Features

A world of pain

07 September 2018

Migraine is more than just a bad headache, writes journalist John Windell. What do you need to know about this serious and debilitating neurological disorder?

Migraine is one of the most common and costly health disorders in the UK – a true headache for society. Around 23% of adults are affected by migraine, which causes up to 43 million lost working days each year, costing the economy as much as £4.4bn (Work Foundation, 2018). Add presenteeism – when people turn up for work despite being ill – and the figures soar to up to 86 million days lost at a cost of up to £8.8bn (Work Foundation, 2018). Either way, migraine is an expensive problem, as well as a debilitating and miserable one for those enduring it.

 

Understanding the causes of migraine

Migraine is a repeated and persistent disorder that presents as moderate to severe headaches lasting from a few hours to a few days. Throbbing pain is the universal symptom, usually on just one side of the head (the word ‘migraine’ means ‘pain in one half of the head’). Other symptoms include nausea, dizziness, fatigue, vomiting, sensitivity to noise and light, and vision disturbances, or ‘aura’. ‘Some people have frequent attacks,’ says Susan Haydon at the Migraine Trust, ‘some have infrequent attacks, some go through a period when they have lot of attacks or when they have few attacks. But it is always quite a disabling condition.’

Migraine also affects children. The Migraine Trust (2018) says that 70% of children have at least one headache a year, one in four of these have recurrent headaches, and about one in 10 have migraine. A child has a 50% chance of inheriting migraine if one parent has the condition, and a 75% chance if both parents do (Migraine Research Foundation, 2018). About half of children affected by migraine will have their first attack before the age of 12, although up to a quarter will outgrow the condition completely (Migraine Trust, 2018). Migraine in children differs from that in adults: the head pain often affects the whole head rather than just one side, attacks come on quicker, are shorter – sometimes less than an hour – and fade faster (Migraine Trust, 2018).

Up to puberty, boys and girls have about the same number of attacks. After puberty, attacks become three times more likely for females, possibly because of the drop in oestrogen just before the start of the menstrual cycle. But the main cause is thought to be genetic. ‘It is a clear factor,’ says Dr Brendan Davies, a neurologist at University Hospitals of North Midlands NHS Trust. ‘But people who haven’t got an obvious family history of migraine can still develop the condition at any age, even after an injury or stroke.’

Migraine was once thought to be a vascular disorder, but neurologists are now confident it originates in the brain, and they are looking for the precise mechanism that sets off an attack. ‘We know the problem lies with the pain-processing neurones in the brain stem,’ says Dr Giorgio Lambru, a consultant neurologist and headache specialist at Guy’s and St Thomas’. Something goes awry with the way these neurones switch on and off. ‘This is probably due to genetic abnormalities, though we don’t yet know what they are,’ says Dr Lambru. ‘We think that the root of migraine pain involves an inflammation of the nerve endings in the membrane around the brain, and that this also accounts for the associated symptoms.’

For anyone with a genetic predisposition to migraine, the attacks seem to be linked to external factors such as eating too much or too little, stress, dehydration, lack of sleep and changes in routine. Some people might point to more specific triggers, such as certain foods, including chocolate, cheese or caffeine, but the latest thinking among neurologists is that these are more correlation than cause. ‘What people think of as the triggers may actually be the start of the biological process in the brain that underlies migraine. They misattribute this as a trigger,’ says Dr Davies.

Dr Lambru explains: ‘During the prodrome phase, when people are about to have a migraine, they will have warning symptoms that start a few hours or even days before. But the abnormal activity in their brain results in the release of dopamine, for example, and that makes them crave a certain food, which they eat and then blame for triggering the migraine. Double-blind tests on chocolate have found no proof it has any role in migraine.’


A guide for parents or carers of children with migraine

  • Get a correct diagnosis from a doctor.
  • Help the child keep a migraine diary.
  • Look for signs of an imminent attack – tiredness or confusion, for example.
  • Disturbed sleep, dehydration, lack of food and screen glare can all be triggers.
  • Inform the school and make a personalised healthcare plan.

Migraine Trust, 2018


 

Managing the pain

The Work Foundation (2018) says that people with migraine should be empowered to self-manage their condition, and calls for a public health campaign to educate people from a young age.

Dr Davies agrees that people who suffer from migraine can take steps to help themselves. ‘I certainly think a healthy lifestyle is important. Try to establish good sleep patterns, make sure you eat appropriately, and avoid or minimise exposure to stress: it reliably makes things worse.’ He also advises people to address the pain as soon as possible. ‘Use over-the-counter medication such as ibuprofen – 900mg of aspirin can be very effective in mild to moderate migraine if taken early. If the pain becomes disabling and starts to affect work or life on a regular basis, people probably need to think about seeking more specific help and advice.’

The search also goes on for more effective treatment for migraine. In particular, it is focused on identifying which chemicals are related to neurones that switch the pain process on and off. The new treatments coming out of this research could revolutionise the management strategy for migraine. ‘For 20 years we have had no new specific treatments,’ says Dr Lambru, ‘but now we are developing compounds that latch onto one of the markers of migraine activity, effectively blocking the migraine when it occurs. More exciting, preventative treatments are being developed that seem to be highly effective at reducing the number of migraines.’

 

Pinpointing the problem

The Work Foundation (2018) says that ‘most cases of migraine – and headache generally – can and should be treated effectively in primary care’. So what can community practitioners do to help the situation?

‘We always say the most important first step is a firm diagnosis because migraine can mimic other health conditions,’ says Susan Haydon. ‘Even if it runs in the family, it is still vital to get that diagnosis, especially if it involves young children.’

After diagnosis, community practitioners can encourage primary caregivers to keep a migraine diary and try and recognise warning signs of attacks, such as yawning, food cravings or muscle pain. Encouraging regular exercise, avoiding sugary snacks and eating balanced meals are all behaviours that can ease or prevent attacks that community practitioners can encourage (Migraine Trust, 2018).

Dr Lambru echoes the point that a quick diagnosis means treatment can start sooner rather than later. ‘It helps to prevent the condition from becoming chronic. You can also help to adjust a person’s lifestyle and surrounding environment in order to ease the condition.’


 

School nurses and migraine: a practical approach

  • Two simple treatment steps can help to stop an attack developing: encouraging the child to eat, and taking any medication the doctor has given them. In many cases, the child will recover quickly and be able to rejoin class.
  • Be aware that many children will vomit in the early stages of migraine; this eases the attack if they are also able to rest quietly for around an hour.
  • Be understanding to the child during an attack because they may feel embarrassed. The sooner they feel they can ask for help, the better – a migraine could then be avoided.
  • Try to recognise possible triggers at school – are work expectations or bullying to blame? Would allowing the child to have a snack or drink in class help? Is the whiteboard causing problems, or are classrooms poorly ventilated?
  • Set aside a quiet area to use when suffering from migraine, or gain permission to take any medication at school.

Migraine Action, 2018; Migraine Trust, 2018

 


 

Resources


 

References

Migraine Research Foundation. (2018) Raising money for migraine research. See: migraineresearchfoundation.org/about-migraine/migraine-in-kids-and-teens (accessed 24 July 2018).

Migraine Trust. (2018) Guide for parents and carers. See: https://www.migrainetrust.org/living-with-migraine/coping-managing/young-sufferers/guide-for-parents-and-carers (accessed 24 July 2018).

Work Foundation. (2018) Society’s headache: the socioeconomic impact of migraine. See: theworkfoundation.com/wp-content/uploads/2018/04/Society%E2%80%99s-headache-the-socioeconomic-impact-of-migraine.-Work-Foundation.pdf (accessed 24 July 2018).

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