Migraines

Headaches in general are not cause for concern. On average 37,000 people visit their general practice in the UK every day ⁽¹⁾. On rare occasions, however, certain types of headaches accompanied by other symptoms may suggest a more dangerous condition. See the assessment and diagnosis section for symptoms that may require onward referral or investigation.

The International Headache Society classifies headaches into primary and secondary headache disorders ^{(1, 2)}. The majority of headaches are primary (approximately 90%). This means that the headache is not caused by a disease. The three most common types of primary headaches are tension-type headache (40%), migraine (10%) and cluster headache (1%-3%) ^{(3, 4)}. Migraine is a chronic neurological disorder characterised by attacks of moderate or severe headache, and reversible neurological and systemic symptoms ⁽⁵⁾. At times, migraine sufferers will experience neck pain and/or visual symptoms such as flickering lights, spots or lines and/or partial loss of vision, sensory symptoms such as numbness and/or pins and needles, and/or speech disturbance called aura ⁽¹⁾.

The earliest stage of a migraine attack starts in the central nervous system ⁽⁵⁾. A study has shown activation in parts of the brain that connect to the limbic system (the system that controls emotion, memories and arousal) which could explain why migraine is commonly triggered by alterations in homoeostasis (e.g. changes in sleep-wake cycles, missed meals) and also some of the symptoms during the premonitory phase, e.g. yawning, polyuria, food cravings, and mood changes ⁽⁵⁾. There is also evidence that migraines can be linked to menstruation in girls and women ⁽¹⁾.

Migraine is one of the most prevalent and disabling medical illnesses in the world. The World Health Organisation ranks migraine as the third most prevalent medical condition and the second most disabling neurological disorder in the world ^{(7, 8)}.

• Over a 1-year period, approximately 12% of the general population will suffer from a migraine ⁽⁴⁾.
• The annual and lifetime prevalences are 18% and 33% in women, respectively and 6% and 13% in men.
• Migraine affects approximately 10% of school-aged children (5–18 years) and at prepubertal ages (the rate of onset of a migraine is slightly higher in boys than in girls).
• Migraine is most regular between the ages of 25-55 years and it rises through early adult life and then falls after midlife (i.e. 55 years).

Your GP will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Diagnosis into subtypes of headaches like cluster, tension and migraine comes from the symptoms, frequency and triggers you may experience. For those who present with headache and any of the following features, further investigations and/or referrals may be considered to rule out secondary and dangerous headaches ⁽⁶⁾:

• Worsening headache with fever.
• Sudden onset headache reaching maximum intensity within 5 minutes (thunderclap headache).
• New onset neurological deficit.
• New onset cognitive dysfunction.
• Change in personality.
• Impaired level of consciousness.
• Recent (typically within the past 3 months) head trauma.
• Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze.
• Headache triggered by exercise.
• Orthostatic headache (headache that changes with posture).
• Symptoms are suggestive of giant cell arteritis.
• Symptoms and signs of acute narrow-angle glaucoma.
• A substantial change in the characteristics of their headache.

Further investigations should be considered and/or referral for people who present with or without migraine headache, and with any of the following atypical aura symptoms that meet the criteria in recommendation ⁽¹⁾:

• Motor weakness.
• Double vision.
• Visual symptoms affecting only one eye.
• Poor balance.
• Decreased level of consciousness.

A diary may help you to find what triggers your headache and also help indicate when your GP needs to refer you. Keep a headache diary for a minimum of 8 weeks ⁽¹⁾ including:

• Frequency, duration and severity of headaches.
• Any associated symptoms.
• All prescribed and over-the-counter medications taken to relieve headaches.
• Possible precipitants.
• Relationship of headaches to menstruation.

As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment.  Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.

As always, speak to your GP about possible medical management. A course of up to 10 sessions of acupuncture over 5-8 weeks may be effective depending on any other medical conditions you may have and the risk of adverse events ⁽⁶⁾.