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Migraine is a painful condition that can be chronic and severe.
Symptoms may include:
Migraine attacks last from 4 hours to 3 days, however it can last longer in certain cases. Some patients may experience warning signs 24 hours or more before each attack also known as ‘Prodrome’. This can involve excessive yawning, tiredness, neck stiffness, brain fog or craving certain foods.
Causes:
Migraine attack is caused by a particular brain activity which we believe may be attributed to genes. When exposed to an environmental trigger such as stress, lack of sleep, oversleeping, skipping meals, hormonal changes then an attack becomes evident.
Headache is a symptom but migraine is a diagnosis. There is a spectrum of migraine conditions and keeping a migraine diary is useful for both the patient and clinician and offering the right diagnosis. This is important so as the most suitable treatments can be offered.
Two main types of migraine:
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At House of Health, we understand that chronic headaches and migraines can severely affect your quality of life.
These conditions are often complex, requiring more than just a quick consultation. At the moment, getting cutting edge treatments on the NHS are difficult. At House of Health we offer Migraine injections, greater occipital nerve injections and offer newer treatments such as CGRP monoclonal antibodies that have a fantastic response to migraine.
At House of Health, Dr Katy Kyprainou leads this service and offers advanced treatments and consultations for headache and migraine without delay.
Our services are tailored to diagnose and treat even the most stubborn headache and migraines, ensuring a treatment plan that works for
This is the commonest type of migraine.
We regard ‘aura’ as a warning for migraine. This can be in the form of visual disturbance (flashing lights, blind spots or other). In migraine without aura, there is no warning sign for the migraine.
Symptoms
Usually one sided headache of throbbing nature classically. It exacerbates with movement e.g. walking, climbing the stairs.
It is moderate to severe intensity which means patients are mostly unable to carry on routine activities.
Nausea and/or vomiting are experienced
Light, sound, movement and /or smell sensitivity has been described.
Treatment:
Acute/ abortive treatment to be taken at the beginning of each attack: Paracetamol 1g, Aspirin 900mg, Triptan and anti nausea medication. Using pain relief for more days per month, than advised by a clinician may lead to medication overuse headache. For triptans, this is no more than 8 days per month.
Preventive treatment: plethora of options such as CGRP antagonists such as Rimegepant, Atogepant, or other classes of medication such as Propranolol, Candesartan, Topiramate and more. These treatments aim to reduce the frequency and severity of those attacks. They must be taken daily at the minimum working dose or higher.
Lifestyle changes:this can involve sleep hygiene, dietary advice, exercise, hydration and supplementation.
Affects 1 in 3 individuals experiencing migraine.
Symptoms:
Aura as above.The auras typically occur prior to a headache. In some people the headache may not happen.
Auras develop from 5 minutes to 60 minutes.
Auras are usually visual (blind spots, zig zag lines, coloured spots/lines etc) but can be speech and cognitive (e.g. disorientation, brain fog and confusion).
Sensory aura can be tingling in parts of the body, numbness/alterned sensation, motor aura is muscle weakness and vestibular aura is usually vertigo/dizzy spells.
Treatment: as above
Symptoms
At least two of the following:
slurred of speech
dizzy spells
high pitched ringing in the ears
double vision
Unsteady walk
Temporary reduced awareness (syncope)
Pins and needles and /or numbness affecting both upper and/or lower limbs
Bilateral visual disturbance such as flashing lights
Causes:
These attacks can be triggered by certain environmental or other triggers.
Treatment:
Acute/ abortive treatment to be taken at the beginning of each attack: Paracetamol 1g, Aspirin 900mg, Triptan and anti nausea medication. Using pain relief for more days per month, than advised by a clinician may lead to medication overuse headache. For triptans, this is no more than 8 days per month.
Preventive treatment: plethora of options such as CGRP antagonists such as Rimegepant, Atogepant, or other classes of medication such as Propranolol, Candesartan, Topiramate and more. These treatments aim to reduce the frequency and severity of those attacks. They must be taken daily at the minimum working dose or higher
Symptoms
Patients experience a temporary weakness on one side as part of the attack.
The weakness may be in addition to other auras (visual, sensory, cognitive, vestibular)
These are often scary as may resemble a stroke. The weakness can last from one hour to a few days, but usually settles within 24 hours. A headache may follow, occur before it or not at all.
Treatment:
Acute/ abortive treatment to be taken at the beginning of each attack: Paracetamol 1g, Aspirin 900mg. We recommend avoidance of triptans. Use of anti-nausea medication where required. Using pain relief for more days per month, than advised by a clinician may lead to medication overuse headache.
Preventive treatment: plethora of options such as CGRP antagonists such as Rimegepant, Atogepant, or other classes of medication such as Propranolol, Candesartan, Topiramate and more. These treatments aim to reduce the frequency and severity of those attacks. They must be taken daily at the minimum working dose or higher.
Experiencing headache for 15 days per month or more, with 8 of those having migraine symptoms, for 3 months or longer.
Causes:
There are a number of medical conditions that can increase your tendency to have migraine. These include:
Fibromyalgia
Sleep apnoea
High blood pressure
Pain relief medication overuse: 2/3rds of individuals with chronic migraine experience medication overuse headache where the acute abortive regime e.g. triptans or over the counter medication are taken above the recommended days per month in which case they start to cause headache rather than treat it.
Hormonal changes e.g. perimenopause
Treatment:
Acute
abortive regime: Options include Naproxen with a proton pump inhibitor or CGRP antagonist called Rimegepant.
Preventive:
Options include Botox, calcitonin gene-related peptide (CGRP) monoclonal antibodies or a Greater Occipital Nerve (GON) block.plethora of options such as CGRP antagonists such as Rimegepant, Atogepant, or other classes of medication such as Propranolol, Candesartan, Topiramate and more. These treatments aim to reduce the frequency and severity of those attacks. They must be taken daily at the minimum working dose or higher.
Non-drug options
supplements – such as riboflavin (B2), magnesium or co-enzyme Q10
Neuromodulationdevices such as Cefaly or gammaCore
relaxation techniques and psychological interventions (such as CBT).
For this type patients experience a mix of vertigo, dizziness or balance difficulties alongside other migraine symptoms.
Symptoms
Migraine is usually associated with a range of typical symptoms alongside headache including:
Nausea and /or vomiting
Sound, movement and / or light sensitivity
Additionally other symptoms involved are:
Smell sensitivity
Vertigo
light or head touch exposure causing discomfort (allodynia)
Some patients experience just the vertigo symptoms without the pain. Vestibular migraine to be diagnosed migraine headache should be present for certain of those attacks.
Diagnosis
According to the ICHD-3 the diagnosis of vestibular migraine requires:
at least five episodes
a history of current or past migraine attacks
vertigo/dizzy spells lasting between 5 minutes and 72 hours
Headache or other migraine symptoms in >=50% of those episodes
Treatment:
Acute/ abortive treatment to be taken at the beginning of each attack: Paracetamol 1g + Triptan + Aspirin 900mg + use of anti-nausea medication. Using pain relief for more days per month, than advised by a clinician may lead to medication overuse headache.
Preventive treatment: plethora of options such as CGRP antagonists such as Rimegepant, Atogepant, or other classes of medication such as Propranolol, Candesartan, Topiramate, and more. These treatments aim to reduce the frequency and severity of those attacks. They must be taken daily at the minimum working dose or higher. Flunarizine is not available through the GP but is available from headache clinics and often a preventive of choice in this setting. Botox orGreater Occipital Nerve blocks may also be used in this setting.
A significant portion of women state that bleeding is a trigger for their attacks.
Cause:
The drop in oestrogen levels before your bleeding starts is linked to this type of migraine. Women with heavy and painful bleeds have higher levels of prostaglandin which plays a role in migraine development and so Mefenamic acid use may prove helpful.
Diagnosis:
An attack occurs from two days before and up to three days into menstruation, in at least two out of three consecutive cycles.
Treatment:
For those with regular cycles options include:
NSAIDs such as naproxen or mefenamic acid
Frovatriptan tablet (2.5 mg twice daily on the days migraine is expected – generally from two days before until three days after bleeding starts)
Zolmitriptan tablet (2.5 mg twice or three times a day on the days migraine is expected
Rimegepant also known as Vydura 75mg tablet to be taken 2 days before due a bleed up to 3 days into bleed
Botox injections
For those with irregular cycles and who may require contraception:
Combined pill can be taken back to back without a break
Mirena coil can suppress ovulation and help with reducing frequency
Mini pill such as Drospirenone can be taken back to back skipping the last 4 dummy pills
Botox injections
Attacks are predictable and regular as they take place in a time cycle of several weeks.
Symptoms
Nausea and/or vomiting
From 1 hour to 10 days in a row
Each cluster is at least a week apart and usually occur at the same time of the day, week, or month
Feeling normal between clusters
Treatment:
Treatment is similar to other types of migraine.
Identify triggers such as bright light, poor sleep, travel or hunger. Avoid and limit them. Hydration is key to ensure fluid and electrolytes are replenished.
Symptoms
abdominal pain that lasts from 2-72 hours
nausea and/or vomiting during attack
no headache involved
normal self between attacks
Treatment:
Treatment is similar to other types of migraine but can be limited with children.
Review for any triggers and work on avoiding them.
Its most common cause is stress.
Symptoms
Tight pressure band like sensation around the head
May involve the neck and shoulders
Duration of 30 minutes to days
It has the potential to become chronic in which case it can be debilitating
Treatment:
Eliminating triggers (e.g. stress, dehydration etc). Using over the counter medication with robust instructions to not exceed a certain number of days use per month to avoid promoting medication overuse headache.
Cluster headache is extremely painful. It’s rare; approximately 1 in 1000 people have it. It is more common in men than women and mainly affects individuals in their 30s and 40s (but can affect any age).
The main symptom is an excruciating headache on one-side of the head, often around the eye. It occurs in clusters.
Symptoms
Severe pain which comes on very quickly, with no warning and involves one side of the head but can change sides. It usually occurs around the eye. It causes agitation and restlessness. People often pace, rock back and forth and may hold their head in agony.
one or more of the symptoms below may be experienced during the attack:
red or streaming eye
drooping or swelling of the eyelid
a smaller pupil than normal
sweaty red hot face
blocked or streaming nose
They last from 15 minutes to three hours. Patients may have up to 8 attacks a day.
Attacks tend to occur around the same time of day as well as month of the year and can be closely linked to alcohol intake leading to an attack within 60 minutes of the drink.
Cluster headache tends to improve with advancing age, with patients experiencing less frequency and longer remission periods.
Tends to start during the exercise or within 30 minutes of stopping. It is of sudden onset and can last between minutes to under a day. It is of pulsating character usually. It can affect one or both sides of the head. It can be associated with nausea, vomiting
Can be associated with nausea, vomiting, light or sound sensitivity
Factors such as exercising in heat, high humidity, high altitude, poor nutrition, caffeine use and alcohol use may be triggers.
Treatment
Can get better on its own over a few months
Ensure patients engage in adequate warm-up before and reduce intensity of the workout
Medications: oral indomethacin plus proton pump inhibitor such as Lansoprazole for gastroprotection.
Symptoms of cardiac cephalalgia
Patients with coronary artery disease, such as angina or heart attacks, may experience headache associated to exertion such as walking, and that resolve upon resting.
This headache is normally over the back of head/occiput. May be associated with chest/neck/arm discomfort, breathlessness, dizziness, nausea and sweating, similar to angina. Migraine symptoms such as aura, light and sound sensitivity do not occur with it.
Your GTN spray can help relieve the discomfort.
Treatment
Avoid triptans and have an ECG via your GP.
Manage risk factors: diet, diabetes, alcohol, smoking, blood pressure control.
Treating the heart condition relieves this type of headache
Occurs during sleep and wakes one up like an ‘alarm clock’ hence the second name alarm clock headache. Common in patients over the age of 60 and more common in females.
Symptoms
Headache described as dull, throbbing, pulsating, stabbing or burning which wakes one up. It can occur on both or one side of the head and can last from 15 minutes to 4 hours. It can occur 1-3 times per night.
It may be associated with watery eyes, eyelid droop or a blocked nose. May also be associated with nausea, light and sound sensitivity.
Diagnosis
The official diagnostic criteria for hypnic headache include:
Recurrent headache waking one up from sleep
Experienced on > 10 nights per month for over 3 months lasting 15 minutes to 4 hours
Treatment
Caffeine (strong espresso or similar) just before bed as both abortive and preventing regime. This is effective and does not interfere with sleep quality.
Indomethacin (a NSAID) can be another option. Always used in combination with a proton pump inhibitor such as Omeprazole to safeguard the gastrointestinal system.
Hemicrania continua describes a continuous on sided pain.
Symptoms
Pain plus associated symptoms such as eye-watering and redness, streaming and or blocked nose and /or eye lid drooping. These are on same side as headache
Nausea, vomiting, light sound or smell sensitivity
Diagnosis
Trialling Indometacin NSAID oral medicine helps diagnosing it as responders confirm diagnosis. Preventative options may be used as with other migraine disorders.
Also known as acute mountain sickness.
Symptoms
Bilateral headache at altitudes about 8500 feet and this escalates with climbing higher, bend over, cough or Valsalva or exertion.
Causes
At high elevation there is usually less oxygen in the air and so the body has less oxygen available to nourish the organs requiring it. This can lead to hypoxia
Treatment
Hydration is key. Over-the-counter painkillers such as paracetamol or ibuprofen alongside prescribable anti-nausea medication.
How can you prevent high altitude headache?
Allowing the body to adjust to heights is vital. If planning to climb altitudes over 8500 feet do so slowly and no more than 1600 feet per day. Hydration, carbohydrate nourishment and breaks are key. Avoid smoking and alcohol.
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