Sub-optimal treatment has led many patients to incorrectly think little can be done

Whiplash and Botox may not be two words you’d associate with migraines, but according to Professor Richard Stark, a neurologist from the Alfred Hospital in Melbourne, they can be a trigger and a treatment.

Migraines can be debilitating, particularly for those who suffer from them frequently and they aren’t always easy to diagnose. In fact, Professor Stark says they are under-diagnosed, even though there are some excellent treatments and prophylactic measures that can result in positive outcomes.

“It’s a common story that people say, look, it’s a migraine, my mother had it, I’ve got it, it’s my burden in life. And they really have a very negative view that nothing can be done, but we do have things we can do, and we really encourage people to be treated and take advantage of the advances we’ve made.”

Differential diagnosis – some useful questions to ask

“From a purely medical technical point of view, migraine is defined by its features. So, it is typically a headache. It’s usually episodic. It’s associated with things like light, sound sensitivity, sound sensitivity, nausea, maybe vomiting. It may be unilateral, it may be bilateral, it is often throbbing, it’s often made worse by exertion. So, these are the sorts of things that go into making the definition of migraine.

The key to diagnosis lies in the presentation and patient’s history.

How long has this been going on for?

If you have someone who’s had recurrent attacks since they were a teenager, and the pattern has been stable over that time, that’s very typical of migraine, Professor Stark says. However, if someone has been perfectly well until they were 36-years-old, and then in the last six months has developed increasingly severe headaches, it could still be migraine, but you would be very anxious that it might be something else.

Are there atypical features?

Someone who describes different neurological symptoms other than the typical aura—might have another underlying cause.

Is the headache worse when lying down or standing up?

The former may indicate a raised intracranial pressure, possibly due to a brain tumour, but if it’s worse when standing, it could point toward low intracranial pressure, possibly caused by CSF leakage.

How long did it take for symptoms to evolve?

If it’s a very sudden onset, a subarachnoid haemorrhage may be suspected.
With aura it can take 20 minutes or so, and it’s similar for sensory symptoms such as tingling in the hands and arm. An MRI may be appropriate to rule out underlying causes such as a TIA, he says.

Common triggers

Neck pain, caused by accidents like whiplash may be an aggravating factor. “A person with occasional migraines in the past may find they become much more frequent and severe after a neck injury,” Professor Stark explains.

Other common triggers include changes to stress levels, hormones levels, poor sleep, being overtired and dietary factors.

Lethargy and cravings may precede a migraine. A craving for chocolate is quite common, which has led to debate about whether chocolate causes migraines, or if the cravings are a warning sign.

Treatment

When it comes to treatments, a number of effective options are available. Choosing the right one will depend on factors such as the frequency of migraines and whether the side effect profile might cause problems for the patient (for example avoiding beta blockers in someone with asthma).

Triptans are very effective, but there is a risk of overuse in people with very frequent migraines, as they shouldn’t be used for more than about 10 days per month.

For those with frequent migraines, Professor Stark recommends starting with an anti-inflammatory at the onset, and then using a triptan if the migraine persists.

“For people with infrequent migraine, early use of effective treatment such as a triptan is vital: if you take medication too late in the attack, it tends to sit in the stomach and not be absorbed.”

In terms of prophylaxis, the blood pressure drug candesartan at around 16mg/day is a well-tolerated option, he says.

Other options include amitriptyline, pizotifen, beta-blockers and sodium valproate, but all of these have well known potential side effects, so the benefit has to be balanced against potential adverse effects.

Another option is Topamax. “It has been around for over 10 years now. It’s a bit fiddly to use. It does have a series of side effects, but if you build it up gradually it is often well tolerated and it probably is a little bit more effective than some of the other standard ones,” Professor Stark says.

Botox is another useful tool for chronic migraines. It involves injecting around 31 sites on the scalp that target sensory nerves, but this must be done by a neurologist, usually every 3 months.

CGRP antibodies are now available for patients with chronic migraine who have failed other treatments, and these can be highly effective.

Getting the right treatment can be a bit of trial and error, Professor Stark sums up, but once the right mix is found, it can make a huge difference to the patient’s life.

For more on treatments and how to implement a stepped approach for migraines, listen to Professor Stark’s podcast with Healthed here.