Migraine: Identifying Triggers and Choosing the Right Treatment

Migraine affects roughly one in seven people and is among the leading causes of disability in adults under 50. It is frequently dismissed as a bad headache, which is both inaccurate and the main reason people under-treat it.

What a migraine actually is

Migraine is a neurological disorder in which the brain is hypersensitive to change. An attack involves activation of the trigeminovascular system, release of inflammatory peptides including CGRP, and a wave of altered brain activity. The headache is one phase of a process, not the whole event.

The four phases

Prodrome, hours to two days before. Yawning, neck stiffness, mood change, food cravings, increased urination, difficulty concentrating. Recognising your own prodrome allows earlier treatment, which works far better.

Aura, in about a quarter of people, lasting 5 to 60 minutes. Most often visual: zigzag lines, flashing shapes, blind spots that expand. Also tingling spreading up an arm, speech difficulty, or one-sided weakness in rarer forms.

Headache, 4 to 72 hours untreated. Characteristically one-sided, throbbing, moderate to severe, worse with movement, with nausea and sensitivity to light, sound or smell. Not everyone has all features.

Postdrome, up to a day afterwards. Exhaustion, difficulty concentrating, a hungover feeling.

Common triggers

Triggers are individual and often need two or three together to provoke an attack:

• Missed or delayed meals
• Dehydration
• Irregular sleep, both too little and too much, including weekend lie-ins
• Stress, and the let-down after stress, which is why attacks often start on holidays
• Hormonal changes, especially the fall in oestrogen before periods
• Bright or flickering light, screen glare
• Strong smells: perfume, paint, smoke
• Weather and barometric pressure changes
• Alcohol, particularly red wine
• Caffeine, both excess and withdrawal
• Aged cheese, processed meat with nitrates, and for some people MSG or aspartame
• Physical exertion when unaccustomed
• Travel and time zone change

A headache diary for 8 to 12 weeks, recording attacks against sleep, meals, stress and cycle, is more useful than any elimination diet started on guesswork.

Acute treatment

Treat early. The single most important rule. Medication taken within the first 20 to 30 minutes works far better than the same drug taken two hours in, once central sensitisation has set in.

• Simple analgesics: high-dose aspirin, ibuprofen, naproxen or paracetamol, ideally soluble forms for faster absorption
• Anti-nausea drugs such as domperidone or metoclopramide, which also improve absorption of the painkiller
• Triptans: sumatriptan, rizatriptan and others, specific to migraine and effective for moderate to severe attacks. Not for people with uncontrolled hypertension, ischaemic heart disease or previous stroke
• Gepants and ditans, newer classes that avoid the vascular restrictions of triptans, where available
• A dark quiet room, a cold compress, and sleep

Avoid opioids and butalbital-containing combinations. They work poorly in migraine and strongly promote medication overuse.

Medication overuse headache

This deserves its own warning. Taking acute painkillers on more than 10 to 15 days a month converts episodic migraine into a near-daily headache that no longer responds to anything. It is common, under-recognised, and reversible only by withdrawing the overused drug, which is unpleasant for a few weeks.

Track your treatment days. If you are treating more than twice a week, you need preventive treatment, not more painkillers.

Prevention

Preventive medication is considered with four or more attacks a month, disabling attacks, or acute treatment failing:

• Beta blockers such as propranolol
• Amitriptyline
• Topiramate or sodium valproate, with valproate avoided in women of childbearing potential
• Candesartan and flunarizine
• CGRP monoclonal antibodies, monthly or quarterly injections developed specifically for migraine, which have changed outcomes for many patients
• Botulinum toxin injections for chronic migraine, meaning headache on 15 or more days a month

Non-drug prevention with reasonable evidence includes regular sleep and meals, aerobic exercise, magnesium, riboflavin, coenzyme Q10, cognitive behavioural therapy and biofeedback.

Preventives need 8 to 12 weeks at an adequate dose before judging them, and are started low and increased slowly.

When a headache needs urgent assessment

• Sudden severe headache reaching peak intensity within a minute, a thunderclap headache
• Headache with fever, neck stiffness or rash
• Headache with new weakness, numbness, speech difficulty, confusion or seizure
• Headache after head injury
• A clear change in the pattern of long-standing headaches
• New headache after age 50
• Headache worse on lying down, coughing or straining
• Headache with visual loss or a painful red eye
• New headache in pregnancy, with cancer, or with immunosuppression
• Aura lasting more than an hour, or always on the same side

This is general information. Migraine treatment is individual, triptans have specific cardiovascular contraindications, and preventive choice depends on your other conditions, so it belongs with a doctor.