Everyday Health – Headache & Migraine – Home Remedies for Headache Treatment
WebMD – Migraines & Headaches Health Center
PREVENTATIVE TREATMENT
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
MENSTRUAL MIGRAINE AND MENSTRUALLY ASSOCIATED MIGRAINE
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.
