If migraine is regularly taking days out of your life, it may be worth looking at your treatment again

For many people, migraine becomes something they simply learn to live around.

You recognise the early warning signs. You keep medication in your handbag, desk drawer or beside the bed. You cancel plans when an attack arrives. Perhaps you struggle through work when you really need to be somewhere dark and quiet.

And if you sought medical help years ago, you may have been left with the impression that there wasn't very much that could be done.

That is changing.

Our understanding of migraine has developed considerably, and the range of treatments available is much broader than it was even a decade ago.

If migraine is regularly taking days out of your life, particularly if treatments you tried in the past were ineffective or difficult to tolerate, it may be worth looking at it again.

Migraine is more than a headache

Migraine is a neurological disorder.

The headache can be severe — often throbbing or pulsating and sometimes affecting one side more than the other — but migraine can involve much more than pain.

People may experience nausea or vomiting, sensitivity to light, sound or smells, difficulty concentrating, profound fatigue and sometimes dizziness.

Some people experience an aura, which can include visual disturbance, pins and needles, numbness or difficulty speaking.

An attack can last from several hours to several days. There can also be a period before or after the headache when you simply don't feel yourself.

For someone experiencing frequent attacks, the effect on everyday life can be enormous.

Getting the diagnosis right matters

Not every recurrent headache is migraine.

There are several different headache disorders, and sometimes more than one type of headache can occur in the same person. Occasionally, headache can also be a symptom of another medical condition.

A good headache assessment therefore starts with the story.

How often do the headaches happen? How long do they last? What does the pain feel like? What other symptoms occur? What happens before and afterwards? What medication do you take, and how often?

A headache diary can be remarkably useful. Patterns that are difficult to remember over several months often become much clearer when they are written down.

A new headache, a substantial change in your usual headache pattern, or headache accompanied by concerning new symptoms should always be assessed rather than simply assumed to be migraine.

Treating the attack

For many people, the first priority is finding something that reliably treats a migraine when it happens.

Simple painkillers or anti-inflammatory medicines may be sufficient for some people. Migraine-specific medicines called triptans have been available for many years and can be very effective.

Sometimes treatment works better when medicines are combined, and anti-sickness medication can be helpful even when nausea isn't the predominant symptom.

Timing matters too. Treatment taken appropriately early in an attack may work better than the same treatment taken once the migraine is firmly established.

And if one triptan hasn't helped, that doesn't necessarily mean another won't.

The aim is to develop a plan for an attack rather than having to improvise each time one occurs.

When migraine becomes too frequent

There comes a point when repeatedly treating individual attacks isn't enough.

If migraine is happening frequently, significantly disrupting your life, or requiring acute medication on many days each month, it may be worth considering preventative treatment.

Preventative treatment aims to reduce how often migraine occurs and, ideally, make attacks less severe and easier to treat when they do happen.

Medicines such as propranolol, topiramate and amitriptyline have been used for many years and remain useful options for some people.

The right treatment depends on the individual. Other health conditions, possible side effects, pregnancy or plans for pregnancy, other medications and personal preference all matter.

New doesn't automatically mean better. The aim is to find the treatment that offers the best balance of benefit and burden for you.

Migraine treatment has moved on

One of the biggest developments in migraine medicine has come from understanding the role of calcitonin gene-related peptide, or CGRP.

This has led to treatments designed specifically around biological pathways involved in migraine.

These include CGRP monoclonal antibodies, such as erenumab, fremanezumab, galcanezumab and eptinezumab, as well as newer medicines called gepants, including atogepant and rimegepant.

These treatments aren't appropriate for everyone and access depends on factors including migraine frequency and which preventative treatments have already been tried.

But their arrival is important.

For people who have lived with migraine for years and have already tried several conventional treatments, there are now options that simply didn't exist when they first sought help.

Botulinum toxin — usually known as Botox — is another established preventative treatment for appropriately selected people with chronic migraine.

These specialist treatments aren't currently prescribed through Wye Sanctuary. If your history suggests that one of them may be appropriate, I can discuss this with you and recommend further assessment through your GP, a neurologist or a specialist headache service as appropriate.

Sometimes the most useful part of a consultation is not prescribing another medicine, but recognising that there is another treatment worth exploring.

When treating headache can accidentally make it worse

There is an unfortunate paradox in headache medicine.

Medication taken to relieve headaches can, when used very frequently, begin to contribute to them.

This is known as medication-overuse headache.

It can occur with commonly used painkillers as well as migraine-specific medication. Understandably, someone takes more medication because their headaches are becoming more frequent, only for frequent medication use eventually to become part of the problem.

If you are reaching for acute headache medication on many days each month, it is worth discussing this with a healthcare professional rather than simply continuing to increase how often you take it.

It may be a sign that the overall migraine treatment plan needs to change.

Sometimes there is more than one source of pain

Migraine is a neurological disorder, but that doesn't mean every pain around the head and neck is necessarily migraine.

Some people also develop significant pain around the back of the head, neck and shoulders.

Muscles can become painful and tender. Particular areas may reproduce familiar pain when pressed. The occipital nerves, which carry sensation from the back of the head and scalp, may also be involved in someone's pain.

These problems can coexist with migraine.

Recognising them doesn't mean that tight muscles or an irritated nerve are somehow the underlying cause of migraine. It means that more than one pain mechanism can be present at the same time.

And occasionally those additional sources of pain can be treated.

Occipital nerve blocks

An occipital nerve block involves injecting local anaesthetic, sometimes with a small amount of steroid, around one or more of the occipital nerves at the back of the head.

These blocks can be considered in selected headache disorders, particularly when there is a significant occipital component to the pain or tenderness around the nerves at the back of the head.

They do not cure migraine and they aren't appropriate for everyone.

For some people, however, an occipital nerve block can provide a period of relief and may be a useful part of a wider headache treatment plan.

Occipital nerve blocks are available at Wye Sanctuary following clinical assessment.

Trigger point injections

Persistent headache can also coexist with significant muscular pain around the neck and shoulders.

Sometimes there are particularly tender areas within these muscles — often called trigger points — which reproduce or contribute to someone's familiar pain.

Where muscular pain appears to be an important part of the overall picture, a trigger point injection with local anaesthetic may sometimes be helpful.

Again, this isn't about treating migraine as though it were simply caused by tense muscles.

It is about recognising that someone can have migraine and a musculoskeletal source of pain, and treating each appropriately.

Selected trigger point injections are also available at Wye Sanctuary following assessment.

Prevention is about more than medication

Medication and procedures are only part of migraine management.

Regular sleep, eating regularly, hydration, exercise where possible and understanding your own patterns and triggers can all be useful.

Hormonal factors can be particularly important. Some women experience a clear relationship between migraine and their menstrual cycle, and migraine can change during pregnancy, perimenopause and menopause.

Stress can influence migraine too, as it can many neurological and pain conditions.

But recognising that sleep, stress, hormones or emotional wellbeing can affect migraine does not mean that migraine is psychological.

Migraine is a neurological condition whose threshold can be influenced by what is happening elsewhere in the body and in our lives.

When should you ask for more help?

It may be worth revisiting your migraine treatment if:

• Your headaches are becoming more frequent

• Migraine regularly interferes with work, family life or activities you value

• You frequently need medication to control attacks

• Your current treatment doesn't reliably work

• Side effects prevent you taking an effective treatment

• You tried preventative treatment years ago but haven't reviewed your options recently

• You have significant additional pain around your neck or the back of your head

• You were previously told that there were few other treatment options

You don't need to wait until migraine has become unbearable before asking whether there is a better way to manage it.

There may be another option

There is still no single treatment that works for everyone with migraine.

Sometimes the answer is getting acute treatment right. Sometimes it is prevention. Sometimes it is recognising medication overuse. Sometimes there is an additional source of head or neck pain that can be treated.

And for people with difficult migraine, newer specialist treatments have significantly widened the options available.

So if you sought help years ago and concluded:

“I've tried treatment before. There probably isn't anything else to try.”

It may be worth looking again.

Migraine can quietly take an enormous amount from someone's life.

Good treatment is about trying to give some of that life back.