70-90% of people with migraine experience this type
Common symptoms of ‘migraine without aura’
Likely frequency of attacks
May occur anything from once a year to several times per week.
70-90% of people with migraine experience this type.
A common type of migraine featuring additional neurological symptoms
What is aura?
Aura is a term used to describe a neurological symptom of migraine, most commonly visual disturbances.
Common symptoms of ‘migraine with aura’
People who experience ‘migraine with aura’ will have many or all the symptoms of a ‘migraine without aura‘ and additional neurological symptoms which develop over a 5 to 20 minute period and last less than an hour.
Visual disturbances can include:
Other aura symptoms can include:
Speech and hearing can be affected and some people have reported memory changes, feelings of fear and confusion and, more rarely, partial paralysis or fainting.
These neurological symptoms usually happen before a headache, which could be mild, or no headache may follow.
Likely frequency of attacks
Frequency can vary anywhere from once a year to several times per year.
10-30% of people with migraine experience this type.
If you experience headache on more than 15 days per month you may have chronic migraine
Chronic migraine is a distinct and relatively recently defined sub-type of Chronic Daily Headache. The International Headache Society defines chronic migraine as more than fifteen headache days per month over a three-month period of which more than eight are migrainous, in the absence of medication over use. Episodic migraine is the other migraine sub-type, which is defined as less than 15 headache days per month.
Impact of chronic migraine
It is estimated that this condition affects fewer than 1% of the population, but this still means that there over 610,000 chronic migraine sufferers in the UK.2 Due to the nature and length of time that the sufferer is affected, people with chronic migraine experience significantly more time absent from work, school, leisure, housework and social activities than episodic migraine patients.3 Efficiency is also reduced due to chronic migraine, resulting in a more than 50% reduction in productivity from work or school.3,4 This is often described as a migraine ‘hangover’ by sufferers.
The impact of chronic migraine can be very disabling.5 Being incapacitated for over half the month sometimes means that people are unable to work at all, with some claiming disability living allowance. Unfortunately, in many cases, current therapies are not enough to prevent or reduce the impact that chronic migraine has on people’s lives. This can lead to sufferers frequently becoming depressed and unable to cope.
The World Health Organisation (WHO) has recognised the impact of migraine worldwide and categorised it as the same level of disability as dementia, quadriplegia and acute psychosis. Furthermore, WHO classified chronic migraine as more disabling than blindness, paraplegia angina or rheumatoid arthritis.
Some estimates put the cost of migraine, just in terms of medications at £150 million annually in the UK, but the overall cost is much more than that. An estimated 25 million working days are lost due to migraine, and at average gross weekly pay of £450, this costs the UK £2.25 billion per annum.
Causes of chronic migraine
Just like episodic migraine there is no single cause for chronic migraine. Some people find that they have defined triggers such as caffeine, bright lights, hormone, food or sleep deprivation.
However, for some people there is a steady progression in headache frequency, especially in long term sufferers. This can lead to the migraines becoming so frequent that they cross the threshold of more than 15 days per month and become defined as chronic migraine.
Every year between 2.5 and 4.6% of people with episodic migraine experience progression to chronic migraine. The good news is that approximately the same proportion regress from chronic to episodic migraine spontaneously.
Treatment for chronic migraine
Many of the therapies prescribed for chronic migraine are the same as those prescribed for episodic migraine. These include both prescription and over the counter painkillers and as well as migraine specific drugs such as triptans. These are known as abortive or acute medications.
A combination of lifestyle changes and understanding the migraine triggers is important. There are also preventive treatments available for chronic migraine, but these are often associated with side effects, and many people cannot tolerate them for long periods of time.
It has been shown that up to 73% of chronic migraine patients over use headache medications. This may result in further complications, so it is important that if use of acute medication becomes daily, then help should be sought from their GP or neurologist.
Currently there is no known cure for chronic migraine, although there are some new treatment options under investigation for the prevention of some types of migraine including chronic migriane.
Specialist migraine/headache clinics
People with chronic migraine are three times more likely to consult their GPs compared to episodic migraine. In the UK 43% of people with chronic migraine visit a neurologist or headache specialist compared to only 18% of people with episodic migraine.
Furthermore patients with chronic migraine are nearly four times more likely to end up visiting the accident and emergency department in any three month period, than those with episodic migraine.
As more and more is understood about the different types of chronic daily headache and chronic migraine in particular, the role of the neurologist and specialist migraine clinics is becoming increasingly important.
Further investigations into chronic migraine may be required as well as tailored treatment plan to try to minimise the frequency and severity of attacks. People with chronic migraine also need specialist therapies that should only be prescribed whilst under the care of a neurologist.
Taking control if you have chronic migraine
Chronic migraine is a distinct type of migraine that is sometimes progressive. It is therefore important to recognise how often everyday life is disrupted by migraine and keep a record of how many days per month you have a headache. If this is more than half the month, you may well have chronic migraine and should see a neurologist, as he or she may be able to offer you a wider range of treatments to help reduce your symptoms.
Whilst many women report that menstraution is a migraine trigger, there is a specific condition known as ‘menstrual migraine’.
Menstrual migraine is associated with falling levels of oestrogen. Studies show that migraine is most likely to occur in the two days leading up to a period and the first three days of a period. This type of migraine is thought to affect fewer than 10% of women. The two most accepted theories on the cause for menstrual migraine at the moment are:
There are no tests available to confirm the diagnosis, so the only accurate way to tell if you have menstrual migraine is to keep a diary for at least three months recording both your migraine attacks and the days you menstruate. This will also help you to identify non-hormonal triggers that you can try to avoid during the most vulnerable times of your menstrual cycle.
Treating menstrual migraine
There are several treatment options depending on the regularity of your menstrual cycle, whether or not you have painful or heavy periods, menopausal symptoms or you also need contraception. Although none of these options are licensed specifically for menstrual migraine, they can be prescribed for this condition if your doctor feels they would benefit you.
If you have migraine and heavy periods, taking an anti-inflammatory painkiller such as mefenamic acid could help. Mefenamic acid is an effective migraine preventive and is also considered to be helpful in reducing migraine associated with heavy and/or painful periods. A dose of 500 mg can be taken three to four times daily. It can be started 2 to 3 days before the expected start of your period. If your periods are not regular, it is often effective when started on the first day. It is usually only needed for the first two to three days of your period. Naproxen can also be effective in doses of around 500 mg once or twice daily around the time of menstruation.
You may wish to discuss using oestrogen supplements with your doctor. Topping up your naturally falling oestrogen levels just before and during your period might help if your migraine occurs regularly before your period. Oestrogen can be taken in several forms such as skin patches or gel. You put the patch on your skin for 7 days starting from 3 days before the expected first day of your period. Similarly, you rub the gel onto your skin for 7 days. In this way the oestrogen from the patch or gel is absorbed directly into your blood stream. You should not use oestrogen supplements if you think you are pregnant, or you are trying to get pregnant. Again, keeping a diary of your migraines will help you to judge when best to start the treatment.
If your periods are irregular your doctor may suggest other ways to try and maintain your oestrogen levels at a more stable rate such as a combined oral contraceptive pill.
FAQ: Will having a hysterectomy help menstrual migraine?
In order to answer this question, it’s important to understand the female reproductive organs, i.e. the uterus (womb) and the two ovaries each side of the uterus. The ovaries contain the eggs and also produce the sex hormones oestrogen and progesterone. At the beginning of each menstrual cycle, some of the eggs will start to mature under the influence of hormones produced by the ovaries. In the middle of the cycle, one egg (sometimes more) will ovulate. If the egg is not fertilised it will get absorbed by the body but more importantly the level of hormones fall. This fall of hormones triggers the lining of the womb to break down and be shed through the vagina – called menstruation.
It is this withdrawal of hormones that acts as a trigger in women with menstrual migraine or menstrual-related migraine. So, if someone is considering a hysterectomy to treat menstrual migraine, it would not help as the ovaries would need to be removed.
There are a few diagnoses where for a small minority of women, surgical removal of the ovaries is the only measure that will allow them to continue a normal life. It is a very controversial treatment and is therefore very rare.
The first options are non-surgical ways of putting the ovaries out of action. Once the ovaries are out of action (in whatever way) the woman must take hormone replacement therapy until the average age of menopause (age 55) to prevent the long term consequences of oestrogen deficiency (e.g. risk of osteoporosis).
One way to suppress the hormonal cycle is to use different forms of hormonal contraception. The combined contraceptive pill, one progestogen-only pill, the progestogen-only injection and implant will work by stopping ovulation.
A rare condition involving temporary weakness on one side of the body
What is hemiplegic migraine?
Hemiplegic migraine is referred to as a “migraine variant”. The word hemiplegic simply means paralysis on one side of the body. A person with hemiplegic migraine will experience a temporary weakness on one side of their body as part of their migraine attack. This can involve the face, arm or leg and be accompanied by numbness, or pins and needles. The person may experience speech difficulties, vision problems or confusion. This can be a frightening experience for the individual as these symptoms are similar to those of a stroke. This weakness may last from one hour to several days, but usually it goes within 24 hours. The head pain associated with migraine typically follows the weakness, but the headache may precede it or be absent.
What causes the symptoms of hemiplegic migraine?
To understand this, it is important to look at the mechanism of hemiplegic migraine. The brain and nervous system depend on a combination of electrical and chemical signals to function. When a nerve impulse (electrical) of sufficient strength passes down from one nerve cell towards another, it opens a so-called ‘channel’ which acts like a ‘gate’. This process releases neurotransmitters (or chemical messengers) which contact the neighbouring cells and tell them how to respond. If a channel in the brain is not working properly, neurotransmitters, such as serotonin, may be released in an abnormal way. In the case of hemiplegic migraine, the way the channel dysfunctions is known to have a role in the condition.
Types of hemiplegic migraine
There are two types of hemiplegic migraine – familial hemiplegic migraine (FHM) and sporadic hemiplegic migraine (SHM).
Familial hemiplegic migraine
Familial hemiplegic migraine (FHM) is defined as migraine attacks occurring in two or more people in the same family who experience weakness on one side of the body as a symptom with their migraines. On average 50% of children who have a parent with hemiplegic migraine will develop this disorder.
At least three different genes have been implicated in FHM. In half of the families where FHM occurs, a gene with a defect on chromosome 19 has been identified. This causes the related calcium channel to work incorrectly from time to time, and when it does a series of biochemical changes result in a migraine attack. For other families, chromosome 1 is implicated which alters the behaviour of a channel involved in cell energy and in still others a sodium channel gene on chromosome 2 is altered. Even these do not account for all cases so more genetic causes will be found during future research.
Sporadic hemiplegic migraine
If someone experiences all the physical symptoms of FHM but doesn’t have a known familial connection, they are diagnosed as having sporadic hemiplegic migraine (SHM). The cause of SHM is unknown, some are due to new or so called ‘sporadic’ gene mutations.
Research has shown that people with SHM usually experience all four of the typical aura symptoms – visual, sensory, aphasic and motor symptoms – during their attacks. It was reported in the people who were studied that the motor weaknesses were always one sided and more often experienced in the upper limbs. For two thirds of people the symptoms lasted around an hour; whilst only 8% experienced this weakness for more than a day. None experienced the one-sided weakness in their body without experiencing other symptoms as well, and the most common of these accompanying symptoms was visual disturbance. All experienced the headache of the migraine.
Getting a diagnosis and treatment
When symptoms of either type of hemiplegic migraine occur, it is vital that a firm diagnosis be made and that you therefore seek specialist medical advice to explain the sudden onset of one-sided weakness or numbness. The SHM and FHM diagnosis must always be based on a thorough evaluation of the symptoms as experienced by the individual and include a full family history.
Specialist advice will also ensure that you avoid embarking on the wrong treatment regimen. Triptans, for example, are best avoided during the aura phase of SHM or FHM, despite often being prescribed for the more common types of migraine.
There is little conclusive research as yet to establish a single best course of drug treatment for hemiplegic migraine. What has so far been published, and clinical experience also suggests, is that treatment with either flunarizine or topiramate may be the best option.
Vestibular migraine or migraine with prominent vertigo
What is vestibular migraine?
Vestibular migraine (also referred to as migrainous vertigo, migraine-related dizziness, vestibular migraine or migraine with prominent vertigo) is a type of migraine where people experience a combination of vertigo, dizziness or balance problems with other migraine symptoms.
Migraine is usually associated with a range of typical symptoms alongside headache including nausea and/or vomiting, sensitivity to light (photophobia), sensitivity to sound (phonophobia) and a sensitivity to movement (for some people exercise can make their headache worse). These symptoms all feature in the criteria used to diagnose migraine.
However, there are other migraine symptoms that are not included in the criteria used to make a diagnosis (despite them being common). These include vertigo, sensitivity to smells (osmophobia), light causing pain not just sensitivity (photic allodynia) and sensitivity to touch on the head or face (cranial allodynia).
What is vertigo?
Vertigo can be defined as a sensation of motion. For some people it is described as a spinning dizziness (external vertigo), for others it’s a sensation of swaying (internal vertigo).
The best way to work out which one you may be experiencing is whether it is the world that is moving, or is it yourself?
Vertigo can be spontaneous and can also be triggered by position (standing up or lying down), head movement or visually induced.
Vertigo can be very disabling and very prominent in migraine. This is why vestibular migraine has its own category in the International Classification of Headache Disorders (ICHD-3).
The symptoms of vestibular migraine are vertigo or dizziness (vestibular symptoms) alongside other migraine symptoms such as headache, nausea, sensitivity to light and sound and aura (visual disturbances, sensory disturbances, motor disturbances).
It is possible for people to have vertigo attacks without any headache. However, for vestibular migraine to be diagnosed migraine headache should be present at some point.
Many people with symptoms of vestibular migraine are seen by ear, nose and throat (ENT) specialists and neuro-otologists (experts in dizziness and balance disorders). People may be more likely to see these specialists (rather than a general neurologist or headache specialist) when they have vertigo symptoms without any headache.
According to the ICHD-3 the diagnosis of vestibular migraine needs:
As shown in the diagnostic criteria, the length of the vertigo attacks or ‘dizzy spells’ may be different for different people. For many people these would last for hours but others report their vertigo attacks could last for minutes or days and a minority reports that they last for seconds.
Ruling out other vestibular disorders may be needed. This is where management by a range of professionals, such as GPs, neurologists and neuro-otologists or ENT specialists is recommended.
The vestibular function tests (these assess the inner ear balance organs and identify if one or both are working properly) should show that vestibular function (in people with suspected vestibular migraine) is within normal limits Abnormal results in vestibular function tests should lead to the suspicion of other vestibular disorders such as Meniere’s disease.
Treatment of vestibular migraine is similar to that of other types of migraine, with special focus on standard migraine preventive medications such as amitriptyline, propranolol, candesartan, flunarizine. Flunarizine is not available through the GP but is available from headache clinics and often a preventive of choice in this setting. Greater Occipital Nerve blocks may also be used in this setting.
The acute treatment of the headache attacks is the same as the usually recommended for migraine. This is based on migraine-specific medications, triptans or non-specific such as non-steroidal anti-inflammatory drugs (naproxen, ibuprofen, etc) and acetaminophen (Paracetamol). Opioids should be avoided. For the vertigo attacks, the use of antiemetic medications such as ondansetron and domperidone may be useful.
Unusual and rare subtype, formerly known as basilar-type migraine
The symptoms will include two or more of the following:
Former names/previously used terms for migraine with brainstem aura:
Most often seen in children, a syndrome that may be associated with migraine
Abdominal migraine is an episodic syndrome that may be associated with migraine. Most cases are reported in young children, though it can occur in patients of all ages.
As children with abdominal migraine grow older, about half of them “grow out” of abdominal migraine by the age of 14-16 years. Typical attacks of migraine headache are reported by two-thirds of children with abdominal migraine either concurrently with abdominal migraine or in the place of abdominal migraine during late adolescence and early adult life.
Physicians, treating adult patients, have recognized many patients with symptoms typical of abdominal migraine and they make the diagnosis after extensive investigations to exclude other possible causes. Many adult patients who were labelled, in the past, as suffering from non-specific dyspepsia, irritable bowel syndrome and functional abdominal pain are now thought to have had abdominal migraine. Many research articles have been published in the gastroenterology literature describing abdominal migraine in the adult population with clinical features and treatment options similar to those in childhood.
Children have a lower threshold for vomiting than adults. It is not unusual for children to vomit in the course of common illnesses such as upper respiratory tract infection, ear infection, gastroenteritis and urine infection. Children also vomit after minor head injuries as well as in the course of serious illnesses such as meningitis. The vomiting centre in the brainstem can therefore be triggered by many stimuli, from local brain disorder or by chemicals produced in other parts of the body. Pain, smell and emotional upset may also cause the child to vomit.
Vomiting is also common among children with migraine; 85-90 per cent experience nausea and 55-60 per cent experience actual vomiting during attacks of migraine. Vomiting may therefore dominate the clinical picture of migraine attacks, and headache may be of secondary importance to the child. In some children, especially those under the age of six years, vomiting may be the main symptom of migraine presenting as recurrent episodes of vomiting lasting for several hours or days. The child may have all the features of migraine attacks except for the headache. This condition is known as ‘cyclical vomiting syndrome’ or CVS. Between attacks the child is well and returns to normal health.
Clinical features of cyclical vomiting syndrome (CVS)
Around two per cent of children experience episodes of vomiting at least five times per year which is one criterion for the diagnosis of CVS. Younger children are more commonly affected than older ones, and boys and girls are equally affected. As they grow older some children stop having CVS, perhaps by the teenage years, while others continue through adult life. About half of the children with CVS grow up to get typical migraine attacks with headache as the major symptom.
The attacks of CVS often occur with predictable regularity every two to eight weeks. Attacks last for an average of 24 hours, but longer attacks are not uncommon. During the attack of CVS, the child looks pale and unwell, loses appetite, feels nauseated and vomits several times per hour. The child will be lethargic and may get dehydrated. Occasionally the child may complain of abdominal pain or headache and may report light, noise or smell intolerance. The attacks resolve spontaneously after a variable duration of up to three days after which the child wants to lie down and sleep. Between attacks the child returns to normal.
Criteria for cyclical vomiting
The International Headache Society has accepted CVS as a migraine syndrome of childhood and includes it in the 2004 International Classification of Headache Disorders. The criteria for the diagnosis of CVS include the following:
History and physical examination do not show signs of gastrointestinal disease.
Management of cyclical vomiting syndrome (CVS)
A complete diagnostic assessment including history, physical examination, biochemical blood and urine tests and on occasions an X-ray or an ultrasound scan may also be needed to exclude other conditions that may present with episodes of vomiting.
Once the diagnosis of CVS is confidently made, a comprehensive treatment plan can be designed on the same lines as those of the migraine model comprising management of acute attacks and also measures for prevention.
The objectives for treatment of acute attacks are to provide medications that may prevent or stop vomiting and to give as much fluids as can be tolerated in order to prevent dehydration.
Several anti-emetic drugs can be given, with caution, orally as soon as possible after the onset of attacks. These may include ondansetron, promethazine, metoclopromide or prochlorperazine.
Fluids may be given orally at home, if possible, or by intravenous infusion in hospital. Specific anti-migraine drugs such as nasal Imigran (sumatriptan) have been used on occasions with success and may abort the attack, but this treatment is not licensed for children under the age of 12 years.
The other aspect of treatment is prevention which can offer a better chance of controlling the disease and avoiding frequent hospital admission. Anti-migraine prophylactic medications such as pizotifen, amitriptyline and propranolol can be considered though none is sure to be successful in all cases. The antibiotic erythromycin can also prevent episodes of vomiting and may have a role in the prevention of CVS. Other drugs have been reported, but with limited supporting evidence of their benefits.
Primary exercise headache and Cardiac cephalalgia
Exercise has long been recognised as an important factor in maintaining good physical and mental health. However, for people with migraine, exercising can be difficult as exercise is a recognised ‘trigger’ for a migraine attack.
Approximately 20-40% of people with migraine will report that exercise triggers an attack. In contrast, people who rarely exercise are more likely to have more migraine attacks and vice versa. Moderate aerobic exercise, such as walking, jogging or cycling has been found to reduce migraine frequency and improve the symptoms of migraine attacks.
While migraine is common and exercise as a trigger for a migraine attack is also common, there are important headache syndromes associated with exercise which should be investigated and require specific treatment. Two specific headache syndromes associated with exercise are described below.
Primary Exercise Headache
Primary exercise headache is a rare headache that is distinct from exercise induced migraine. Many people with this condition also have migraine.
This headache can occur with many different exercises or sports.
Primary Exercise Headache is not dangerous. However, more serious causes of headache associated with exercise should be excluded.
Rarely, patients with atherosclerotic coronary artery disease, such as angina or heart attacks, may experience headaches that begin with exertion, such as walking, and which resolve with rest.
It’s important to identify cardiac cephalalgia so the underlying heart disease can be managed. It also means that migraine specific treatments such as triptans can be avoided.