Migraines: what those who suffer from them get wrong
The electric forehead stimulator newly approved by the NHS may help some people but there’s no universal treatment, says Dr Mark Porter. Here’s his expert’s guide
A third of women and one in eight men in the UK will experience migraines at some stage of their lives, and about 200,000 people will have one today. The range of treatments available has expanded significantly during my career, the novel approaches ranging from the triptan family of drugs (such as sumatriptan), introduced in the early Nineties, to botulinum toxin-containing injections and the electric forehead stimulator (see below) appraised by the National Institute for Health and Care Excellence (Nice) last week.
Given how debilitating migraines can be, it has always surprised me that there aren’t more people seeking medical help. Most will not need any of the fancy new treatments, but because so many self-medicate with over-the- counter medication they are often missing out on the best basic therapies, and in some cases inadvertently aggravating their symptoms.
I have mentioned this before, but it bears repeating: if you get a migraine only once in a blue moon, lying down in a darkened room and taking simple painkillers — Nice advocates ibuprofen (400mg to 600mg), three aspirin (900mg) or two paracetamol (1,000mg) — is probably all that is required.
However, if your migraines are severe and/or happen frequently, and disrupt your quality of life and ability to work, follow these four steps: have the diagnosis confirmed to exclude other causes of pain such as tension or medication overuse headache (see below); identify avoidable triggers; ensure you are using the best available medication for an acute attack; and if they are frequent (weekly) or you are struggling to control the symptoms, ask your GP about preventive therapy.
Your doctor will be able to run you through all these, but here are a few pitfalls to avoid. First, don’t underestimate the benefit of self-help. Some common triggers for migraine, such as pregnancy, stress and poor sleep, are impossible or hard to do anything about. Yet others, such as dehydration, missed meals and too much caffeine, are easier to avoid, and doing so can have significant benefits. For more guidance on identifying and managing the triggers visit migrainetrust.org.
Second, be careful what you take and how often. Painkillers do relieve migraines, but paradoxically if you take too many they can make headaches worse, creating a downward spiral that can result in daily symptoms (medication overuse headaches). This applies to general painkillers such as aspirin, paracetamol and ibuprofen, but tends to be more of a problem with stronger versions that contain codeine, such as co-codamol, and migraine-specific triptans such as sumatriptan.
As a rough guide, you are likely to be making matters worse if you take simple painkillers at least once a day for two weeks or more each month, and for ten days or more a month when it comes to co-codamol and triptans. If this rings a bell, please cut back and talk to your GP about alternative options.
One of these options will be preventive therapy: taking medication daily to reduce the frequency and severity of migraines. In women prone to monthly headaches related to their menstrual cycle this may involve hormonal contraception to stop their periods. Some types of contraception can aggravate migraines and/or cause other rare complications (such as increasing the risk of stroke), so need to be prescribed with care. It is not a one-size-fits-all solution.
For everyone else, preventive therapy will typically involve one of three types of medication: beta blockers such as propranolol, the old-fashioned antidepressant amitriptyline (now mainly used in low doses to treat nerve pain) and topiramate (also used for epilepsy and not suitable for pregnant women). These can all take at least six to eight weeks to work, and if helpful can be gradually withdrawn after six to 12 months, when, often, the migraines won’t return. At least not as frequently as before.
Finally, if you and your GP cannot get good control of your migraines, do ask about a referral to a neurologist. Most large hospitals have dedicated headache clinics that can confirm the diagnosis in tricky cases and have access to other treatments, ranging from botulinum toxin-containing injections to electric and magnetic stimulators. Waits can be frustratingly long, but if you are struggling please don’t let that put you off.
For the latest on diagnosing and managing migraines go to nice.org.uk.
The new migraine devices
● Nice’s latest appraisal of migraine therapies looked at eTNS — a small device attached to the forehead that uses transcutaneous electric stimulation to help to relieve a migraine (it is not recommended for prevention).
● Some clinics may offer transcranial magnetic stimulation to treat and prevent migraine.
● Access to both therapies is restricted and available only through specialist clinics.
● Neither is a panacea — Nice advises that benefits are limited. You can read the new guidance on eTNS at nice.org.uk.
Q&A
Q Can you recommend any exercises for vertigo? I have periods when I get dizzy after bending down, looking up or rolling over in bed. My GP has been very helpful and has done the Epley procedure on me a few times with excellent results. Unfortunately she is so busy it takes a while to get in to see her when the vertigo strikes. Can I do it to myself at home?
A The Epley procedure is a series of movements thought to reposition debris in the fluid-filled balance mechanisms of the inner ear — something that accumulates in most of us as we get older. It is used to treat the most common cause of dizziness (benign paroxysmal positional vertigo, or BPPV), and you describe the classic symptom of movement-induced vertigo perfectly.
The Epley procedure involves positioning the head in a series of movements while lying on a couch. It is possible to do it at home, and if you google Epley you will find lots of video demonstrations, although doing it on your own can be a strain on your neck because no one is supporting your head. Brandt-Daroff exercises are another, more DIY-friendly option.
References
Dr Mark Porter | Monday October 31 2022, 5.00pm, | The Times