Migraines in the UKMigraines in the UK

Mohammad Moazzam FazleeMohammad Moazzam Fazlee

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Punnam MittuPunnam Mittu

Migraine in the UKMigraine in the UK

WHO has classified headache as a major health disorder and has WHO has classified headache as a major health disorder and has rated migraine amongst the top 20 most disabling lifetime rated migraine amongst the top 20 most disabling lifetime conditions.conditions.

1 in 7 people in the UK suffer from migraine.1 in 7 people in the UK suffer from migraine. Twice as many women as men.Twice as many women as men. All age groups (even young children) and all social classes.All age groups (even young children) and all social classes. Migraine costs the UK around £2.25 billion per annum.Migraine costs the UK around £2.25 billion per annum. One attack can last for between 4 and 72 hours (with an average One attack can last for between 4 and 72 hours (with an average

of 13 attacks each year).of 13 attacks each year). Around 60% of sufferers never consult their GP because they Around 60% of sufferers never consult their GP because they

mistakenly think that nothing can be done to help them. mistakenly think that nothing can be done to help them. For most people there is not just one trigger but a combination For most people there is not just one trigger but a combination

of factors which individually can be tolerated but when they all of factors which individually can be tolerated but when they all occur together a threshold is passed and a migraine is triggered.occur together a threshold is passed and a migraine is triggered.

Types of HeadacheTypes of Headache

Tension - the common "everyday" headache most people Tension - the common "everyday" headache most people will experience at some point in their lives. In some cases will experience at some point in their lives. In some cases people have tension headaches on most days of the month.people have tension headaches on most days of the month.

Migraine - severe headache that can last for several days. It Migraine - severe headache that can last for several days. It gets worse with activity and often comes with nausea as gets worse with activity and often comes with nausea as well as sensitivity to light and sound.well as sensitivity to light and sound.

Cluster - extremely severe pain around the eye and side of Cluster - extremely severe pain around the eye and side of the face, also includes swelling and a red watery eye. Some the face, also includes swelling and a red watery eye. Some people report eight attacks a day, which can last up to people report eight attacks a day, which can last up to three hours.three hours.

Medication overuse - feels like a tension headache or a Medication overuse - feels like a tension headache or a migraine, but is due to taking too many painkillers.migraine, but is due to taking too many painkillers.

However, there are more than 200 types of headache.However, there are more than 200 types of headache.

How do you know when itHow do you know when it’’s a Migraine?s a Migraine?

AssessmentAssessment

Is it a primary headache (tension, migraine or cluster?Is it a primary headache (tension, migraine or cluster?

Is it secondary to an underlying cause?Is it secondary to an underlying cause? Headache History Headache History

Time Time Onset (recent or long time sufferer)Onset (recent or long time sufferer) Frequency (daily? Quantify)Frequency (daily? Quantify) PatternsPatterns Duration of attackDuration of attack Character Character Site (where does pain start, does it spread)Site (where does pain start, does it spread) Intensity (scale of 1-10)Intensity (scale of 1-10) Duration of painDuration of pain

Causes Causes

Family history? Family history?

Triggers/aggravating factors/relieving factors Triggers/aggravating factors/relieving factors

ResponseResponse

Patients actions during attack – what they do to Patients actions during attack – what they do to relieve headache i.e. medication usedrelieve headache i.e. medication used

Limitations during an attack – does medication work Limitations during an attack – does medication work completely/partially/make it worse?completely/partially/make it worse?

Is patient symptom free between headachesIs patient symptom free between headaches

IntervalsIntervals State of health between attacks – concerns, State of health between attacks – concerns,

anxieties and fears about attacks?anxieties and fears about attacks? How does patient feel between attacks?How does patient feel between attacks?

How do you know when itHow do you know when it’’s a s a Migraine?Migraine?

MigraineMigraine

Typically recurrent, episodic Typically recurrent, episodic

Moderate or severe painModerate or severe pain

May be unilateral/and or throbbingMay be unilateral/and or throbbing

Duration – from 4 hours up to 3 daysDuration – from 4 hours up to 3 days

GI + visual symptoms commonGI + visual symptoms common

Activity limitedActivity limited

Dark/quiet preferredDark/quiet preferred

Free from symptoms between attacksFree from symptoms between attacks

Phases of Migraine AttackPhases of Migraine Attack

ProdromeProdrome

60% migraine sufferers experience60% migraine sufferers experience

Occurs within hours or up to days before an attackOccurs within hours or up to days before an attack

Physical symptoms: stiff neck, cold, ↑ thirst, ↑ urination, Physical symptoms: stiff neck, cold, ↑ thirst, ↑ urination,

loss of appetite, diarrhoea, constipation, sensitivity to loss of appetite, diarrhoea, constipation, sensitivity to

light/soundlight/sound

Psychological symptoms: Depression, Euphoria, Psychological symptoms: Depression, Euphoria,

Restlessness, Drowsiness, Fatigue, Irritability, Impaired Restlessness, Drowsiness, Fatigue, Irritability, Impaired

concentration, Scalp tenderness, Mood changes concentration, Scalp tenderness, Mood changes

AuraAura

20% sufferers experience right before an 20% sufferers experience right before an

attackattack

Develops 5-20mins before attack, lasts no Develops 5-20mins before attack, lasts no

longer than 1 hour longer than 1 hour

Symptoms:Symptoms:

Numbness or tingling of the face arm, or Numbness or tingling of the face arm, or

hand on one side of the body, Muscular hand on one side of the body, Muscular

weakness weakness

Mild paralysis on one side of the body Mild paralysis on one side of the body

Difficulty speaking or loss of speech Difficulty speaking or loss of speech

AnalgesicsAnalgesics

Aspirin 75-900mgAspirin 75-900mg

Paracetamol (little efficacy on own) 125 – 500mgParacetamol (little efficacy on own) 125 – 500mg

Ibuprofen 100-600mgIbuprofen 100-600mg

Common side effectsCommon side effects

DrowsinessDrowsiness

Flushing (redness of face)Flushing (redness of face)

DizzinessDizziness

Feeling sick (nausea), being sick (vomiting)Feeling sick (nausea), being sick (vomiting)

Pain sensationsPain sensations

Tingling and Heat sensationsTingling and Heat sensations

‘‘Brain gets used to painkillers’Brain gets used to painkillers’

Warwick Medical SchoolWarwick Medical School““Anyone taking painkillers for more than 15 days during a Anyone taking painkillers for more than 15 days during a month were likely to suffer from analgesia-induced month were likely to suffer from analgesia-induced headaches’. Dr Brian Hope headaches’. Dr Brian Hope "This can end up getting into a vicious cycle where your "This can end up getting into a vicious cycle where your headache gets worse, so you take more painkillers, so your headache gets worse, so you take more painkillers, so your headache gets worse and this just becomes worse and worse headache gets worse and this just becomes worse and worse and worse’’ Prof Martin Underwoodand worse’’ Prof Martin UnderwoodThis is a huge problem in the UK population. The figures in This is a huge problem in the UK population. The figures in terms of the number of people who have medication overuse terms of the number of people who have medication overuse headache are one in 50, so that is approximately a million headache are one in 50, so that is approximately a million people who have headaches on a daily or near daily basis people who have headaches on a daily or near daily basis because they're using painkillers.because they're using painkillers.

Trigger or predisposing?Trigger or predisposing?

TriggersTriggers PredisposingPredisposing

PsychologicalPsychological Depression, anxiety, anger, Depression, anxiety, anger, tiredness, etc,tiredness, etc, relaxation after stress: relaxation after stress: weekends/holidays weekends/holidays

StressStress

Change in HabitChange in Habit change in sleep patterns change in sleep patterns e.g. missing sleep, lying in, missing meals, e.g. missing sleep, lying in, missing meals, long distance travellong distance travel

Depression/anxietyDepression/anxiety

EnvironmentalEnvironmental Smoking, smoky rooms, Smoking, smoky rooms, VDU screens, bright/flickering lights/loud VDU screens, bright/flickering lights/loud noise/strong smells, weather extremesnoise/strong smells, weather extremes

MenopauseMenopause

Diet + foodsDiet + foods (alcohol, cheese, citrus fruits (alcohol, cheese, citrus fruits – foods containing tyramine) possibly – foods containing tyramine) possibly chocolate; missed or delayed meals, chocolate; missed or delayed meals, dieting too fast,dieting too fast,

MenstruationMenstruation

MedicinesMedicines HRT, some sleeping tablets + HRT, some sleeping tablets + contraceptive pillcontraceptive pill

Head or neck traumaHead or neck trauma

OtherOther Menstruation, menopause, shift Menstruation, menopause, shift workers, Strenuous unaccustomed exerciseworkers, Strenuous unaccustomed exercise

Management strategy Stress: Relaxation and coping strategies may help

with specific stress or anxiety present.

Yoga and meditation.

Alter poor sleep or eating patterns.

Diet: Exclude suspected food from diet for several weeks to see an improvement, and consult a dietician to avoid malnutrition.

Avoid particularly energetic sessions. However, maintain good physical fitness.

Migraine related to menstruation can be more difficult to treat than migraine related to other factors i.e. hormonal factors.

AdviceAdvice Diary to monitor patterns + triggers – review after at least Diary to monitor patterns + triggers – review after at least

5 attacks5 attacks

Improving physical fitnessImproving physical fitness

Physiotherapy (but no evidence)Physiotherapy (but no evidence)

AcupunctureAcupuncture

Psychological therapyPsychological therapy

– Relaxation (yoga + meditation)Relaxation (yoga + meditation)

– Stress reductionStress reduction

– Coping strategies Coping strategies

– BiofeedbackBiofeedback

1st line if underlying cause e.g. anxiety/stress

Things to include in diary…Things to include in diary… Date of Attack     Date of Attack      Time Started       Time Started        Time Finished       Time Finished        Aura – Yes/No Aura – Yes/No Severity – severe/moderate/mildSeverity – severe/moderate/mild Time needed off school, work or other activities – Time needed off school, work or other activities –

Yes/NoYes/No Other Symptoms Other Symptoms

Feeling Sick – Yes/No      Feeling Sick – Yes/No      Vomiting – Yes/No      Vomiting – Yes/No      OtherOther

Things to include in diary…Things to include in diary…

MedicationMedication DoseDose Time TakenTime Taken Relief - yes/partial/noRelief - yes/partial/no Time to ReliefTime to Relief

Possible triggersPossible triggers Food and drink taken 6-8 hours before attackFood and drink taken 6-8 hours before attack For women: record periodsFor women: record periods  

ReferencesReferences

http://www.bbc.co.uk/news/health-http://www.bbc.co.uk/news/health-1962201619622016

http://www.migraine.org.uk/index.php?http://www.migraine.org.uk/index.php?sectionid=11sectionid=11

Thank You For ListeningThank You For Listening