Migraine is not just a headache. It is a complex brain disorder that has genetic and environmental triggers. It often starts with premonitory symptoms that include cravings and behavioural changes such as yawning and heightened perception and at times can be associated with fluid retention. In around 30% of patients, it will then be followed by an aura, which includes flashing dots and lines in vision as well as, in rare patients, speech difficulties, numbness and even weakness. The headache then follows, associated with a sensitivity to lights and in some sounds and smells, nausea and vomiting and typically disability. This can often last 4 to 72 hours and is followed by a postdrome, with patients feeling hungover, off their food as well as tired.
Chronic migraine is the presence of eight migraine days a month in a person who has 15 headache days a month.
Around 20% of people have a migraine at some point in their lives, and between 1 to 5% of patients have chronic migraine, depending on the study. Chronic migraine is when patients have more than 15 headache days a month, of which a majority are identifiable migraines.
There is a combination of treatments that we typically use, including a specific anti-migraine medication called a triptan, often in combination with other medications such as painkillers and anti-inflammatories as well as anti-nausea medications, if needed. Often, the neurologist needs to tailor this to the patient’s specific migraine symptoms.
The key to migraine treatment in patients with more than four migraines per month is preventative. Regular medication is taken to reduce the frequency and severity and improve response to acute treatment. The exact medication chosen needs to be tailored to the patient preferences and needs. We often use a detailed intake questionnaire at East Neurology to help tailor treatments to needs and preferences, titrate doses to make medications tolerable, and then carefully monitor effectiveness in a headache diary to be sure things are improving. You can download a diary at https://neurol.news/diary.
It is very important to also address specific triggers. I have developed a variety of online resources for our patients to go through each of these in detail, including stress management, diet, sleep, dry eye and many others.
Botox was introduced under the PBS for migraine treatment some years ago. It remains very effective with response rates of over 60% of patients. There are some qualifying criteria – I created a quiz to see if patients qualify at https://neurol.news/quiz.
Another new class of medication are the CGRP receptor blockers. These are medications that specifically target a chemical called CGRP or calcitonin gene related peptide, which is the chemical that the nerves release onto the surface of the brain that triggers the inflammation that causes the headache. These medications are given by the patient as injections into their tummy once a month. The response rates are around 30 to 40% of patients receiving a significant improvement in their migraine frequency. Their advantage is that the dosing is quite infrequent – being monthly – as well as there being very few side effects, mainly injection site reactions and constipation.
It is most important for people to realise that migraine is treatable. It is not your lot in life. It is not your fault. And there is a lot that we can do about it. So take the first step, get it properly diagnosed and then start on the pathway to improving and treating this very important and common condition.
Dr Ron Granot
Dr Ron Granot is an experienced neurologist, with a focus on headache and chronic pain conditions as well as neurophysiology. Dr Granot graduated from the University of New South Wales with a Bachelor of Medicine, Bachelor of Surgery and Medical Science (Medicine and Surgery) in 1999, with First Class Honors and the University Medal. He completed fellowships in neurophysiology and pain. Dr Granot is accredited with the Medical Board of Australia, and is a Fellow of the Royal Australasian College of Physicians and Australian Association of Neurologists. He is a conjoint lecturer at UNSW.