I’m a GP – the migraine treatments that actually work, and those to avoid

If you don’t suffer from migraines, then you have probably dismissed them as just a “bad headache”, but migraine is a complex, long-term neurological condition, that affects an estimated one in seven people. “That’s over 10 million people in the UK – comparable to the number of people living with diabetes, asthma, and epilepsy combined,” points out Debbie Shipley, head of information at The Migraine Trust. Migraine can be episodic, meaning it happens from time to time, or chronic, defined as 15 or more headache days a month, with at least eight having migraine features for more than three months. Shipley says it is more common in women than men and can change over a person’s lifetime. “Attacks can become more frequent, or change in symptoms and patterns. Some women notice an increase in frequency and severity when they enter perimenopause – which may then settle down after menopause.” How to know if you’re having a migraine “There is so much more to migraines than head pain,” says Dr Nikki Burger, a GP at Circle Health Group and Linbury Doctors in Worcestershire. “A headache is a symptom; migraine is the condition. The headache associated with migraine is often throbbing, moderate to severe, and worsened by normal movement. It may come with nausea, vomiting, exhaustion and sensitivity to light or sound. Some people experience aura, such as flashing lights or zigzag patterns in their vision, which can occur without a headache. Symptoms can begin before the headache and continue after the pain has settled, so taking away the headache does not necessarily mean someone feels well again. Shorts “During a migraine attack it is difficult to concentrate or function properly and often the person needs to lie down in a dark room or go to sleep,” Burger continues. “It can be difficult for people who have never experienced a migraine to understand how incapacitating it can be. It can affect work life, social life and relationships, which can make a person living with migraine feel very isolated.” Common migraine triggers “Triggers can bring on an attack in someone who is susceptible to migraine, but they do not cause the underlying condition,” Burger explains. “Often it is a combination of factors that causes an attack.” Hormonal changes can trigger migraine in people who are prone to them. “Women with migraines often find they are more susceptible around the time of their period, and during perimenopause, when oestrogen levels fluctuate unpredictably, migraines may become more frequent or harder to manage, and disrupted sleep can contribute,” she continues. “For many women, attacks improve after menopause once hormone levels become more stable, although this is not everyone’s experience.” Other common migraine “triggers” typically involve changes to routine in some way, such as getting too little or too much sleep, missing meals, dehydration, changes in caffeine or alcohol intake, as well as stress. Keep a migraine diary “I often suggest a simple headache diary for a few weeks to understand the pattern, associated with symptoms and possible triggers,” Burger says. Certain healthy lifestyle measures can support migraine management. “Regularity is particularly helpful. I encourage going to bed and waking at roughly the same time every day, including weekends, maintaining good hydration and eating regular, balanced meals. I also ask people to look at their caffeine and alcohol intake and whether either affects their symptoms. With caffeine, abrupt changes can be a problem, so consistency matters. “If someone is relatively inactive, I encourage gentle exercise and a gradual build-up, rather than immediately starting strenuous workouts. I also discuss supplements such as riboflavin, magnesium and coenzyme Q10. There is some evidence that these can reduce migraine frequency in some people, although the evidence varies and benefits are not guaranteed. Speak to a doctor or pharmacist before taking these supplements to check for suitability and interactions with other medication.” Best ways to treat a migraine attack Migraines can be managed both acutely (when an attack comes on to try and stop or reduce symptoms) and preventatively, Shipley explains. The sooner you treat a migraine, the better. “Anyone who experiences migraines needs a plan for treating attacks promptly,” Burger advises. “Depending on their medical history, that might include an appropriate painkiller, a migraine-specific medicine such as a triptan, and sometimes an anti-sickness medicine. But frequent use of attack treatments can itself worsen headaches, so it’s important that we keep an eye on how often the attacks are happening. Not all treatments will be suitable for all people, so before starting any regular treatment it’s important to seek advice from a doctor who understands migraine to get the best treatment regimen.” Coca-Cola If you feel like you need to lie down in a dark room, then do so for as long as you need, she advises. “Don’t try and ‘power through’ as this this can lead to more prolonged attacks.” “One surprisingly effective treatment for migraine is aspirin taken with a glass of Coca-Cola,” Burger says. “The combination of the anti-inflammatory effect of the aspirin with the caffeine, sugar and gas bubbles in the Coca-Cola can be very effective for some. Many people also find a migraine cold cap soothing, which can be kept in the fridge. Some people feel significant neck stiffness at the start of or during an attack, and for this, heat is an option, too.” Triptans There are lots of different types of migraine-specific medications, known as triptans. “Different triptans work better for different people,” Shipley says. “Gepants are a newer tablet that some GPs may be able to prescribe, which can be used as both an acute or preventative treatment. They can be a good option for people who can’t take – or don’t tolerate – triptans, as they don’t seem to cause medication overuse headache, like triptans and other painkillers can.” Avoid codeine When it comes to pain relief, stronger is not always better, Burger warns. “Because of the severity of the pain, people often go for over-the-counter co-codamol (paracetamol with codeine), and in some cases are prescribed codeine phosphate for bad headaches. However, codeine or opioid painkillers can actually worsen migraines and make it much more likely you will get another migraine or develop what we call chronic migraine.” The best long-term medication “If attacks are more frequent or disabling, we discuss preventive treatment,” Burger explains. “Effective medication should not be delayed when it is needed, so it’s important to discuss your options with a doctor or pharmacist.” Preventive medication such as amitriptyline, propranolol and topiramate, can be taken regularly to reduce the frequency and severity of migraine attacks, Shipley adds. “They typically take six to 12 weeks to see an improvement, and people may need to try several types to find one that works for them. If people have tried at least three preventive medications via a GP, and they have not helped, they may then be referred to a neurologist, but waiting lists can be long.” Other preventive treatment options include CGRP mAbs (Calcitonin Gene-Related Peptide monoclonal antibodies), which target and block the chemical CGRP, known to be associated with migraine attacks. “Most are given as injections under the skin (similar to an EpiPen or insulin pen), every month or every three months.​ Gepants target the same CGRP chemical, but are given in tablet form. As mentioned, they can also be offered preventively, taken every day or every other day,” Shipley says. ​Botox injections have also been approved for use on the NHS for the treatment of chronic migraine in adults. “For migraine – it’s given into specific areas of your head and neck, at doses known to be effective for migraine” Shipley explains. “It’s important to get it from a trained specialist in migraine. Most people have at least two treatment cycles before deciding if Botox is effective.” Treatment typically needs to be repeated approximately every 12 weeks and “compared with tablets and other treatments, it has a very low side effect profile,” Burger adds.