Managing migraine

MIGRAINE is a disabling primary headache disorder and is ranked the third highest cause of disability worldwide among men and women under 50 years old, according to the Global Burden of Disease Study 2010.

It affects more than 10% of the global population and is two to three times more common among women than men, largely because of hormonal influences. In addition, 1.7% to 4% of the world’s adult population have headaches that affect them 15 days or more every month. And half of all migraine cases can be attributed to genetic factors.

Migraine is characterised by recurrent attacks of throbbing or pulsating headaches of moderate to severe intensity. It can be associated with nausea or vomiting and concomitant feelings of unpleasant, heightened sensitivity to their surroundings – commonly to sound (phonophobia) and light (photophobia). It usually affects one side of the head but may also occur at different parts of the head.

Bouts can last anywhere between four and 72 hours, and sometimes even up to a week. The frequency of migraine attacks can be from once a year to once a week, with some patients reporting daily attacks that vary in intensity, duration and severity.

People who have 15 or more headaches per month for more than three months, of which at least eight attacks have the features of a migraine, are said to have chronic migraine. This group of patients are the most challenging to treat and have the most social, emotional and functional disabilities. About 2.5% of people with episodic migraine develop chronic migraine.

Some people may have warnings (aura) before or during a migraine attack. This can be in the form of visual changes, altered sensations to the body or, though rarely, weakness in the limbs, which may mimic a stroke.

Others may have difficulty with their speech, buzzing or ringing in the ears or dizziness. Many patients complain of extreme fatigue following a severe migraine attack.

Triggers vary among patients. Chocolate and caffeine may trigger migraine in some people, but act as a reliever for others. Potential migraine triggers:

> Emotions: Stress, anxiety, depression.

> Diet: Alcohol, caffeine, chocolate, cheese, foods that contain additives like tyramine such as yoghurt, shrimp paste, soy sauce, soybean, tempeh and certain nuts and fruits.

> Dehydration: Lack of fluids.

> Hunger: Missing meals, low blood sugar.

> Physical: Fatigue, lack of sleep, over-exertion, shoulder or neck pain/tension.

> Environment: Strong smells, bright lights, heat, stuffy rooms, drastic temperature changes, flickering screens, prolonged exposure to screens of electronic devices, loud noises.

> Medication: Hormone replacement therapy, combined oral contraceptive pills.

> Hormones: Menstruation.

Despite it being a treatable ailment, 60% of people with migraine are not diagnosed by healthcare professionals. It is important to not ignore your headache if it occurs frequently and seek medical attention as soon as you can. Pain management for migraine consists of medication and lifestyle changes, including avoiding migraine triggers. Improving your mental and physical well-being and getting enough rest and sleep is important to avoid further attacks.

Prophylaxis treatment, which is different from acute pain relief, is aimed at reducing the frequency, duration and severity of migraine attacks. It is usually recommended to patients who have four or more migraine attacks per month or severe debilitating headaches.

Only one in eight migraine patients receives preventative treatment. It is important for people with frequent migraine attacks to be under the care of neurologists or experienced specialist physicians as they need to be educated and counselled on their disease and potential side effects of medication.

Some people may need to be on preventative treatment for three months or more, depending on the severity of headaches. Compliance to treatment is paramount to assess efficacy of the medication.

Other than medication, psychotherapy such as biofeedback, cognitive behavioural therapy and relaxation therapy can be used alongside pharmacologic treatments.

It is important for patients to keep a diary of their headaches and monitor their progress. There are migraine management apps that keep track of your headaches.

A good patient-doctor rapport is also vital, as pain control may not be achieved immediately, especially in those with chronic migraine. Patients must have trust and confidence in their neurologists, and, if possible, easy access to their clinics so that care continuity can be maintained and concerns can be addressed as soon as possible.

Dr Sherrini Ahmad Bazir Ahmad is a consultant neurologist and general physician at Subang Jaya Medical Centre, president of Epilepsy Society Malaysia, and honorary treasurer for Epilepsy Council, Malaysian Society of Neurosciences.

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