Enough is Enough.

Migraine is often misunderstood as just a bad headache. Although we don't know what causes migraine, we do know that migraine is a neurological condition that impacts our nervous system by causing temporary changes to the chemicals, nerves and blood vessels in our brain.^1-4

Migraine attacks vary from person to person and the way you experience them can also vary or change over time. You could have a migraine attack that lasts a few hours, or it could go on for several days.¹ For some people migraine attacks can be infrequent, happening months or years apart, whereas others experience migraine attacks more regularly.² For these reasons, migraine can be difficult for you to recognize and manage.¹

A migraine attack is typically felt as an intense, throbbing headache, usually to one side of the head.³ You may experience nausea and/or sensitivity to light or sound.³ Although the impact of migraine depends on the severity and frequency of attacks, for some, a migraine can be completely incapacitating, forcing them to miss out on many aspects of everyday life.^2,3

References

1. The Migraine Trust. More than 'just a headache'. https://www.migrainetrust.org/about-migraine/migraine-what-is-it/more-than-just-a-headache/ [Last Accessed: April 2020]

2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33: 629–808. Also available from https://www.ichd-3.org/1-migraine/[Last Accessed: April 2020]

3. NHS Choices. Migraine. http://www.nhs.uk/Conditions/Migraine/Pages/Introduction.aspx [Last Accessed: March 2020]

4. Migraine Research Foundation. Migraine fact sheets. http://migraineresearchfoundation.org/about-migraine/migraine-facts/ [Last accessed: April 2020]

Taking medication during an attack can be effective in controlling symptoms, but it is not a suitable solution for all migraine sufferers. For some people, stopping migraine attacks before they start is the key to regaining control, particularly those who experience frequent or persistent migraine symptoms.¹

If you are living with migraine, you'll be all too aware of how painful and debilitating it can be, so reducing the frequency, intensity and/or duration of your migraine attacks can mean less time missing out and more time living life to its fullest.

References

1. Pringsheim T, Davenport W, Mackie G, et al; Canadian Headache Society Prophylactic Guidelines Development Group. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012; 39(2 Suppl 2): S1–59. https://headachesociety.ca/wp-content/uploads/2017/12/Pringsheim-prophyl-guideline-CJNS-2012.pdf [Last Accessed: April 2020]

There are two groups of migraine treatment and your doctor can tell you which is best for you;^1,2

• 1. Acute treatments (for example, pain medications and anti-sickness tablets) are taken during a migraine attack to help relieve headaches and other symptoms associated with your migraine.

• 2.Preventive treatments are taken regularly, even when you aren't experiencing a migraine attack, to help stop them before they even start.

References

1. The Migraine Trust. Medication. https://www.migrainetrust.org/living-with-migraine/treatments/medication/ [Last Accessed: April 2020]

2. Pringsheim T, Davenport W, Mackie G, et al; Canadian Headache Society Prophylactic Guidelines Development Group. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012; 39(2 Suppl 2): S1–59. https://headachesociety.ca/wp-content/uploads/2017/12/Pringsheim-prophyl-guideline-CJNS-2012.pdf [Last Accessed: April 2020]

Preventive treatments do not always eliminate headaches entirely and sometimes it can take a while before you experience their full benefit, so you may need to take an effective acute treatment as well.^1,2 However, it is important to avoid overusing your acute treatment as this can affect the amount of relief you get from your preventive medication.² If you have questions on the combined use of acute and preventive treatment, you should always ask your doctor about how to manage your migraine.

References

1. 1. Migraine Trust. Preventative Medicines. http://www.migraine.org.uk/information/treatments-and-therapies/preventative-treatments/ [Last Accessed: April 2020]

2. MacGregor EA, Steiner TJ, Davies PTG. British Association for the Study of Headache Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache Writing Committee: 3rd edition (1st revision); approved for publication, September 2010. https://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf [Last Accessed: April 2020]

Although it can be an important way of treating migraine, regular use of medication to treat migraine symptoms can cause ´medication overuse headache.´Doctors call these types of headache a drug-induced headache, medication-misuse headache or rebound headache.¹

It is important that you are aware of medication overuse headaches, as it can affect the pain relief you get from your treatment. If you regularly take medication to relieve your headache symptoms and you have a headache on 15 or more days a month, your doctor may consider medication overuse to be the cause of your weekly or daily migraine pain.¹

If you suspect medication overuse headache, it is important to discuss it as soon as possible with your doctor rather than just stopping your treatment, for a number of reasons:^2,3

1. The amount of medication use that is classified as 'overuse' varies from medication to medication and some people are more susceptible than others; your doctor will take all factors into consideration and come up with a plan of action that is most likely to help you.

2. Medication overuse may be a sign that your current medication isn't giving you enough migraine control and preventive treatment may be required

3. If you are already on preventive treatment, your doctor may choose to stop or alter your medication to improve your chances of responding to it

Remember that if you take painkillers for other conditions (for example back pain), this can also cause medication overuse headache, so be sure to discuss all your medication with your doctor.

References

1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33: 629–808. Also available from https://www.ichd-3.org/1-migraine/ [Last Accessed: April 2020]

2. MacGregor EA, Steiner TJ, Davies PTG. British Association for the Study of Headache Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache Writing Committee: 3rd edition (1st revision); approved for publication, September 2010. https://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf [Last Accessed: April 2020]

3. Pringsheim T, Davenport W, Mackie G, et al; Canadian Headache Society Prophylactic Guidelines Development Group. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012; 39(2 Suppl 2): S1–59. https://headachesociety.ca/wp-content/uploads/2017/12/Pringsheim-prophyl-guideline-CJNS-2012.pdf [Last Accessed: April 2020]

Many people who experience the debilitating effects of migraine simply want to know how to cure a migraine, so it can be difficult to hear that there is currently no cure. However, there are a number of preventive treatments available to you, whether you have episodic (up to 14 headache days a month) or chronic (15 or more headache days a month, for three or more months, of which 8 are migraine days).¹ Migraine is a complex and highly individual condition, which means that the preventive treatments available are varied and the effects they have will differ from person to person.²

Although you may not get rid of migraine completely, acute migraine treatments are also available to ease symptoms,² as well as preventive medications that may reduce the frequency, intensity and/or duration of migraine attacks. Usually, the first step in migraine management is to try to identify and avoid, if possible, your migraine triggers.^2-3

References

1. Katsarava Z, Buse D, Manack A, Lipton R. Defining the differences between episodic migraine and chronic migraine. Current Pain and Head Reports 2012; 16: 86-92

2. MacGregor EA, Steiner TJ, Davies PTG. British Association for the Study of Headache Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache Writing Committee: 3rd edition (1st revision); approved for publication, September 2010. https://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf [Last accessed: April 2020]

3. NHS Choices. Migraine – Prevention. http://www.nhs.uk/Conditions/Migraine/Pages/Prevention.aspx [Last Accessed: April 2020]

A preventive treatment is aimed at reducing the frequency and/or severity of your headaches. It commonly involves medication but also include making healthy choices, known as migraine lifestyle modifications, such as limiting stress, eating well and getting enough sleep.^1,2

To help stop migraine attacks before they start, preventive treatments are used. These medications are taken regularly, even when you aren't experiencing a migraine attack. Usually, a preventive migraine treatment will be considered by your doctor if you have more than four migraine attacks a month.³

Some medications used to prevent migraine were developed for the treatment of other (non-migraine) health conditions. Some examples of these medications repurposed for migraine prevention include:³

• Blood pressure lowering medication

• Anti-depressant medication

• Anti-epileptic medication

• Injectable neurotoxins

A class of migraine treatments called calcitonin gene-related peptide (CGRP) inhibitors has been designed specifically to prevent migraine.⁴

References

1. Pringsheim T, Davenport W, Mackie G, et al; Canadian Headache Society Prophylactic Guidelines Development Group. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012; 39(2 Suppl 2): S1–59. https://headachesociety.ca/wp-content/uploads/2017/12/Pringsheim-prophyl-guideline-CJNS-2012.pdf [Last Accessed: April 2020]

2. NHS Choices. Migraine – Prevention. http://www.nhs.uk/Conditions/Migraine/Pages/Prevention.aspx [Last Accessed: April 2020]

3. Migraine Trust. Preventative Medicines. https://www.migrainetrust.org/living-with-migraine/treatments/preventive-medicines/ [Last Accessed: April 2020]

4. Russo AF. Calcitonin gene-related peptide (CGRP): a new target for migraine. Annu Rev Pharmacol Toxicol. 2015; 55: 533–552

There are a number of reasons some people don't always take their medication as prescribed; a busy life can make it easy to forget to take tablets, or your motivation to continue medication can wane if you don't feel like it is helping.¹ However, it is very important that you take any preventive medication you are given exactly as prescribed by your doctor, as it is the only way he or she can tell whether your medication is right for you, or if you need to try a different approach. This is because:

1. It sometimes takes a while before you feel the full benefit of new medication, if you don't take it as prescribed, or stop taking it too soon, you may miss out on migraine relief.^1,2

2. As migraine is highly individual, some preventive medications work within a range of doses. For these, you will need the dose fine-tuning over time. If you do not take your treatment as prescribed, it can make it much more difficult to find this optimum dose.^1,2

3. Your migraine symptoms may evolve over time, if you don't take your medication as prescribed, it may not be clear whether these changes are due to treatment effects or not.^1-3

Make sure you have regular reviews with a doctor and, if you feel that your treatment isn't working for you, discuss any concerns you have during the appointment. Keeping a migraine diary, for example using an app, can help you and your doctor understand how treatment is going, and can be a useful tool in identifying other treatment options that may work better for you.

References

1. Pringsheim T, Davenport W, Mackie G, et al; Canadian Headache Society Prophylactic Guidelines Development Group. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012; 39(2 Suppl 2): S1–59. https://headachesociety.ca/wp-content/uploads/2017/12/Pringsheim-prophyl-guideline-CJNS-2012.pdf [Last Accessed: April 2020]

2. MacGregor EA, Steiner TJ, Davies PTG. British Association for the Study of Headache Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache Writing Committee: 3rd edition (1st revision); approved for publication, September 2010. https://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf [Last Accessed: April 2020]

3. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629–808. Also available from https://www.ichd-3.org/1-migraine/ [Last Accessed: April 2020]

Usually, a preventive migraine treatment will be considered by your doctor if you have more than four migraine attacks a month.¹ Some chronic migraine treatment guidelines have suggested that preventive treatment should be considered in people experiencing three or more severe migraine attacks per month that don't respond well to acute treatment, but your doctor will make the decision based on your individual needs and circumstances.² Guidelines recommend that preventive therapy is also considered in patients who have severe or prolonged symptoms associated with migraine, even if their attacks are relatively infrequent.²

Some experts also suggest that migraine preventive treatment be considered in the following cases: ²

• In people whose migraine attacks continue to have a significant impact on their lives, despite taking acute medication and reducing lifestyle-based triggers

• If the migraine attacks are so frequent that the person suffering from them is at risk of experiencing headaches caused by overusing acute medication (medication overuse headache)

• If the preventive treatment approach is preferred by the patient and is recommended by the doctor according to his or her own clinical judgement

• In patients unable to take acute medication due to side effects, co-existing conditions or are taking other medications which may interact with acute treatment

References

1. 1. Migraine Trust. Preventative Medicines. http://www.migraine.org.uk/information/treatments-and-therapies/preventative-treatments/ [Last Accessed: April 2020]

2. Pringsheim T, Davenport W, Mackie G, et al; Canadian Headache Society Prophylactic Guidelines Development Group. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012; 39(2 Suppl 2): S1–59. https://headachesociety.ca/wp-content/uploads/2017/12/Pringsheim-prophyl-guideline-CJNS-2012.pdf [Last Accessed: April 2020]

It can be terribly frustrating to feel like your prescribed medication is not working for you. If this is the case, it is vital you don't just give up and instead discuss your symptoms with your doctor. Remember that finding the right treatment, at the right dose, can take time.

Bear in mind that there are different types of preventive medication and they have different ways of working. Migraine is very individual, if one medication is not working for you, another may be effective. Your doctor may suggest changing your preventive medication if one or more of the following applies to you:^1,2

• It isn't providing you with the symptom relief you need

• You are experiencing side effects from treatment

• You have developed a condition that may affect the way the treatment works on your body

• You need to take drugs for another condition that may interfere with it

• You are finding it difficult to keep up with the dosing schedule

Be aware that some medication is not safe during pregnancy and so you should tell your doctor immediately if you are pregnant or are thinking of getting pregnant.¹

Keeping a migraine diary can help you and your doctor see how well your treatment is working.²

References

1. MacGregor EA, Steiner TJ, Davies PTG. British Association for the Study of Headache Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache Writing Committee: 3rd edition (1st revision); approved for publication, September 2010. https://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf [Last Accessed: April 2020]

2. Pringsheim T, Davenport W, Mackie G, et al; Canadian Headache Society Prophylactic Guidelines Development Group. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012; 39(2 Suppl 2): S1–59. https://headachesociety.ca/wp-content/uploads/2017/12/Pringsheim-prophyl-guideline-CJNS-2012.pdf [Last Accessed: April 2020]