How do I know if my headache is a migraine?

A migraine headache will usually have several of the following features:

• Typically throbbing and severe.
• Usually at the front of the head.
• Usually localised to one side of the head but not always.
• Stuffy nose.
• Nausea, queasiness, vomiting.
• Intolerance of bright light (photophobia).
• Other heightened sensitivities, e.g. to noise and strong smells.
• A sufferer will often need to avoid normal activities.
• Usually lasts a few hours but can last up to 3 days.
• Aura - a migraine may start with symptoms such as flashing lights, seeing zigzag lines, blurring, having a blind spot. Other sensory aura may include tingling sensations, problems with coordination and concentration, speech difficulty, and rarely arm or leg weakness or blackouts.
• Once the migraine headache has gone, tiredness and 'washed out' feelings are common and can last up to several days.
• Completely symptom free between migraines.

If in doubt discuss with your GP to clarify the diagnosis.

I have just started to get migraine - should I be worried?

Discuss with a GP if you are worried about new headaches/migraine, especially if:

• You are over the age of 40.
• There are also other signs of being generally unwell, e.g. unintentional weight loss, persistent neurological (numbness/weakness/tingling) symptoms, eye symptoms/pain.
• If you develop a new severe headache in pregnancy.
• There is a very sudden onset of very severe headache, sometimes called 'thunderclap' headache.

Does migraine run in families?

It has long been assumed that there is a genetic link to migraine as most migraine sufferers know of close relatives who also suffer and this family link has been confirmed in formal studies. Research in recent years has identified a specific migraine gene in a few rare types of migraine. In general it is believed that most migraines are linked to a complex interaction between genes and environment.

Are women more likely to get migraine?

Yes. Migraine is three times more common in women. It affects 1 in 4 women but only 1 in 12 men in the UK. This is believed to be due to variations in female hormone (oestrogen) levels, being a migraine trigger.

Do periods affect migraine?

Many women develop migraine during or just before their periods. This is linked to the drop in the female hormone oestrogen which happens before a period.

What is a migraine 'aura'?

Migraine 'aura' do not occur in everyone or with every migraine. They are caused by a change in the electrical pathways in the brain before the migraine headache begins. This can lead to nervous system symptoms (neurological). The symptoms usually develop over 5-20 minutes before the headache but can also occur without any headache.

The most common visual aura are:

• Flashing lights.
• Seeing zigzag lines.
• Blurring.
• Having a blind spot (scotoma).
• Coloured spots.
• Sparkles or stars.
• Tunnel vision.
• Temporary blindness.

Aura can affect any part of the nervous system and other aura include:

• Tingling or numbness.
• Problems with coordination and concentration.
• Speech difficulty.
• Pins and needles in the arms and legs.
• Weakness on one side of the body.
• Dizziness or a feeling of spinning (vertigo).
• Speech or hearing difficulty.
• Memory changes.
• Feelings of fear and confusion.
• Partial paralysis.
• Fainting or blackouts.

Aura symptoms go away when the migraine moves into the headache phase. If any of the above symptoms persist, contact a doctor.

What causes a migraine?

There is a lot of ongoing research into the exact causes of migraine. Recent theory suggests that there are electrical changes in the brain which affects the brain's blood vessels. They then stretch and become 'leaky', so causing the headache. Research has shown biochemical changes in the body, caused by different migraine triggers, can occur several hours before the headache. The various symptoms of migraine are caused by a combination of all these different effects.

Can other medications I take cause migraines?

Although there is no clinical evidence that other drugs can cause a migraine there are several that have been linked to potentially increase the amount you are having. These include acid reflux tablets, some antidepressants, hormonal medication containing oestrogen such as the combined pill or HRT, steroid nasal sprays, and bone density medication.

Should I have a brain scan?

Most people who suffer from migraine headaches will not need a brain scan. Sometimes severe headaches can be a sign of something more serious. You should discuss your headaches with a GP in the following situations:

• When headaches start for the first time over the age of 40.
• Very sudden onset of very severe headache, sometimes called 'thunderclap' headache.
• Headaches change in type or there are new symptoms.
• There are new headaches and other signs of being generally unwell, e.g. unintentional weight loss, persistent neurological symptoms, eye symptoms/pain.

What medication helps migraine?

In many cases, simple anti-inflammatory tablets, such as ibuprofen (400mg to 600mg), or aspirin (900mg) are effective on their own.

Anti-sickness tablets can help absorption of the antimigraine medication and reduce symptoms of nausea.

There are also specific anti migraine medications called triptans. These include sumatriptan, naratriptan, rizatriptan, almotriptan, eletriptan, zolmitriptan, and frovatriptan. They are sometimes known by their original brand names of Imigran, Naramig, Maxalt, Almogran, Relpax, Zomig, and Migard or Mylatrip.

Vydura (rimegepant) is a new specific antimigraine medication which is recommended for people who have previously tried two different types of triptans, or who are unable to take triptans due to their age, or other medical conditions.

How do triptans work?

The triptan medicines work by causing the stretched and leaky blood vessels in the brain to shrink back down to their normal size.

How does Vydura work?

Vydura is in the gepant class of medication which are oral CGRP antagonists. CGRP (calcitonin gene‑related peptide) is a brain protein. During a migraine, there is an increase in the levels of this protein in the brain, which leads to pain and swelling of blood vessels. Vydura contains rimegepant which blocks the activity of CGRP so reducing the pain and swelling, and reducing the symptoms of migraine.

Which is the best triptan?

There is not much difference between the efficacy of the different triptan tablets. Most people start with sumatriptan (the original triptan) and it often works well. If not, it is worth trying a variety to find the one which suits you best. Dr Fox also prescribes rizatriptan and zolmitriptan.

What is the difference between triptans and Vydura?

Triptans and Vydura (rimegepant) work on different parts of the migraine pathway. During a migraine, there is an increase in the levels of CGRP in the brain, which leads to pain and swelling of blood vessels. Vydura contains rimegepant which blocks the activity of CGRP which reduces the pain and swelling, and stops the symptoms of migraine. Triptans act directly to reduce the swelling of the blood vessels, which will reduce migraine symptoms.

Both triptans and Vydura are effective treatments for a migraine. There has not yet been a direct comparison research trial, but early studies suggest that Vydura is slightly less effective but has fewer side effects and can be safely taken by a wider range of people, than triptans.

How do I choose between tablets and nasal sprays?

Ordinary tablets are swallowed with water and absorbed in the stomach. If nausea and vomiting are a problem then a dissolve-in-the-mouth tablet (Maxalt Melts, Zomig Rapimelt, orodispersible zolmitriptan) or a nasal spray may suit you better.

Nasal sprays (Imigran/sumatriptan, Zomig) work more quickly as they are directly absorbed from the nose without going through the stomach.

Which triptan medication works fastest?

The nasal sprays (Imigran, sumatriptan, and Zomig) are the quickest acting migraine treatment supplied by Dr Fox. They start to work within 15 minutes. GPs may prescribe Imigran/sumatriptan injections which work even more quickly.

What is the difference between branded and generic triptans?

Brand name and generic medications contain exactly the same active ingredient manufactured to the same standards. The brand names - e.g Imigran, Zomig, Maxalt - were the names used by the pharmaceutical companies which first developed the medication. Once the original patent has expired (usually after 15 years or more), other companies are allowed to manufacture the same medications. They often use the generic name of the active ingredient, e.g. sumatriptan, zolmitriptan, rizatriptan. See also Generic medicine FAQs.

How do I take migraine triptan tablets?

Triptan tablets should be taken as early as possible in the headache phase of a migraine. They are not preventative and do not work if started during the 'aura'.

• Start with the standard dose: Maxalt/rizatriptan 10mg, Imigran/sumatriptan 50mg, Zomig/zolmitriptan 2.5mg.
• The headache should begin to settle after 30 minutes to 1 hour.
• After 2 hours, if the headache has not completely resolved, a further Zomig/zolmitriptan or Imigran/sumatriptan tablet can be taken (but not another Maxalt/rizatriptan).
• If the headache occurs again in the 24 hours after the first tablet, then a further tablet can be used after at least 2 hours since taking the first tablet. Maxalt/rizatriptan, and Zomig/zolmitriptan up to a maximum of 2 tablets in 24 hours. The maximum for Imigran/sumatriptan in 24 hours is 300mg (6 x 50mg or 3 x 100mg).
• The stronger dose Imigran/sumatriptan 100mg or Zomig/zolmitriptan 5mg tablets can be used in the next attack if the standard dose was not totally effective. Stronger doses increase the risk of side effects.
• Do not mix different triptans in the same migraine attack.

Instructions on how to take the tablets are detailed in the manufacturers' patient information leaflets supplied with the medicine.

How do I use 'melts' and orodispersible tablets?

Maxalt Melts, Zomig Rapimelts and zolmitriptan orodispersible tablets work best if taken on an empty stomach, as soon as the headache begins. They are not a preventative treatment and do not work if started during the aura.

• Make sure hands are clean and dry.
• The tablet should be carefully removed from the packaging, so that it doesn't break.
• Place it on the tongue.
• Leave to dissolve and then swallow with saliva.
• The headache should start to settle within 30 minutes.
• The Maxalt Melt should not be repeated if the headache does not completely resolve.
• A second Zomig Rapimelt can be taken for the same headache after 2 hours.
• If the headache has gone but comes back, another one of either melt can be used after 2 hours.
• Maximum of 2 melts in 24 hours.

Instructions on how to take the melts and tablets are detailed in the manufacturers' patient information leaflets supplied with the medicine.

How do I use a triptan nose spray?

A nasal spray is a good option if you feel very nauseous and often vomit with a migraine headache. It also works very quickly, as the active ingredient is mostly absorbed directly from the nose.

The spray is most effective if used as soon as the headache begins but it can be taken at any time later in the attack. It is not a preventative and will not work if used during the 'aura'.

• Zomig and Imigran nasal sprays are single use spray units. Use one spray in one nostril (left or right). Do not sniff.
• Signs of improvement can be noticed in 15 minutes.
• If the headache has not completely gone a second dose of spray can be used after 2 hours.
• Maximum of two spray doses in 24 hours.

Instructions on how to use the sprays are detailed in the manufacturers' patient information leaflets supplied with the medicine.

What things can trigger a migraine?

'Triggers' include a variety of factors which can set off a migraine attack in a susceptible person. Keeping a migraine diary can help to identify your triggers. Not everyone has them all or the same triggers.

A combination of several triggers will be more likely to start a migraine and you can often 'get away with' a single trigger on its own.

Triggers can include:

• Stress.
• Hormonal changes in women.
• Lack of sleep, or too much sleep.
• Changes in routine, e.g. weekend migraines.
• Lack of food/skipping meals.
• Too much sugar/sweet foods.
• Chocolate (although sweet food/chocolate cravings can also be part of the very early phase of an attack).
• Alcohol - especially red wine which contains tyramine.
• Cheese - can also contain tyramine.
• Caffeine.
• Food additives - monosodium glutamate, nitrates, and aspartame.
• Mild dehydration - make sure you regularly drink plenty of water.
• Computer screens, glare, flickering lights.
• Environment - high altitude, weather changes, high humidity.
• Sudden vigorous exercise - but regular exercise is beneficial.
• Teeth grinding during sleep - a dentist may be able to help.

Further information: The Migraine Trust - Migraine attack triggers

Are there any other things I can do to help my migraines?

It can be helpful to address migraine triggers in your life. Use a migraine diary to work them out.

Try and avoid your personal triggers and especially situations where there may be a combination of several triggers.

The most important thing is a consistent routine around sleep, food, and exercise.

Do migraine tablets contain lactose or sucrose?

Some manufacturers add lactose and sucrose to their triptan tablets. Please send a message with your Dr Fox order if you require lactose or sucrose free medication. Vydura does not contain lactose or sucrose.

What medication is best if I vomit with migraine?

It is best to use a nasal spray (Imigran/sumatriptan, Zomig/zolmitriptan) or dissolve-in-the-mouth tablets (Maxalt Melt/ rizatriptan, Zomig Rapimelt, zolmitriptan orodispersible, Vydura) if you tend to vomit with migraines.

Your GP can also prescribe anti-sickness medication which may help.

I take preventative migraine treatment - can I still take triptans?

If you take propranolol regularly, then a reduced dose of Maxalt/rizatriptan should be used (discuss with your GP). No dose adjustment is needed for sumatriptan and zolmitriptan.

Triptans can be taken with other preventative medications.

See also manufacturers' patient leaflets for individual medications.

What are the different phases of a migraine attack?

There are four or five distinct phases to a migraine attack. Research shows that the migraine starts well before the actual headache, though many people are not aware of the early phases. Not all the phases are present in every migraine.

1. Prodrome - can include tiredness, yawning, mood changes, food cravings, and thirst and fluid imbalance.
2. Aura.
3. Headache.
4. Sleep - often part of the migraine recovery.
5. Post drome - passing excess urine to restore fluid balance, washed out hungover feelings which can last a couple of days.

See also What is a migraine attack? from The Migraine Trust.

Why does my migraine start to get better after I vomit?

As part of a migraine attack the gut stops moving and slows down. This contributes to the feelings of nausea. As the migraine is coming to an end, the gut starts to function again and this is thought to lead to vomiting towards the end of an attack.

Can I drive with migraine?

Migraine is not on the DVLA medical conditions notification list. However if your migraine or the medication which you take causes visual problems, drowsiness, dizziness, or other symptoms that would make driving unsafe, then you should not drive until the attack has gone.

See also The Migraine Trust - Migraine and driving.

Why do I feel so tired after a migraine?

Tiredness after a migraine is part of the 5th stage of migraine, often called the post drome and is part of the restoring of the body's normal balance after the migraine attack.

At what age do migraines stop?

Most migraine improves over aged 50, with 4 in 10 people having stopped experiencing attacks by age 65.

Some women find that they worsen around the menopause, probably related to changes in female hormone (oestrogen) levels.

See also Q&A: Living with migraine later in life.

Does getting migraine mean I'll have a stroke when I'm older?

Studies show that there is a very small link between suffering from migraine with aura and the risk of having a stroke caused by a blood flow blockage in the brain. The risk is greater if you are a smoker, have high blood pressure, or if you have migraine with aura and take the combined contraceptive pill. Smoking and having high blood pressure without being a migraine sufferer also increase the risk of having a stroke. Do not smoke, or take the combined contraceptive pill (mini pills/POP containing only progesterone are safe), if you suffer from migraine with aura.

What is medication overuse headache?

Medication overuse headache, sometimes called rebound headache, is a headache actually triggered by using triptans or other painkillers for headaches too often (more than 10-15 days per month). This can cause headaches which are often chronic daily headaches. This leads to a cycle of taking further pain relief which then actually maintains the headache cycle. Treatment involves completely stopping use of painkillers or triptans. The recovery is difficult and can take a withdrawal period of up to 2 months. It may be useful to consult with your GP for help if needed with this.

It is thought that the newer migraine medication Vydura/rimegepant is not linked with causing medication overuse headache.

See also Medication-overuse headache.

What is Serotonin syndrome?

Serotonin syndrome is a very rare condition where serotonin levels in the body become too high, leading to symptoms of confusion, agitation, muscle twitching, sweating, shivering, diarrhoea. In severe cases it can cause seizures (fits) irregular heartbeat (arrhythmia), and unconsciousness. Triptans slightly increase serotonin levels and if taken with other medications that also increase serotonin, the syndrome can be triggered. The triptans prescribed by Dr Fox (sumatriptan, rizatriptan, or zolmitriptan) are the least likely triptans to cause serotonin syndrome.

Dr Fox checks for medication which may interact and lead to a risk of serotonin syndrome in the online consultation. See also manufacturer's patient information leaflets supplied with medicine packs.

Migraine treatment