to have different effects and degrees of effects at different stages of the pregnancy.

Over time a database has been built up to try to evaluate exactly what effects drugs have. This information tends to be ‘opportunistic’ (not the result of scientific research), and often reflects the fact that women have taken drugs in the very early stages before they realized they were pregnant.

Deciding to take anything during pregnancy is about balancing the potential risk of the drug affecting the developing baby and the potential consequence of not managing a problem that needs treating. Discuss the benefits and risks with your doctor or midwife before making a decision.

What can I do if my migraine gets worse while I am pregnant?

Any drug is best avoided in pregnancy. Preventing migraine by following a diet and lifestyle regimen that will keep your threshold as high as possible is a vital first step to staying in control. Making a decision to take drugs is about weighing up the risks and benefits to you and to your baby, which do change in the different stages of pregnancy.

Some drugs that are used to treat migraine are also used for other conditions, and occasionally the potential benefit may well outweigh the theoretical risks of using these drugs in pregnancy.

Talk to your doctor or midwife about lifestyle changes you can make now and what the options might be if your migraines get worse.

How does the specialist decide what I can take to treat my migraine while I am pregnant?

It is never an easy decision to make and tends to depend on the severity of the symptoms you are experiencing and whether the benefit of taking something outweighs the risk. Some drugs, such as beta-blockers and antidepressants, that can be used to treat migraine, are also used to treat high blood pressure and depression during your pregnancy. These drugs are introduced because not treating the high blood pressure or depression would have a detrimental effect on both mother and baby. Starting these drugs to treat migraine does depend, though, on whether you feel that the possible risk is worth it.

I am taking a preventative drug for my migraine but want to get pregnant. Do I need to stop it?

It is a good idea to stop and see what happens to the frequency of your migraines as a result. The probability is that things will be OK. The advice will always be ‘avoid any drug during pregnancy’ if at all possible. Some drugs carry a lower risk of harm than others, but taking any drug needs careful thought and consideration.


  • Cause intra-uterine growth retardation (slow the growth of the baby in the womb)
  • Cause bradycardia (slowing of the heart rate) after birth
  • Cause hypoglycaemia (very low blood sugar) after birth Anti-epilepsy drugs (AEDs):
  • When used to treat epilepsy the risk of harm outweighs the risk of treatment
  • When used to treat epilepsy the risk of harm increases if more than one drug is used at the same time

There is increased risk of neural tube (spina bifida) and other defects associated with any AED but especially with:

  • Epilim (sodium valproate)
  • Carbamazepine
  • Oxcarbazepine
  • Phenytoin

If I stop my preventative drug, will my migraines get worse? If they do get worse, what can I do?

There is no way of knowing if they will get worse but they shouldn’t. No preventative drug is taken permanently, so they will have to be stopped some time. The best way to stop it is to reduce the dose slowly, in steps, until you stop taking it altogether. During the

phase of ‘stepping down’ and stopping the drug you need to really focus on the diet and lifestyle areas to keep your migraine threshold as high as you can.

I am planning to breast-feed and wondered what I can take to treat my migraine?

Paracetamol is top of the list. If you need something different, you could try ibuprofen but aspirin and other NSAIDs are to be avoided, as should codeine. If you need something to help the nausea and/or vomiting, opt for domperidone rather than metoclopramide; you could try prochlorperazine if you cannot tolerate domperidone.


My sister, who also gets migraine, was told she could not go on the Pill. Why is that?

It rather depends on what sort of migraine she gets. If she gets migraine with aura, current guidelines recommend that she should not go on the combined oral contraceptive pill – that is to say, she can’t take a Pill containing oestrogen. However, there is no reason why she can’t use the progesterone-only pill, progesterone injection or progesterone-containing coil.

I have been on the Pill for about two years. I got an aura with my last two attacks, and my doctor has told me to stop taking the Pill. Why do I have to stop?

It is all to do with risk and your risk of developing a stroke, specifically an ischaemic stroke. An ischaemic stroke occurs as a result of a reduction or loss of blood supply to part of the brain. It is estimated that between 1 and 3 women per 100,000 women under the age of 35 years may experience an ischaemic stroke. On an individual level your chance is very low but there are other risk factors that need to be considered and migraine is one of them. Other factors include smoking, being overweight and taking the combined Pill.

Having migraine increases your chance of having a stroke by three and a half to four times. Migraine with aura carries twice the risk of migraine without aura. If you smoke and have migraine, your risk is increased by ten times. Taking the Pill and smoking increases your risk by 34 times.

As you can see, the risks tend to be cumulative. Although the absolute numbers are quite small, the nature of the cumulative risk cannot really be ignored and the fact that you have developed aura is the decider.

Why has my doctor told me that if I want to stay on the Pill I should stop smoking?

If you have migraine without aura and more than one risk factor for stroke, you should stop the Pill – assuming you mean the combined oral contraceptive (COC) pill. Smoking is a potent risk factor, and having migraine and being a smoker and being on the COC pill is not a wise mix. All these, as well as other risk factors such as being overweight or having a high cholesterol, are reasons to think about stopping the Pill.

I know I am overweight but I need reliable contraception. I have been told that, because I smoke, I really should not go on the Pill. Why not?

If you have migraine without aura and want to go on the combined oral contraceptive (COC) pill, you should either lose weight or stop smoking – or, ideally, both. It is about cumulative risk factors and too many risks become a ‘no’.

If you feel unable to do either of those things, you need to consider a contraceptive option that does not involve oestrogen. From a hormone point of view, that would be the progesterone-only pill, progesterone injection or coil.

Topiramate works really well as a preventative drug but I’m having problems with using the Depo injection for contraception. Why can’t I go back on the Pill?

Topiramate is an anti-epilepsy drug that is known to stimulate or induce liver enzymes to work harder. This means that any drug that is processed by the liver before getting into the circulation is broken down or inactivated more quickly, and so less of the drug is active or ‘bioavailable’ to do the job it is meant to do.

Any drug taken by mouth has to be processed by the liver and its bioavailability is affected as a result. Going back on the Pill is possible but it would be less reliable from a contraceptive point of view, because more of the hormone would be broken down by the liver and less would be available to have its contraceptive effect.

I have been started on topiramate for my migraine. What are my contraceptive options?

Your best options, in terms of effectiveness and reliability, would be progestogen-only injections or the LNG-IUS (levonorgestrel intra-uterine system). The former is given every 10 to 12 weeks and the latter is a coil that is impregnated with progestogen that is slowly released within the womb; once fitted, the coil can stay in place for five years.

I am keen to go back on the Pill despite being on topiramate, as it controls my periods better than the injection. What can I do to make it more reliable as a contraceptive?

You could go back on the Pill but you would have to double up on your contraception in order to increase the contraceptive effect. You could do this by taking a stronger pill – a 50 μg pill, which is no longer available as a standard ‘off-the-shelf’ prescribable option, so you would have to double up with one that is still available or you might opt to use condoms with or without spermicides. You will need to chat to your doctor or visit your local family planning clinic for more advice.

I want to stay on the Pill, as it suits me really well. What could I take to reduce the total number of migraine days I get?

You could try valproate, gabapentin or levetiracetam. These are all anti-epilepsy drugs that will not have an effect on the contraceptive reliability of your Pill and have all been shown to have some effect in preventing migraine – they are not liver enzyme ‘inducers’.

I am on the Pill, having been using condoms while taking topiramate, which I’ll be stopping soon. How long do we need to carry on using condoms?

You should continue to use condoms for four weeks after you have stopped taking topiramate. This allows your liver enzymes to get back to normal so that the Pill can work as effectively as possible, once its bioavailability is back to normal.


(44) Migraine

Migraine Pathophysiology (Video)

What is migraine? What causes migraines?



Everybody says my migraines will get better when I stop having periods. Are they right?

There is a good chance that your migraines will improve once you reach the menopause and have stopped having any periods. Unfortunately, there is also a chance that they will get worse or even stay the same. There is no way of knowing or predicting what will happen.

I am convinced that my migraines have started to get worse now that I am getting some sweats and flushes. Is this because I am becoming menopausal?

Probably, is the simple answer? Sweats and flushes are common in and around the time of the menopause. Menopausal symptoms are caused by fluctuating hormone levels, and it is quite likely that it is these peaks and troughs in oestrogen levels that lower your threshold so that migraine attacks are triggered more easily.

My gynaecologist has suggested that I have a hysterectomy. I have really bad periods and my migraines are getting worse. Will the hysterectomy help?

A hysterectomy will definitely help the periods but will probably make the migraines worse. Evidence suggests that a natural menopause reduces the chance of having migraine to about 7% whereas having a ‘surgical’ menopause leaves you with a 27% chance of getting migraine if you have no premenstrual syndrome (PMS) symptoms. Not the best of odds, I am afraid. See also the next question and answer.

I used to get bad premenstrual syndrome when I was a teenager and it is getting bad again. The migraines are kicking off as well. My periods are irregular and really heavy. Is hysterectomy the best option?

Premenstrual syndrome (PMS) is not much fun at the best of times and is not easy to treat. It is often associated with migraine-type headaches and migraine can also occur more closely associated with the period. Regulating the period cycle is a good idea, as it may make it easier to control the PMS. Hysterectomy is not the best of options: the evidence suggests that a ‘surgical’ menopause with a history of PMS gives you a 44% chance of getting migraine afterwards compared with 7% without an operation.

I stopped having periods last year. I have never had an aura in my life but last month I became aware of short episodes of flashing lights, just like forked lightning. They last 15 to 20 minutes each time but I don’t always get a headache. Should I be worried?

It is not uncommon to experience aura in the absence of headache and is a recognised entity. If you have never ever had aura, it is a good idea to see your doctor so that a full assessment can be made to ruleout any other possible cause for the aura developing. It is a good idea to check your blood pressure, cholesterol and other similar risk factors for stroke. It may even be necessary to have a brain scan to be absolutely certain that the aura is just migrainous. That decision is best made by a specialist.

My migraines seem to have got worse as my periods have got more irregular. The specialist has suggested I see my doctor to discuss HRT but I have read so much about it in magazines that I am not sure what to do. Why is HRT a good idea?

HRT can help some of the people some of the time. There are, of course, a lot of pros and cons, and the decision-making is nowhere near as easy or straightforward as it used to be. HRT is believed to help by keeping your oestrogen levels as even and steady as possible, because it is thought that it is the peaks and troughs in oestrogen levels that may push down your migraine threshold to a point where triggers are more easily able to generate a migraine attack.

I always thought that HRT protected you against stroke, at least that is what my aunt was told when she started HRT ten years ago. My doctor has said that it increases the risk of stroke. What has changed?

Over recent years a lot more research has been completed that has looked at the long-term effects of using HRT. A careful review and analysis of these studies suggests that, on the basis of the best current evidence, the use of HRT increases your chance of ischaemic stroke by 1.29. There is no evidence that it has an effect on haemorrhagic stroke (1.07) or transient ischaemic attack (1.07).

What do these figures mean? If the number is ‘1’, this means that there is no difference. If the number is less than 1, this means that you are less likely to have a problem; if the number is more than 1, you are more likely to have a problem. The bigger the number the greater the risk of an event happening.

My mother and her sister both had breast cancer. My migraines have got much more frequent during the last few months. I am getting sweats and flushes and my periods are all over the place. I have been thinking about going on HRT, but will it make a difference and what are the risks?

If you are getting a lot of menopausal symptoms, tend to get menstrual migraine and want to find a way of regulating your periods, HRT may well help you. If you are under the age of 50, on the basis of current evidence, there is no perceived risk because all you are doing is replacing those hormones that you are not producing consistently. If you are over the age of 50, the current evidence suggests that you can use HRT for up to five years with no significant increase in risk of developing breast cancer.

What you need to think about is your personal risk of developing breast cancer on the basis of your family history. You have quite a strong family history of breast cancer, which will tend to raise your personal risk, or chance, of developing breast cancer. This risk is higher than in someone with no family history of breast cancer. There is an increase in risk of developing breast cancer once you have been on HRT for five years or more. Your personal level of risk, and hence your starting point, is higher; going on HRT does not magnify this risk any further, your line just runs along a little higher.

I have been thinking about starting HRT to try to help my migraines. My doctor has said that I am more likely to get a blood clot in the first year of taking HRT. How likely am I to get a blood clot? Is it worth the risk?

Your second question is quite difficult to answer because you are the one who should decide whether it is worth the risk. You need to try to assess your personal risk of getting a DVT (deep venous thrombosis – blood clot in the leg). Age is also a factor: the older you are, the more likely you are to get a DVT. The statistics are given as [number] per 1,000 women in five years.

There are other times when your risk is increased: when you have been immobile for a prolonged period of time, or anything else that slows your circulation.

I’ve heard of the coil for contraception. What is a Mirena coil?

A Mirena coil is a specific type of coil that has been impregnated with a particular hormone that is released slowly into the womb. It is also referred to as an LNG-IUS, ‘LNG’ standing for levonorgestrel and ‘IUS’ standing for intra-uterine system. Originally developed as a form of contraception, it is now used to treat heavy periods and can also provide the progesterone needed for protection of the womb lining when using oestrogen patches or gel for HRT.

If it is the oestrogen that helps the migraine and I need HRT to help the migraine, why can’t I just take oestrogen?

That way I won’t get periods. The reason you can’t take oestrogen alone, if you have not had a hysterectomy, is that you have to protect the lining of the womb. The lining of the womb – the endometrium – can be over-stimulated when oestrogen is taken on its own and may lead to endometrial cancer.

Five in 1,000 women who are aged between 50 and 64 years of age might expect to develop endometrial cancer if they do not use HRT. Nine in 1,000 women, of the same age, using oestrogen alone for five years might expect to develop endometrial cancer. Obviously, the longer you use oestrogen, the greater the risk. Fifteen in 1,000 women who use oestrogen alone for ten years might expect to develop endometrial cancer.

Using combined HRT is essential, as the numbers then drop dramatically. Fewer than 2 in 1,000 women using combined HRT for ten years might expect to develop endometrial cancer.

I had a hysterectomy several years ago because of fibroids and am thinking about starting HRT to try to help my menopausal symptoms and my migraines. What should I use?

The advantage of having had a hysterectomy is that all you need to think about is oestrogen. Ideally, you should use a patch or gel. If you start at a low dose and gradually increase it, you will minimize the chance of an increase of migraines rather than a hoped-for fall in the number of attacks.

I am using HRT and am trying to decide how long I should take it. It has really helped my migraines but I’ve been reading about HRT and breast cancer. How long can I safely take it?

Answering that question is about trying to understand the figures from research, which looks at population risk, and translating that into your personal risk. If you are over 50, the longer you take HRT, the greater your potential personal risk.

Different organisations present the figures in different ways, and trying to make sense of it all is not easy. If you consider women aged 50 who do not use combined HRT, 32 in every 1,000 would be diagnosed by the age of 65 years.

If you start combined HRT at the age of 50 and take it for five years, there are 6 extra cases of breast cancer, and if you take it for ten years there are 19 extra cases. This translates to 38 in every 1,000 who take combined HRT for five years and 51 in every 1,000 who take combined HRT for ten years.

Only you can decide how long you can safely take HRT. It depends on how you weigh up the risks and benefits of taking HRT. This is a very personal choice and a very individual decision.

I have been on HRT for five years and my migraines have been fantastic. My doctor says I have to stop after five years but can I carry on using it?

If you have been on combined HRT for five years, you need to consider the facts and decide what level of risk you are prepared to accept to achieve the benefit you are experiencing. If you feel that the risk of developing breast cancer and the potential increase in risk of stroke are worth it, you can make an informed decision to continue.

If you are taking oestrogen alone and do not need any progesterone for protection of the womb lining, the increase in risk of breast cancer is minimal. There is only one extra case of breast cancer per 1,000 women after five years’ use, and a further five cases after ten years.

I have been talking to my doctor about HRT after my specialist said I should try it. Tablets, patches or gels: how do I decide?

Patches and gels are going to offer a better option than tablets. It is the peaks and troughs that tend to trigger migraine attacks, and patches and gels will provide a steady blood level. The advantage of patches, when using a ‘matrix’ patch, is that you can cut it into quarters and halves and thereby slowly increase the dose of oestrogen. The slower the increase, the easier it is to get control of the migraine without causing a rebound increase in migraine attacks due to too much oestrogen.

I am still getting periods but they are irregular and some of them can be quite heavy. How can I ease my periods and help my migraine?

One option is the low-dose combined Pill, provided you don’t smoke and don’t get aura. If you get menstrual migraine, you could ‘tri-cycle’ the Pill, which would reduce the number of periods and the number of migraines. This works because if you take the Pill in the normal way, you get thirteen periods a year. If you tri-cycle the Pill, take three packs one after the other; then you will get only five periods a year and therefore, potentially, only five migraines.

Another option would be the LNG-IUS (Mirena) coil, which would potentially stop your periods. If this, in itself, is not enough to help the migraines, you might consider top-up oestrogen to stabilise fluctuating hormone levels.

I last had a period two years ago and I am thinking about starting HRT to try to reduce the number of migraines I am getting. I don’t want to start periods again, though, so what are my options?

If it has been that long since you had a period, you could try a continuous combined HRT (CCHRT). This has reasonable chance of giving you bleed-free HRT. You might get some irregular spotting or bleeding but, if CCHRT suits you, you should get few or no periods.

If you do not settle with an off-the-shelf option of CCHRT (one of the standard prescribable options), it is possible to get a little more creative. There are two progestogen products that can be taken on a daily basis and then you can use top-up oestrogen, but start at a low dose and slowly increase it until you get the balance right.

Every time I start HRT, my migraines get worse. Why is this?

It is probably because you started with too much oestrogen too quickly. The only way to combat this is to start again at a low dose of oestrogen and then slowly increase it. You also need to take progesterone. If you are just starting with menopausal symptoms (being

peri-menopausal), it needs to be given cyclically; that is to say, you will need to take the progesterone for a short part of each cycle – giving you a period on a regular basis. If you are two years beyond the menopause and you are using oral progesterone, it should be taken daily. An alternative would be to use the LNG-IUS coil as the progesterone source.

Oestrogen, in this circumstance, is best delivered by a ‘matrix’ oestrogen patch, which you can cut into quarters and halves. The size of the dose can be manipulated by quartering the patch and increasing the dose by the smallest increment – doing this weekly, fortnightly or monthly. Increasing the dose in this way will allow you to find the amount of oestrogen that will control your migraines and, hopefully, improve any menopausal symptoms you have.

If my migraine gets worse with the tablet HRT, why will patches be better?

The theory is that tablet HRT causes peaks and troughs in oestrogen levels, which might increase the risk of migraines being triggered. Patches will produce a steady level of oestrogen and are therefore less likely to trigger migraines.

My doctor has said that too much oestrogen is as much of a problem as too little, so how can I find the right dose and get the balance right?

Finding the right dose and getting the right balance need time and patience if an off-the-shelf formulation does not suit you. Different types of progesterone suit different people, and the dose of oestrogen needs to be just right. This means that you and your doctor need to ring the changes and permutations until you get it right.





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