Migraine Treatment

Management

Migraine or more specifically the tendency to have migraine events (whether headache or dizziness or other symptoms) can not be cured. This tendency is probably genetically determined. At different time in a patient’s life this predisposition may be more prominent and also behave differently. For example younger patients tend to have more intense headaches while older patient may have more dizziness. Migraine has to be managed with a combination of methods. Generally migraine is managed by either preventative or abortive treatment. Preventative measure aim to, as the same suggest, prevent migraine before it starts. Abortive treatments aim to manage the migraine after the migraine episode has started. In some patient the symptoms become very frequent and in these cases preventative treatments are appropriate.

Abortive Treatment

Typical migraine headaches can respond to the “usual” treatments e.g. paracetamol and/or ibuprofen particularly if taken early at the time of the onset of headache. These medication are labelled as abortive. Often the patient has to lie in a quiet dark room and rest for a few hours. Some patient benefit from special abortive drugs such as triptans. Codeine and caffeine are also used but can cause rebound headaches/symptoms if taken regularly and hence are not recommended for regular use. The aim is to abort or stop the migraine pain. Other symptoms which may occur at other times when no headache is present such as dizziness may fail to respond to the abortive medications usually used for migraine headache such as paracetamol, ibuprofen and triptans. Therefore preventative measures are the mainstay of treatment for these migraine associated problems including dizziness. There include prophylactic medications (i.e. preventative medications.)

During an attack of dizziness Buccastem (Prochlorperazine) can be used (for further information on this medication click here). This has to be prescribed by a doctor. The tablet is placed under the lip/gum and is absorbed without swallowing. It reduces nausea although it may not stop the attack.

Preventative Treatment

Certain factors can reduced the threshold for migraine symptoms. i.e. certain things make the migraine more likely. These “trigger” factors include psychological / physical stress, hormone levels (e.g. menstrual cycle in women), lack of sleep, hunger, thirst, dietary factory (particularly lack of caffeine). This is not an exhaustive list and in some patient rather strange things may act as triggers e.g. strawberries or citrus fruit. Lifestyle measure aim to deals with these factors.

Certain dietary supplement or medication are also able to modify how likely one is to develop a migraine symptom.

The factors which can be modified by the patient include lifestyle measure and exercise.

Lifestyle

Lifestyle measures which help improve migraine are varied. These essentially involve avoiding triggers. One of the commonest triggers is stress. This can be related to unusual work or family factors which may be temporary. Sometimes however, problems may persist. If possible patients should try to take a 5 minute break every 2 hours while at work. Try to spend the 5 minutes walking. Use a portable shiatsu machine to massage your neck. Pay attention to your posture, especially your neck while at work.
Codeine or codeine type of drugs can, if taken regularly over a prolonged period of time, cause a mild addiction which can lead to chronic migraine. It is advised that codeine or codeine type drugs are stopped completely. This may initially cause a deterioration in your symptoms but eventually there will be an improvement.

Dietary factors include caffeine. This can addictive in a similar way to codeine. Although taking caffeine does not necessarily cause a migraine, patients are often mildly addicted to caffeine. It is generally recommended that all caffeine intake is eliminated at least initially. This includes coffee, tea and fizzy drinks containing caffeine. Decaffeinated drinks can be substituted although some patients may be sensitive to the chemicals in decaffeinated drinks. Later once your problem is under control the caffeine drinks can be reintroduced to see what effect they have. Other common dietary triggers include chocolate, cheese, alcohol, monosodium glutamate and certain types of preservative. More unusual foods which can trigger migraine include citrus, strawberries and yeast for example in bread. You may need to analyse your diet carefully to determine if there are any specific foods which may be precipitating migraine / dizziness. If your problem is particularly severe you may consider adhering to a strict diet eliminating as many of these factors as possible. A book entitled “Heal Your Headache” by Dr D Buchholz deals in great detail with dietary triggers of migraine and how to avoid them.This book can be purchased over the Internet (e.g. from Amazon) or you could ask your local bookshop to order this for you. Some patient claim that eliminating certain food types can help e.g. gluten/wheat, yeast and dairy products. Reducing sugar and or artificial sweetener has help some.

It is recommended you remain well hydrated. Research carried out for Meniere’s Disease (which is closely related to Migraine) showed drinking 35ml/kg water per day reduced attacks. This equates to nearly 2.5 litres per day for a 70 kg “average” man.

Lack of sleep or too much sleep can act as a trigger.

Other possible approaches include relaxation and meditation. There are many websites, book and specialist who can help with this (e.g. the book: Full Catastrophe Living, Revised Edition: How to cope with stress, pain and illness using mindfulness meditation). The aim with these is learn relaxation and reduce adverse reaction to stress. A course on Mindful based stress reduction are available here.

Other potentially useful resources for managing stress is found here, here and here.

Understanding your condition and/or psychological approach is also of benefit. The book “The Pain Survival Guide” by Dr D Turk is a book mainly aimed at patient with chronic pain but many of the ideas and approaches can also be used to help with other symptoms of migraine including dizziness. A copy of the book is available here.

Mr Rejali and Mercia Health have no link/relationship (commercial, financial or personal) with any of the resources/people/books/courses mentioned above. None are guaranteed to work.

Exercise

Generally aerobic exercise (such as walking and running) is good for feeling of well being and can be helpful in migraine. It increases patient’s resilience to physical stress which can be helpful in work. In some patient with migraine however, exercise or physical stress can act as a trigger to start headaches / dizziness. The approach here is to work out a level exercise which can be managed without acting as trigger. For example if you run a mile in 10 minutes and this makes you unwell for many hours or days then start by walking for 5 minutes. If this cause problems then walk very slowly for 2 minutes.This way you can work out what you can manage. Once you are comfortable then very slowly build up you level of exercise. On occasions however (for example if you have been stressed for other reasons) a level of exercise previously well-tolerated may trigger a attack of migraine/dizziness. It is important therefore to be able to read your own body and consider other factors when deciding how much exercise to carry out. Generally more frequent less intense exercise is better. In some patients it may be easier to think of body as having a battery which once flat needs time to recharge. Pushing yourself too far will cause problems. You need to know how far your battery will take you.

If you plan to carry out a unusual physical activity which will be quite physical and/or stressful you may opt to take some ibuprofen (assuming you do not have any contraindications to taking this medication such as gastric problems or severe asthma) before undertaking this activity. Ibuprofen can be purchased over-the-counter. This can’t be done too regularly as Ibuprofen can cause inflammation / damage to the lining of your stomach if taken too often but it can be helpful on the odd occasion. It may help prevent triggering of the migraine process.

Specific balance exercises can be found here.

Dietary Supplements

Magnesium has been show in some trials to reduce recurrence of migraine.

Natural sources of magnesium include: unrefined whole grains, spinach, nuts, legumes and white potato. Some of these however can act as a migraine trigger in some patients. Alternatively magnesium supplements can be obtained from supermarkets or online (e,g, Amazon). The usual dose is 400 mg once daily. Magnesium Glycinate is well tolerated. The magnesium needs to be taken for 1 months before any change would be noted. Side effect can include diarrhoea. If this happens you may opt to reduce the dose, take calcium supplements which could counteract the diarrhea or stop the Magnesium. Magnesium can interfere with absorption of a medication called Gabapentin. Magnesium and Gabapentin must be taken at a different time during the day. If you have kidney/renal failure then the Magnesium dose may build in the body can cause potentially serious problems. Do not take magnesium if you have renal/kidney failure. For further information click here.

Co-enzyme Q10 has also been shown to be of some benefit in some patients with Migraine. The usual dose is 100 mg 3 times a day. There are no common serious side-effects. Rare side effect include loss of appetite, nausea and diarrhoea. Co-enzyme Q10 may interfere with some medications including: Warfarin, anisindione and dicumoral. If you are any o fate medication you must discuss this with you GP before taking Co-enzymw Q10. As with magnesium patients may need to take Co-enzyme Q10 for 3 months before they notice any effect. For further information click here.

Riboflavin (also know as Vitamine B2) has been used for treatment of migraine. The dose has to be quite high i.e. 400mg/day. The normal requirements being 1.3 mg per day in an adult male. It can make the urine yellow / orange. Side effects are rare. These include include diarrhoea and passing large amount so urine. For further information click here.

Polyunsaturated omega 3 fatty acids (OPFAϖ-3) has been show in some trial to be useful for prophylaxis of migraine attacks.

Palmitoylethanolamide (PEA) has been show in trials to help reduce pain caused by nerve entrapment (e.g. sciatica).

Herbal treatments

Butterbur / Petastites. Butterbur is plant. It contains various chemicals. Some of these chemicals can help prevent migraine. These include: petasine and isopetasine. The plant also contains very dangerous toxins (pyrrolizidine alkaloids) which can damage the liver.

Although certain preparation (e.g. Petadolex) have claimed to have removed the harmful chemicals, there has been some reported of cases of liver damage after taking this preparation. There is even more safety concern regarding other preparations and unbranded extracts.

At present, in view of this safety concern, preparations of Butterbur may not be safe.

For a full review please see here.

Preventative Medication

As mentioned above abortive medications such as paracetamol and ibuprofen are generally not successful at improving dizziness in migraine. The medications which are more successful in treating dizziness related to migraine are preventative migraine medications which need to be taken every day. These include medications which were often originally used for other conditions such as depression or high blood pressure. Many patients with migraine are quite sensitive to medications and the usual starting dose may need to be smaller than usual. All medication have potential side effect and this need to be measure against the potential benefit. The medication below will need to be prescribed by you doctor. Some have potential interaction with other medications. With respect for treatment of migraine all of the medication below are used off-license. This means the original license for use did not list migraine as a target disease. Nevertheless if there are no suitable licensed medication, off-license medication can and are often used for prevention of migraine.

Amitriptyline

This is an antidepressant class of drug. It is fairly effective for migraine. Common side effects include dryness of the mouth and occasionally tiredness or lethargy. It is best taken in the evening/night time. It is usual to start at a low dose such as 10 mg (milligrams) or even 5mg and the dose increased slowly e.g. by 5 to 10 mg every 2 to 3 weeks. If the dose has reached 50 mg and there has been no benefit it is unlikely it will be beneficial. The dose can be increased to 75 mg if required. It is a drug that is not recommended for use in patients with heart problems such as irregular heartbeat. It can also cause problems with passing urine or can on rare occasions precipitate glaucoma (pain in the eye, red eye and blurred vision). Some patients may experience suicidal ideas. The drug is not recommended if there is a history of suicidal thoughts. Nortriptyline is a drug which is better tolerated but has similar actions to amitriptyline. The starting dose is the same but the eventual effective dose may be higher (up 100 mg once a day). For further information click here.

Propranolol

This is a type of beta-blocker. Its traditional use has been as a blood pressure lowering agent. Side effects include lethargy, dizziness when standing up due to low blood pressure. It is not recommended for use in people with asthma, depression or diabetes. The usual starting dose is 40 mg twice a day or if not tolerated well to start at 20 mg twice a day. Eventually a slow release formulation can be used such as 80 mg once a day. For further information click here.

Verapamil

This is a medication that is used for irregular heartbeat. Its side effects are generally mild including swelling of the ankle or constipation. It is not advised to take this medication while taking beta-blockers such as propranolol. The usual dose is 120 mg sustained-release formulation once a day. This can be increased to 240 mg a day. For further information click here.

Venlafaxine

This is also an antidepressant class drug. It has less sedating side effects than amitriptyline. The usual starting dose is half a 37.5 mg sustained-release tablet once a day for one week and followed by a whole tablet. Some patients may experience suicidal ideas. The drug is not recommended if there is a history of suicidal thoughts. The dose can be increased further if necessary. For further information click here.

Topiramate

This was originally used as an anti-epileptic (anti-convulsant / anti-seizure) medication. This medication seems to reduce irritability and sensitivity of nervous tissue. It is still used as an anti-epileptic medication. It is also used as a migraine preventative medication. The starting dose is usually 25 or 50 mg at night and this is increased in steps to 50 mg twice a day. Generally it is well tolerated. Side effects include cognitive difficulty (difficulty thinking), pins and needles (parasthesia), kidney stones or visual problems. Some patients can lose weight. If taken for a prolonged period it would be a good idea to have your blood acid/base levels monitored by your doctor. For further information click here.

Cinnarizine

This can obtained over the counter (e.g Stugeron) and has been shown to be effective as both a anti-migraine and anti-vertigo medication. Long term use can have extra-pyramidal side effects such as “parkinson disease type shaking”.

Flunarizine

Used in many countries but not licensed in the UK. It has similar properties to Cinnarizine above.

 

Interventional treatments and Surgery

Some patient may benefit from a local anaesthetic injection/block, botulinum (Botox®) injection or surgery.

Disclaimer

Mr Rejali and Mercia Health have no link/relationship (commercial, financial or personal) with any of the resources/people/books/courses/manufacturer of medications/supplements mentioned above. None are guaranteed to work.