Migraine: why the debilitating condition is more than a big headache

Irish Examiner

a day ago

STORM Floris on August 4 was a literal headache for migraine sufferers. When the Irish Examiner spoke to Dr Sabina Brennan the following day, she was still suffering.
'I spent all of yesterday vomiting and overcome with pains in my legs and an intense headache, and I'm exhausted today,' says the 63-year-old neuroscientist and psychologist from Dublin. 'My migraines are often triggered by the atmospheric pressure changes that precede a storm.'
Two things about Brennan make her a typical migraine sufferer. One, she is a woman. According to the World Health Organisation (WHO), migraines affect three times as many women as men.
The other is that her migraines are far more severe than headaches and can't be treated by popping a pill.
'People associate migraines with headaches,' Brennan says. 'I've had migraines since I was a child, and they certainly involve headaches, but they also involve much more than that.'
Brennan's headaches vary and can be debilitating. 'Sometimes, they are like an icepick digging into the trigeminal nerve that runs down the sides of my face,' she says. 'Other times, they are creepy crawly headaches that feel like spiders coming over the top of my head, and I also get headaches that consist of severe pain on one or the other side of my head, often around my eyes.'
Her other symptoms vary, too. She can get nausea and vomiting, pains in her legs, an extra sensitive sense of smell, blurred vision, ringing in her ears, light-headedness, dizziness, and brain fog.
Dr Paul Shanahan, a consultant neurologist specialising in headaches at the Beacon Hospital in Dublin, says that migraine is far more than a headache.
'It's a brain disorder that affects about 17% of women and 6% of men,' Shanahan says. 'It involves multiple regions of the brain, which results in a wide range of neurological symptoms. Pain is the most obvious, but there are many others. There is even a small proportion of people who get migraines without any headaches at all.'
In a typical attack, he says, 'there's a throbbing or pounding headache on one or both sides of the head, accompanied by sensitivity to light or sound. There may be nausea or vomiting.
'In 30% of cases, the attack may be preceded, or accompanied, by an aura, which consists of visual disturbances like seeing lights, zigzag patterns, or shimmering patches; sensory disturbances, like pins and needles or numbness; speech disturbances, like difficulty finding words; or symptoms like weakness on one side, which can look like a stroke. There is also fatigue and brain fog, and it's not unusual for these symptoms to persist after the headache has settled.'
Dr Sabina Brennan pictured at her home outside Shercock, Co. Cavan. Photo: Lorraine Teevan
Not taken seriously
The World Health Organisation reports that 40% of people suffer from some form of headache disorder, ranging from migraine and tension headaches to cluster headaches and headaches caused by medication overuse.
Migraines have been part of our health landscape since at least 400 BC, when Hippocrates wrote about them. However, they seem to be on the increase.
A study published earlier this year examined global migraine trends between 1990 and 2021 and found that migraine prevalence had increased by 58%.
Naomi Thornton, information and support officer with the Migraine Association of Ireland, says migraine affects half a million people here. 'It disrupts their work and family life and overall wellbeing. The level of disability experienced by these individuals can have a significant effect on their quality of life.'
A 2017 study that tracked the impact of 328 diseases worldwide found that migraine was the second most disabling in terms of years. It was the first most disabling for women under the age of 50.
Yet despite the toll of migraine on people's lives, it isn't always taken seriously as a health condition. 'People with migraines report feeling dismissed or misunderstood at work and school and even within the health system,' says Thornton.
This dismissive attitude is reflected in the funding afforded to migraine studies. Historically, they have received far less attention than conditions that affect fewer people, such as asthma and diabetes.
Shanahan suggests two reasons for this disparity. One is that migraines, unlike other causes of disability, are usually intermittent. 'They are also fairly invisible,' he says. 'This has led to them being under-treated.'
Tom Zeller, science writer. Pic: Kristine Paulsen
Tom Zeller is an American science writer and author of the recently published The Headache: The Science of a Most Confounding Affliction and a Search for Relief. He has also suffered from cluster headaches for more than 30 years.
His research revealed that gender bias explains why migraines have historically been under-studied and under-treated.
'Most people who present with migraine are women, and women's health has historically been given short shrift over the years,' Zeller says.
'In my research, I've come across accounts of doctors telling women they are too nervous or stressed and need to relax more. I've even heard of women being told that having more sex with their husbands would ease their headaches.'
Zeller also refers to 'the cultural baggage' attached to headaches. 'We often call things like having to do our taxes a headache,' he says. 'This downplays the effects of a migraine and makes us disregard it as a real neurological disorder. Combine this with the fact that migraines are multifactorial and hard to diagnose and treat and you begin to see why we are only now beginning to understand them.'
Hormonal influence?
Shanahan has long been convinced that hormonal changes in women may cause migraines. Before puberty, migraine rates are about the same in boys and girls. However, one in five women with migraines is more prone to getting attacks around their menstrual period, and migraines reduce for many women during the later stages of pregnancy and after menopause.
'Hormones are probably not the only factor,' he says. 'But evidence points to strong hormonal influences.'
That evidence includes a 2018 University of Arizona study, which found a link between higher levels of the female hormone oestrogen and lower levels of a sodium proton exchanger called NHE1, which controls pain signalling in the brain.
There also appears to be a link between migraine and mental health, with various studies, including one from the University of Toronto in 2018, demonstrating that people who suffer from migraines are more likely to also suffer from mental health conditions, such as anxiety, depression, and even bipolar disorder.
'It's no surprise that someone with a disabling neurological condition who experiences regular and severe pain might struggle with their mental health,' says Shanahan. 'But the data also shows that a prior history of depression is associated with an increased risk of subsequent migraine. Whether this is cause and effect or whether there may be a common factor underpinning both conditions is not fully clear.
'It's important to be aware of the connection, though, as identifying both problems is the first step to dealing with them.'
So what are the options? Shanahan outlines the range of treatments available.
'The best approach for people who get infrequent headaches is usually a painkiller, like paracetamol, or migraine-specific medications, like Triptan,' he says. 'But painkillers, however helpful on the day, do not make headaches any less frequent and, if taken too often, can make them worse. So anyone getting headaches more than five days a month should consider preventative medications.'
Treatment traditionally consisted of medications developed for other conditions, such as epilepsy, depression, and hypertension. However, the release of calcitonin gene-related peptide (CGRP) inhibitors in 2018 represented a new era for migraine sufferers.
The CGRP protein is released during a migraine attack and seems to cause the increased sensitivity of the sensory and pain systems. CGRP inhibitors interfere with the release of this protein. There are now six CGRP inhibitor drugs available here in Ireland.
After decades of debilitating migraines, Brennan now has an effective treatment plan.
She takes monthly CGRP inhibitor injections and daily tablets to stave off attacks and keeps painkillers on hand for when attacks do occur.
She also gets medicinal Botox to treat migraine-associated stiffness and soreness in her neck and shoulders.
'All of these have been gamechangers for me,' she says. 'I now have far fewer migraines and know what to do if, and when, I get them.'
These advances are a shift away from the historical gender bias and downplaying of the impact of the condition.
'There is still room for improvement in services, as access to specialist care is limited and there are long waiting lists to see neurologists and healthcare specialists, but migraine is increasingly being recognised as a serious health issue,' says Thornton.
'There is more research being carried out than ever before, and greater understanding and more treatment options as a result.
'It's encouraging for those living with migraine.'
Visit the Migraine Association of Ireland's website, www.migraine.ie, for further information and support
Tackling pain
Expert advice on what to do if you regularly get migraines:
1. Get a diagnosis
The World Health Organisation reports that many people with headache disorders are not diagnosed because headaches are not perceived as serious by the general public and lack of awareness that effective treatments exist.
'Many people with migraine don't even know they have the condition,' says consultant neurologist Dr Paul Shanahan. 'They have to be diagnosed to access treatment.'
2. Don't try to treat the condition yourself
'Managing alone can lead to complications such as causing more frequent headaches due to overuse of painkillers,' says Joanne Thornton from the Migraine Association of Ireland. 'Treatment is different for everyone depending on their circumstances, which is why it's so important to seek professional help.'
3. Learn to identify your triggers
'Why an individual attack happens on a given day can be down to a multitude of factors which vary from person to person,' says Shanahan. 'Some of these — like poor sleep, missing meals and consuming alcohol — may be avoidable.'
4. Talk to others
'When I was younger, I assumed everyone had to go to bed for two days before their period,' says psychologist Dr Sabrina Brennan. 'It was only by talking to other people, especially doctors and neurologists, that I learned more about my condition and how to manage it.'
5. Don't give up if a treatment doesn't work
Just because one medication doesn't suit you doesn't mean there aren't others you can try. There are also lifestyle changes you can make to help keep migraines at bay. Keeping a diary might help you pinpoint what might be the best changes for you.
6. Be kind to yourself
Brennan says it's common for migraine sufferers to feel judged. 'There's a scepticism out there that maybe we're hypochondriacs and that our experience isn't as bad as we say it is,' she says. 'I'd love for everyone to accept that people with migraines have a neurological condition and are doing their best to manage it.'
7. Stay involved
Following groups like the Migraine Association will keep you up to date with all the latest developments in how to prevent and treat migraines.