A migraine is more than just a headache, and can have a life-long impact on sufferers. So why do we still know so little about it?

Migraine is a common and potentially debilitating health condition affecting nine million Britons – that’s one in seven people. Each year 25 million days are lost through migraine from UK work or schools, cutting Britain’s economic size by £2.5 billion, yet many people fail to understand the symptoms and the full impact that migraine can have on sufferers. 

In fact, new figures released by The Migraine Trust, Migraine Action and the National Migraine Centre, reveal that almost two-thirds of UK adults believe employers don’t understand very much, or anything at all, about the nature of migraine and its effects on their staff. And one in five people even think healthcare professionals do not realise the characteristics and impact of the condition on their patients.

Migraine or headache?

So what is a migraine, and how is it different from a headache? 

Migraine can affect people of all ages, even young children, as well as all sectors of society, although around two-thirds of sufferers are women.

While a severe headache may be common, especially in adults, migraine is more than that. It affects the whole body and can result in many symptoms including nausea and/or vomiting; increased sensitivity to light, sound or smell; dizziness or vertigo; and neurological symptoms – often referred to as ‘aura’ – such as visual disturbances, confusion, tingling or numbness in the limbs. 

“These symptoms tend to combine into three main types of migraines,” explains Deep Patel, NHS excellence manager at LloydsPharmacy. “These are migraine with aura – when you are likely to experience specific warning signs such as seeing flashing lights just before the onset of the migraine, migraine without aura – the most common type of migraine which occurs without any specific warning signs – and migraine aura without headache, where an individual can experience an aura without a headache.”

Migraine attacks normally last between four and 72 hours and sufferers are symptom-free in between attacks. On average, people with migraine experience around 13 attacks a year, but some experience up to two attacks or more a week and may be bedridden for much of this time. There is no ‘test’ for migraine, which makes diagnosis difficult as it depends on the migraine history and pattern of attacks.

Causes and triggers

The exact cause of migraine is still unknown and research continues to be carried out to investigate the cause. It is believed that everyone has the capacity to suffer from migraine and it seems to have a genetic link. However, in 10-15 per cent of the population there is an increased susceptibility: in other words, a lower threshold at which an attack is triggered. 

Current thinking puts the cause as the release of serotonin from its storage sites into the bloodstream causing changes to the neurotransmitters and blood vessels in the brain. However, exactly what prompts these changes is still a subject for research and debate. More recent theories point to changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway.

According to Arlene Wilkie, chief executive of The Migraine Trust, if a person is prone to migraine there are a number of trigger factors to which they may be sensitive. The most common triggers include:

• Emotional or physical stress (or the relief of stress)
• Lack of food, fluids and/or infrequent meals (e.g. missing meals, low blood sugar levels, dehydration)
• Certain foods (including products containing caffeine, tyramine, alcohol, monosodium glutamate)
• Changing sleep patterns (e.g. weekend lie-ins or shift work)
• Hormonal factors (e.g. monthly periods, the contraceptive pill, hormone replacement therapy or the menopause)
• Overtiredness/overexertion (both physical or mental)
• Extreme emotions (e.g. anger or grief)
• Environmental factors (e.g. loud noise, bright and/or flickering lights, strong smells, hot stuffy atmospheres, computer screens)
• Climatic conditions (e.g. storms, hot weather).

Some people with migraine have been able to identify particular factors that seem to trigger their attacks, but what may trigger a migraine in one person may have no effect on another. For most people, there is not just one trigger, but a combination of triggers that can be tolerated individually but when they all occur together a threshold is passed and an attack is triggered.

Red flag symptoms

Migraine symptoms are different for everyone and some may be mistaken for other conditions. For example, younger children experience abdominal pain with no headache at all, and some people get a more severe form known as hemiplegic migraine, where they experience stroke-like symptoms.

This is where the expert advice of the pharmacy team can make a huge difference to sufferers. “Pharmacists and the pharmacy team can initially identify patients presenting in the pharmacy with symptoms of migraine,” says Hilary Cunningham, Numark information pharmacist, “which allows the pharmacist to either recommend appropriate treatment or refer the patient to their GP for preventative treatment where clinically appropriate, such as patients self-medicating headache symptoms on five or more days each month.” 

Effective counselling or questioning techniques ensure that patients reporting ‘red flag’ symptoms are identified and referred for prompt treatment. Red flag symptoms can include:

• Sudden, severe, frequent or cluster headaches
• Paralysis or weakness in one or both arms and/or side of the face
• Sudden agonising headache causing a blinding pain
• Headache associated with high temperature, stiff neck, mental confusion, seizures, double vision and a rash
• Headaches that started following a head injury
• Headaches associated with voice slurring, garbled speech
  or confusion
• Migraine symptoms linked to use of the combined oral contraceptive.

Wider impact

Aside from dealing with painful and disruptive symptoms, migraine can have a far-reaching impact on people’s lives.

“The frequency of migraine very much depends on the individual,” says Neil Stewart, pharmacist at Well. “Some sufferers experience them every week and others can go for years without an attack, and for patients suffering severe migraines on a regular basis, this can have a very negative impact on quality of life.”

According to charity Migraine Action, sufferers often feel anxious and unsupported at work, as they fear that by missing work they will be letting their work colleagues down, won’t be able to meet deadlines, or miss out on promotions. This leaves many people scared to disclose their condition to their employers and colleagues, and fearful of losing their job and the discrimination they will face.

Migraine also has an impact on family life, leaving sufferers feeling guilty for not being able to take part in family activities or functions because of the debilitating nature of the condition.

Pharmacy advice

Recent clinical trials have offered a glimmer of hope to sufferers of migraine, after research showed a chemical in the brain – calcitonin gene-related peptide or CGRP – is involved in both pain and sensitivity to sound and light in migraine.

About 50 per cent of people participating in a study which used antibodies to alter the activity of chemicals in the brain, halved the number of migraines they had each month, although researchers say the long-term safety data of the treatment still needs to be studied.

In the meantime, pharmacy teams are ideally placed to advise patients suffering from migraine symptoms on the treatment options currently available, which include simple analgesics such as paracetamol or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen. There are many different formulations of the commonly used analgesics and the patient should be able to choose the formulation that suits them best.

Maggie Hook, UK Clinical Pharmacy Association (UKCPA) Pain Management Group member and superintendent pharmacist and director at Banwell Village Pharmacy, says: “NICE guidance recommends only single ingredient products are tried first, and the initial choice is based on patient choice and tolerance, or risk of adverse effects or interactions with medication currently taken by the person.” 

The doses recommended by NICE for acute migraine are:

• 1000mg paracetamol (two 500mg soluble tablets) 
• 900mg aspirin (three 300mg soluble tablets)
• 400mg ibuprofen (20ml 100mg/5ml suspension or 400mg in a liquid capsule form).

Hilary says pharmacy staff should always consider that quick acting formulations, such as soluble formulations or ‘melt’ products, will be more effective as migraines are commonly associated with gastric stasis, which adversely affects drug absorption. Combination anti-emetic and analgesic products can also be a more convenient treatment option for patients suffering from migraine associated with nausea and vomiting.

Drug-free products, such as those containing levomenthol, can be recommended when patients either cannot or do not wish to take analgesics, or cannot tolerate the side effects associated with anti-migraine drugs.

Taking treatments sooner rather than later can help to make the treatment more effective, but Maggie points out: “Some patients may have tried the single ingredients but not soon enough after the start of changes that could develop and simply by changing the timing of when they first take pain relief can prevent the symptoms worsening.” 

Also, many combination products contain the opioid analgesic codeine, and Maggie adds: ”Remember that both caffeine and codeine can be the cause of rebound or chronic headache so NICE recommends they be avoided in migraine.”

When to refer

Most people can treat their migraines successfully with over-the-counter (OTC) medication, such as paracetamol and ibuprofen, often combined with lying in a darkened, quiet room during the attack, but Neil advises: “If OTC medications do not work, pharmacy staff should refer the patient to the GP, as they may need prescription medication, such as certain triptans or anti-emetics.”

Sumatriptan is available for over-the-counter sale – albeit with stringent criteria to assess patients for suitability – and those who have been diagnosed with migraine can be sold the anti-emetic prochlorperazine to relieve symptoms of nausea and vomiting. However, patients unable to tolerate oral formulations may also need referral to their GP as non-oral formulations such as triptan nasal sprays or subcutaneous formulations are only available on prescription.

Avoiding triggers

Avoiding known triggers is another preventative measure, according to Deep, who says: “Pharmacy teams can also highlight the benefits of keeping a trigger diary to note down the factors that have triggered a migraine and the symptoms experienced, which can help patients with managing or avoiding these triggers.”

Arlene adds: “It is often said that the migraineous brain does not like change, so building regularity into daily life may help to reduce migraine triggers. Regular times to get up and go to bed, and regular mealtimes may help. Pharmacists might also consider recommending alternative remedies but this depends on whether that was what the customer wanted and if you have the right treatments in stock.”

Migraine Action says alternative treatments such as acupuncture, physiotherapy, vitamins and minerals (e.g. magnesium, vitamin B2, co-enzyme Q10, or ginger) may help, as well as a range of new non-invasive treatments.

Nonetheless, a spokesperson for the charity says that for many sufferers it takes years to find the best treatment and pharmacy staff can help to support them in this: “Some people with migraine have lived with their condition for many years, and can fall into a pattern of taking medication out of habit rather than reviewing it to see if it still meets their needs, or if there may be better options available. Taking the time to question their migraine experience and management is useful. It really is about treating everyone as an individual and recognising that even for the same person their migraines are likely to change overtime and therefore the help and treatment they need is also likely to change.” 

Migraine attacks normally last between four and 72 hours and sufferers are symptom-free in between attacks