Migraine: It Is Not Just a Headache, and the Treatment Has Changed
Migraine is one of the leading causes of disability worldwide, affects roughly one in seven people, and is still routinely described by sufferers and others as “just a headache”. It is a neurological disorder with a characteristic pattern, and treating it properly requires knowing that pattern.
Recognising it
Migraine is diagnosed clinically. Typical features:
- Moderate to severe pain, often one-sided, though not always
- Throbbing or pulsating quality
- Worse with routine physical activity, so people want to lie still
- Nausea, sometimes vomiting
- Sensitivity to light, sound, and often smell
- Lasting 4 to 72 hours untreated
A useful screening set of three questions: in the last three months, has headache limited your activities for a day or more, have you felt nauseated with headache, and does light bother you when you have a headache? Two or more yes answers makes migraine likely.
The four phases
Prodrome, hours to two days before. Yawning, food cravings, mood change, neck stiffness, increased urination, difficulty concentrating. Learning to recognise your own prodrome is valuable because it is the best time to act.
Aura, in a minority of people. Usually visual: zigzag lines, blind spots, shimmering. Can also be sensory tingling or speech disturbance. Typically develops over five minutes and lasts under an hour.
Headache phase.
Postdrome, the “migraine hangover”. Exhaustion, difficulty concentrating, sometimes lasting a day.
Timing beats dose
This is the most useful practical fact in migraine treatment.
Acute medicines work far better taken early, when the pain is mild, than later when it is established. Migraine causes gastric stasis, slowing absorption, and central sensitisation makes the pain progressively harder to interrupt.
People routinely wait, hoping it will pass, take the tablet at the two-hour mark, and conclude the drug does not work. Taken at the first sign, the same drug often aborts the attack.
Acute treatment
Simple analgesics. Aspirin at an adequate dose, ibuprofen, naproxen, or paracetamol. Soluble or effervescent forms absorb faster.
Triptans. Sumatriptan, rizatriptan, zolmitriptan and others. Migraine-specific, and markedly more effective than simple analgesics for many people. Different triptans suit different people, so failing one is not failing the class; it is worth trying two or three before concluding they do not work. Not suitable in uncontrolled hypertension, coronary disease or previous stroke.
Anti-nausea medicines such as metoclopramide or domperidone, which also improve absorption of the analgesic.
Gepants and ditans are newer acute options that work differently and can be used by people who cannot take triptans.
Avoid opioids and butalbital-containing products. They work poorly for migraine and are among the most likely to cause medication overuse headache.
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Medication overuse headache
This deserves its own section because it is common, under-recognised, and it makes everything worse.
Taking acute headache medication too frequently converts episodic migraine into a daily or near-daily headache, which is then treated with more medication, which perpetuates it.
The approximate thresholds are:
- Simple analgesics: 15 or more days a month
- Triptans, combination analgesics, opioids: 10 or more days a month
If you are taking something for headache on more days than not, this is likely part of the problem. Treatment is withdrawal of the overused drug, which temporarily worsens headache for one to two weeks before improving, ideally alongside starting a preventive. It should be done with medical support.
The practical rule: acute migraine medication on no more than two days a week on average. If you need more, you need a preventive.
Preventive treatment
Considered when attacks occur roughly four or more days a month, when they are severe or disabling, when acute treatment fails or cannot be used, or when there is a risk of medication overuse.
Older options, all originally developed for other conditions:
- Beta blockers such as propranolol
- Amitriptyline
- Topiramate
- Sodium valproate, avoided in women of childbearing potential
- Candesartan
- Flunarizine
Newer, migraine-specific options:
- CGRP monoclonal antibodies, given monthly or quarterly by injection. Designed specifically for migraine prevention and generally well tolerated
- Oral gepants used preventively
- Botulinum toxin injections for chronic migraine, defined as headache on 15 or more days a month
Supplements with some evidence: magnesium, riboflavin and coenzyme Q10. Modest effects, low risk, and reasonable to try alongside.
Any preventive needs 8 to 12 weeks at an adequate dose before judging. Success is usually a 50 per cent reduction in frequency, not elimination.
Triggers, with a caveat
Commonly reported: irregular sleep, skipped meals, dehydration, alcohol especially red wine, stress and the letdown after stress, hormonal changes around menstruation, bright or flickering light, strong smells, and weather change.
The caveat: food cravings during the prodrome mean the “trigger food” is sometimes a symptom rather than a cause. Chocolate is the classic example. A diary is more reliable than recall.
Rather than chasing elimination diets, the highest-value changes are regular sleep, regular meals, hydration and consistent exercise.
When to seek urgent assessment
- A sudden severe headache reaching maximum intensity within seconds to a minute
- Headache with fever and neck stiffness
- Headache with weakness, numbness, confusion, or difficulty speaking
- Headache after a head injury
- A clear change in your usual headache pattern
- New headache after age 50
- Headache worse on lying down, coughing or straining
- Headache with visual loss or a painful red eye
- Aura lasting more than an hour, or aura without headache for the first time
Also relevant: migraine with aura is associated with a small increase in stroke risk, and combined oral contraceptives are generally avoided in women who have migraine with aura. Worth raising if that applies to you.
The short version
Migraine is a neurological disorder with a recognisable four-phase pattern. Treat early rather than waiting, try more than one triptan before giving up on them, and if you need acute medication more than two days a week, the answer is a preventive rather than a stronger painkiller. Daily headache in someone taking daily painkillers is usually being caused by the painkillers.