Migraines: Symptoms, causes and treatment

Around 10 million people in the UK live with regular migraine attacks – but there are ways to treat them

Migraine can be so debilitating that the ancient Greeks believed it was brought on by the wrath of evil spirits, and even attempted to treat it through trepanning, the practice of drilling a hole into the skull.

Fortunately, we've moved on a little in the past 2,500 years, but migraine remains one of the most disabling common neurological conditions. According to the NHS, around 10 million people in the UK live with regular migraine attacks, while the annual impact on the economy from migraine-linked absenteeism from work is placed at around £4.4 billion.

But while migraine is often conflated with an ordinary tension headache, the two are very different. As well as head pain, migraine sufferers can also experience nausea, vomiting and severe fatigue.

"Tension headaches are just telling us that something is out of kilter," says Prof Anne MacGregor, a specialist in headache and women's health at Queen Mary University of London. "With a migraine it's very different. Once it is set off, triggers will build up, and tip over the threshold to a migraine attack. And once that's started, it has to go through its course. That process will usually take a few hours to a few days before it's actually complete and you feel back to normal again."

The different types of migraines

Migraine commonly falls into two categories, with and without aura, the term for the visual or sensory disturbances which can begin before the rest of the migraine symptoms.

Aura can also involve:

• Dizziness
• Numbness
• Tingling in parts of the body
• Muscle weakness

"The neurological process behind aura is caused by a slow wave of altered brain activity called cortical spreading depression," says Debbie Shipley, from UK charity The Migraine Trust. "This leads to temporary changes in the chemicals, nerves and blood flow in the brain that affect how it works."

However, there are also other rarer types of migraine such as hemiplegic migraine which occurs in just 0.01 per cent of the population. This is caused by a single gene mutation and can also lead to one-sided weakness in the body during a migraine attack, which can sometimes mean that it is confused with stroke.

Around 10 per cent of all migraine sufferers experience vestibular migraine which can involve symptoms of vertigo and balance problems alongside the head pain.

Migraine phases

According to Shipley there are between three and four distinct phases of a migraine attack.

1. The premonitory stage

   Where people experience a sudden increased thirst, mood shifts, or increased tiredness and yawning. This can begin up to 24 hours before the onset of other symptoms and is an early sign of neurological change.

2. Aura

   For the one in three migraine sufferers who experience aura, this phase can last a few minutes to an hour, before the onset of pain and other symptoms. "Aura most often presents as visual changes like coloured spots, flashes or zig-zag lines in vision, for example," says Shipley.

3. Throbbing pain

   When the headache begins, people usually experience throbbing pain on one side of the head, a different experience to tension headaches which typically present as a band of pain across the forehand or as a pressure on either side of the head. Shipley says that in severe migraine attacks, the pain can last for up to three days.

4. A 'migraine hangover'

   "The final phase is sometimes dubbed this, as after the resolution of the main headache stage, people often feel very fatigued which can last for hours or days," says Shipley.

Causes

So what is the underlying cause of a migraine? According to Elizabeth Loder, a professor of neurology at Harvard medical school, and one of the world's leading experts in migraine research, evidence is increasingly suggesting that migraine is a brain disorder linked to various inherited gene mutations.

According to one 2023 study, there are now more than 180 different gene variants which have been linked to various networks in the body involved in driving migraine.

"We know more about genes that play a role in increasing susceptibility to migraine," says Prof Loder. "These act in many ways on processes involved in migraine. Identifying genes related to migraine should eventually help us identify targets for the development of new treatments."

This still leaves an important question – why would the human body develop gene variants which cause us such distress? Prof MacGregor believes this is because a migraine is essentially a protective response gone wrong, the body overreacting to a perceived threat and seeking to protect the brain.

"The body is really trying to get you to go into a darkened room, get away from light, sound and smell," she says.

What are the main migraine triggers?

• Disruption to daily routine
• Shifted sleep or missing meals
• Dehydration
• Hormonal changes

According to both Shipley and Prof MacGregor, people commonly link specific foods or drinks like chocolate, red wine or caffeine with migraines, but these associations tend to be red herrings.

"For example, prior to the main attack phase, a person might experience cravings for chocolate," says Shipley. "They then experience the migraine attack and connect what they've eaten as a trigger, when actually the craving was a warning sign of an attack already in progress."

Instead, migraine triggers actually tend to be related to disruption to the daily routine such as shifted sleep patterns and missing meals, hormonal changes, or dehydration.

Professor MacGregor tends to advise sticking with most things in moderation. "We shouldn't be putting out 'avoid this and avoid that', blanket guidelines because people are already controlled by their migraine, and they just end up being controlled even more," says Shipley.

Why is migraine more prevalent in women?

Women of reproductive age are notoriously more susceptible to migraine, three times more so than men. In fact, statistics suggest that between 18 and 25 per cent of women suffer from migraine attacks, making it one of the most common debilitating conditions faced by the female population.

"Many women will notice a link between their menstrual periods and migraines," says Prof MacGregor. "They will often find that during pregnancy, their migraine improves."

Because migraine is so heavily intertwined with hormonal cycles, women who experience particularly heavy periods are more vulnerable.

Prof MacGregor says that women who take the seven-day contraceptive pill break or are going through perimenopause are more vulnerable to something called an oestrogen withdrawal migraine. "Women can experience more severe migraine during perimenopause, and that can then be made worse if they start hormone replacement therapy (HRT) too early in the process," she says.

However contrary to most conditions, migraine actually tends to improve with age. Research has shown that migraine attacks are most prevalent between ages 20 and 40, with both the intensity of attacks decreasing and responsiveness to therapy improving as people get older. "The greater the link between a woman's hormonal cycles and migraine, the greater the likely improvement post menopause," says Prof MacGregor.

Treatment

The first line treatment for migraine attacks has long been a class of medications known as triptans which work by changing how blood circulates in the brain and how pain signals are being processed. Researchers have found that standard triptan doses are effective at relieving some of the symptoms of migraine attacks in between 42 and 76 per cent of people within two hours.

"Triptans have stood the test of time and are likely to remain important treatments," says Prof Loder.

However, triptans can be challenging for many patients. Side effects can include dizziness, nausea, and chest tightness, which can be debilitating in their own way. Some patients report feeling unable to drive or perform daily tasks after taking triptans, which can significantly impact their quality of life.

In recent years, a new class of medications known as small molecule CGRP inhibitors or "gepants" have emerged. These work by blocking CGRP, a protein produced by the brain's nerve cells which plays a role in dilating blood vessels and transmitting pain signals.

Available as tablets, they include drugs such as ubrogepant, rimegepant, and atogepant. "They can be useful for people who can't take triptans, but they are very expensive, so it's not easy to access them on the NHS," says Prof MacGregor. "Some of them cost around £15 per tablet."

While gepants may offer an alternative for those who struggle with triptans, they come with their own set of challenges. The high cost can be prohibitive for many patients, and some report side effects such as nausea and fatigue.

Natural approaches and bespoke treatments

Dr. Peter Chadha, a specialist in bespoke biotics, highlights the importance of considering more natural approaches to migraine management. "Since 2012, NICE has been recommending some interesting natural alternatives that many patients find helpful," he notes.

These NICE-recommended natural treatments include:

• Riboflavin (Vitamin B2) at 400mg daily
• Coenzyme Q10
• Magnesium supplements

Dr. Chadha emphasizes that while these natural options can be effective, patience is key. "It's important for patients to understand that these supplements typically require at least three months of consistent use before their full benefits can be observed," he explains.

The timing of supplement intake can also play a role in their effectiveness. Dr. Chadha recommends taking magnesium in the evening or at night, while CoQ10 and riboflavin are best taken in the morning.

For those looking for convenient access to these supplements, Dr. Chadha mentions the MigraSoothe range of products. "We offer all three of these NICE-recommended supplements in our MigraSoothe triple pack, making it easier for patients to follow this regimen," he says.

This approach has garnered attention beyond medical circles. In an appearance on GB News' morning show on April 26, 2024, Dr. Peter Chadha stated, "Natural supplements like riboflavin, CoQ10, and magnesium are changing the game for many migraine sufferers. Our MigraSoothe triple pack makes it easy for patients to follow NICE guidelines, potentially reducing the need for stronger medications."

The appeal of these natural approaches lies in their potential to offer relief with fewer side effects compared to some pharmaceutical options. However, Dr. Chadha stresses the importance of personalized treatment plans. "What works for one patient may not work for another. That's why we often create bespoke supplement combinations tailored to individual needs."

While these natural treatments offer promise, Dr. Chadha advises that they should be used under medical supervision, especially for patients with pre-existing conditions or those taking other medications. "Always consult with a healthcare professional before starting any new treatment regimen, even if it's natural," he cautions.

The inclusion of these natural options in NICE guidelines represents a shift towards a more holistic approach to migraine management, offering patients a wider range of choices in their treatment journey.

How can you prevent your migraines from coming back?

Prof MacGregor says that much can be done through lifestyle measures such as:

• Staying sufficiently hydrated
• Getting enough exercise and sleep
• Simply looking after your general health
• Managing underlying illnesses

"Migraine is also a barometer of your physical and mental wellbeing, and if you have another underlying illness, that can be the reason why you get more frequent migraine," she says.

New migraine prevention therapies

In recent years the first migraine prevention therapies have emerged, which are particularly applicable for people with chronic migraine, who suffer at least 15 headache days per month.

CGRP inhibitors are available as preventative injections or IV infusions which are either self-administered or at a clinic. They need to be taken on a monthly or quarterly basis depending on the drug, and while not cheap, costing between £250 to £300 per month, they can provide much needed relief to people who are severely affected. "These medications are for people where migraines are affecting their ability to function and get on with their lives, and they are quite effective," she says.

In the coming years, further migraine prevention therapies are likely to emerge, with clinical trials being launched to test another injectable therapy which attempts to block another migraine-causing protein in the brain called PACAP.

"Scientists are now beginning to look back at pathways relating to where migraines begin in a part of the brain called the hypothalamus," says Prof MacGregor. "The aim is to see if they can intervene before people start to experience the headache and prevent that whole migraine process kicking off."

As research continues, the hope is that more effective and tolerable treatments will become available, offering relief to the millions who suffer from this debilitating condition. The inclusion of non-pharmaceutical options like riboflavin in official recommendations is a promising step towards a more holistic approach to migraine management. However, it's clear that navigating the various treatment options remains a complex and often challenging journey for many migraine sufferers.