Common triggers associated with an increased chance of experiencing a migraine attack include stressful events, hormonal changes, weather changes and certain foods.

In around 80% of patients, stress is reported to be associated with a migraine event, making it the most common trigger reported by migraine patients.

But what type of stress is a migraine trigger? A study published in Neurology in 2014 sought to investigate this further.

Patients were asked to keep a 3 month electronic diary, with daily data entered including migraine attacks and stress measures, assessed using a stress scale.

The results were interesting in that the level of the stress status scores were not significantly associated with migraine occurrence. However, a reduction in stress from one evening to the next was consistently associated with migraine attack onset on the third day.

These findings support the ‘let down migraine’ hypothesis, often observed by migraine patients. In this scenario patients will state that Friday night or the weekends, typically the times of their least stress, are the most likely times for their breakthrough migraine events to occur.

Why does this occur? The exact mechanism is uncertain, however there are some possible biological explanations. Stress can activate the ‘fight or flight response’, with short term elevation of steroids, when the acute stress ends however, steroid withdrawal may produce an abnormally heightened sensitivity to pain.

What does this mean? An awareness of a variation in stress, and the activation of strategies to reduce that stress, may be able to decrease migraine attack frequency in susceptible patients.

Reference:

Reduction in perceived stress as a migraine trigger: testing the ‘let-down headache’ hypothesis Neurology 2014 Apr 22;82 (16): 1395-401

Menstrual migraines are common. In fact, 2 out of 3 premenopausal female migraine sufferers report that migraine attacks consistently occur during peri-menstrual time periods. Attacks of menstrual migraine have been found to be more severe, disabling and less responsive to acute medications than those that are non menstrually related.

What causes Menstrual Migraines?

The most likely trigger for menstrual migraine is the decline of oestradiol levels that occur shortly before and during the peri-menstrual time period.

How to diagnose Menstrual Migraines? 

A headache/migraine diary or app is a particularly useful tool for the patient and doctor because you can record the occurrence of migraine and the onset of the menstrual periods, as well as information about other potential triggers. This makes it easier to understand patterns and treat menstrual migraine.

To learn more about keeping a headache or migraine diary and to download a template, head over to this blog post.

How do you treat Menstrual Migraines? 

Acute and Preventative therapies may be utilised for the treatment of menstrual migraine. Acute therapies are used to abort the migraine attack once it has begun, while preventative therapies are used to try and prevent menstrual migraines from occurring.

Patients with regular menstrual periods may be suitable for short term prophylactic (‘miniprophylaxis’) therapies.

The options may include magnesium, NSAIDs, topical oestrogen therapy or triptan medications (for eg Naramig)

Patients with irregular menstrual periods may be more suitable for long term, continuous prophylactic therapies.

The treatment typically involves the use of non-hormonal preventative therapies, or in certain cases, if deemed appropriate following a screening history to exclude prior clotting disorder, DVT/stroke risk factors or migraine with aura symptoms, combination hormonal therapies.

Note: information on this site is not a substitute for professional medical advice

References:

Menstrual Migraine: New Approaches to Diagnosis and Treatment. American Headache Society

Use of Oral Contraceptives in Women with Migraine. American Headache Society

Diagnosis and Treatment of the Menstrual Migraine Patient. Headache 2008; 48:S115-S123

How do I know if I need it?

 There are two type of migraine –Episodic migraine and Chronic Migraine. Each of these subtypes are determined by the frequency of headache days.

Chronic Migraine occurs when patients suffer headaches on at least 15 days of the month, with migraine on at least 8 of those days.

Typical characteristics of migraine without aura are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or light and noise sensitivity. Migraine attacks usually last 4-72 hours.

If you migraine has become chronic, preventative therapy is required to help you achieve remission back to episodic migraine.

Preventative Therapy for Chronic Migraines –What does this involve?

This will typically involve non drug measures as well as medications.

Non drug treatment examples include an aerobic conditioning program, avoidance of triggers, eating healthy, regular spaced meals, allowing for relaxation time, and attention to good sleep hygiene.

Medication treatment for chronic migraine requires effective use of drugs for acute migraine treatment and medications for prevention.

Preventative Therapy for Chronic Migraine –Important issues

The key to success is persistence, with an adequate dose of the medication for an adequate duration required

It is difficult to predict initially whether the treatment prescribed will be effective, and the process is a matter of educated trial and error, which can be frustrating for both the patient and the doctor.

If you have however been taking an adequate dose of a preventative for an adequate time period, and have not experienced a significant improvement, or are experiencing intolerable side effects, then it is time for a change of therapy.

Preventative Therapy for Chronic Migraine- Other considerations

 Aggressive and early treatment of acute, as well as prolonged migraine attacks will help in achieving remission of chronic migraine.

Avoid Medication Overuse Headaches. Overuse of acute medications is associated with the transformation of episodic migraines to chronic migraine disorder.

If you suffer from a migraine co-morbidity such as chronic insomnia, anxiety, depression or other medical problems, talk to your GP about treatment for that condition

References:

Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3^rd edition. Cephalagia 2013;33(9):629-808

Preventative (Prophylactic) Therapy. Headache 2009 American Headache

MOH is a type of daily, or second daily headache, that is common, affecting at least 1% of the population.

It can develop from frequently using acute headache medications. Acute headache medications are those that are taken when a headache occurs, such as Panadol.

Risk Factors for MOH

People at risk of MOHs are those with frequent migraine or tension type headaches.  People taking pain killers for some other reason for e.g. arthritis, are only at risk if they also have a history of headaches.

Which medications can cause MOH?

The medications that most commonly cause MOH are:

• Triptans (i.e. Imigran, Zomig, Naramig, Maxalt, Replax)
• Opiates (i.e. codeine, morphine)
• Simple painkillers (i.e. paracetamol)
• Combination painkillers (i.e. Endone, Mersyndol, Panadeine Forte)
• Ergortamine (ie Cafergot, no longer available in Australia)
• Caffeine – containing medications (i.e. Panadol Extra)

In the case of caffeine, withdrawal causes tiredness, lowered alertness and poor concentration, this causes people to want to consume more caffeine, along with the associated pain killer.

Opiates have a particularly strong association with MOHs and are never an appropriate treatment for chronic migraine/tension headache.

Diagnosis of MOH

The typical patient has a long history of migraine or tension type headaches.  There are no diagnostic tests for MOH, and the history is the most important piece of information to make the diagnosis.

What is Medication Overuse Headache (MOH)? – Part 2 will deal with the management of this condition.

References:

http://headacheaustralia.org.au/news/medication-overuse-headache/

Medication Overuse Headache Australian Prescriber 2005;28:143-5 1 December 2005

Migraine Specialist was founded due to the need of migraine sufferers to find a therapy that could aid their debilitating illness.  There are almost two million migraine sufferers in Australia with females more likely to suffer them than males.  Our Neurologist, Dr Nicole Limberg, has extensive experience in treating chronic migraines and can offer treatments that are both Medicare subsidized, and fully PBS funded.

We are conveniently located at St Andrew’s Place, Spring Hill, Brisbane.

So start taking control and give our friendly team a call on (07) 3831 1611 or contact us.