Migraine: what helps during an acute attack and when prevention makes sense

What happens in the brain during a migraine

Migraine is not a vascular disease and not a sign of stress but a neurological disorder with a strong hereditary component. Nature Reviews Disease Primers describes it as a disorder of sensory processing: the brain of people with migraine reacts more sensitively to changes in sleep, meals, hormones and sensory input. During an attack, nerve fibres supplying the meninges are activated; they release the messenger CGRP, which widens vessels and amplifies pain transmission. The newest medicines act on precisely this messenger.

According to the figures in the Lancet, migraine affects around 15 percent of the population, women three times more often than men, with peak frequency between 25 and 45, in the most productive years of life. It is the second leading cause of years lived with disability worldwide and the leading cause in young women. Nevertheless it is often dismissed as “a headache” and treated properly too late.

Recognising migraine: the criteria

The International Classification of Headache Disorders defines migraine without aura by repeated attacks of 4 to 72 hours with at least two of four pain features, namely one-sided, pulsating, moderate to severe, worsened by physical activity, and at least one accompanying symptom: nausea or vomiting, or sensitivity to light and sound. About a third of those affected experience an aura before the pain: usually visual disturbances such as flickering, zigzag lines or visual field defects, less often tingling that spreads over arm and face, or word-finding difficulty, each lasting 5 to 60 minutes and fully reversible.

Many attacks announce themselves hours ahead: yawning, food cravings, neck stiffness, irritability or unusual clarity. Anyone who knows these warning signs can act earlier. A headache diary over four weeks, with date, duration, severity, accompanying symptoms, medicines taken and cycle, is the most important diagnostic tool and the basis of every consultation.

Feature	Migraine	Tension headache
Side	usually one-sided, may switch	both sides
Character	pulsating, throbbing	pressing, tightening
Severity	moderate to severe	mild to moderate
Movement	worsens	no influence
Nausea	common	none
Light and sound	strongly disturbing	at most one of the two
Duration	4 to 72 hours	30 minutes to days

Treating the acute attack

The guideline of the German Society of Neurology and the German Migraine and Headache Society, and the ten steps by Eigenbrodt and colleagues in Nature Reviews Neurology, describe a stepped scheme based on the severity of the attack.

Immediate measures. Retreat to a quiet, darkened room, a cool compress on forehead or neck, sleep if possible. Many attacks end with sleep.

Mild to moderate attacks. An adequately dosed painkiller taken early: ibuprofen 400 to 600 mg, aspirin 1000 mg, naproxen 500 mg, diclofenac 50 mg or paracetamol 1000 mg. Doses that are too low are the most common reason for “it does not help”. If you feel sick, take metoclopramide or domperidone ten to fifteen minutes beforehand; they improve not only the nausea but also the absorption of the painkiller from the sluggish stomach.

Moderate to severe attacks. Triptans are the most effective specific acute medicines. The Cochrane analysis by Derry and colleagues on oral sumatriptan shows: with 100 mg, 32 percent of patients are pain-free after two hours, with 50 mg 28 percent, on placebo 11 percent; around 60 percent achieve clear relief. Seven triptans are available, from fast-acting sumatriptan and rizatriptan to longer-acting naratriptan and frovatriptan; as nasal spray or injection they also work when vomiting. The combination of sumatriptan with naproxen works better than either substance alone and reduces recurrence of pain. Triptans are taken early in the pain phase, not during the aura, and may be repeated after two hours if pain returns. They are unsuitable with coronary heart disease, after stroke, with uncontrolled high blood pressure, in pregnancy and with migraine with brainstem or hemiplegic aura.

New substances. Gepants such as rimegepant block the CGRP receptor, do not constrict vessels and are an option for people who cannot tolerate or take triptans. Lasmiditan acts via serotonin receptors without vascular effect but causes drowsiness and rules out driving for eight hours.

The 10-day rule. Acute medicines of any kind on no more than 10 days a month, simple painkillers on no more than 15. Anyone who needs more needs prevention, not stronger tablets. Otherwise medication overuse headache develops, which makes migraine chronic.

Prevention: from when and with what

Prophylaxis is recommended from three attacks or four migraine days a month, for attacks lasting longer than 72 hours, for insufficient effect or intolerance of acute medication, for medication overuse and for special forms such as migraine with prolonged aura. The goal is to reduce frequency and severity of attacks by at least half; success is judged after two to three months with the diary.

Established substances are beta blockers such as metoprolol and propranolol, the calcium antagonist flunarizine, the anticonvulsant topiramate, the antidepressant amitriptyline and the blood pressure drug candesartan. The choice depends on co-existing conditions: beta blockers with high blood pressure, amitriptyline with sleep problems or tension headache, topiramate with overweight but not when planning children. Valproate is excluded in women of childbearing age because of the risk of malformations.

If this is not enough or not tolerated, monoclonal antibodies against CGRP or its receptor have been available for some years: erenumab, fremanezumab, galcanezumab and eptinezumab. They are injected monthly or quarterly, work clearly in about every second patient and are well tolerated. Their prescription is tied to neurology or headache centres. For chronic migraine with more than 15 headache days a month, botulinum toxin in a fixed injection scheme is also approved.

Non-drug prevention is equally important and effective in studies: endurance sport three times a week for 30 to 45 minutes, progressive muscle relaxation, biofeedback, cognitive behavioural therapy for stress management, regular sleep and regular meals, enough fluids and steady caffeine intake. Triggers such as red wine, weather changes or the cycle can be identified but rarely completely avoided; regularity matters more.

Migraine in women: cycle, contraception, pregnancy

In many women attacks occur around menstruation, triggered by the drop in oestrogen; they are often longer and more severe. Short-term prophylaxis with naproxen or a long-acting triptan on the critical days or contraception in an extended cycle helps. Migraine with aura increases the risk of stroke; combined pills containing oestrogen are then unsuitable, oestrogen-free methods are fine. In pregnancy migraine without aura improves in most women; paracetamol is allowed, ibuprofen in the middle trimester, triptans after medical consideration. Any new or changed headache in pregnancy needs prompt medical assessment.

When the video consultation fits

Migraine is a diagnosis made from the history; imaging is not needed with a typical picture and normal neurological examination. Much can therefore be clarified by video: classification of the headache type using the diary, optimisation of acute treatment, prescription of triptans on a private prescription after excluding contraindications, starting prevention with a beta blocker or amitriptyline, advice on contraception and the 10-day rule, a sick note during an attack.

An in-person examination is needed for first or changed headaches, for aura that is atypical or lasts longer than an hour, for headache with fever, after injuries, for new neurological deficits, for onset after the age of 50 and when antibody therapy or botulinum toxin is being considered. In these cases the doctor refers you to neurology or, with warning signs, to emergency services.