The expert migraine guide: are old pills best?
An Oxford University review has found that modern, pricey drugs may not be as effective at treating migraines. So what do we know?
What’s most effective for knocking your migraine on the head? A large review led by scientists at the University of Oxford and published in the British Medical Journal last week concluded that triptans — an older, inexpensive class of drug — kill the pain of a migraine attack faster than gepants — newer, costlier medicines. Researchers found that “for sustained pain freedom, the most efficacious interventions were eletriptan and ibuprofen”.
However, the headache specialist Dr Katy Munro, author of Managing Your Migraine, notes that the study didn’t look at what treatment worked best for individuals, “it looked at research papers for all these acute medications and statistically compared their efficacy and adverse effects and tolerability”.
It would be disastrous to assume that “these old drugs are better than the new ones”, she adds. Treatment is complex and a personalised approach is key. “Every week in my clinic I hear the words ‘life-changing’, because patients have suddenly found the right medication for them.”
There are many misconceptions about migraine attacks, she says. But the more we know, the better we can manage them.
A migraine is just a headache, right?
Wrong. “Most people believe that migraine means headache, which is not true. It’s just that headache is the most common symptom of a migraine,” says Dr James Gratwicke, a consultant neurologist in the NHS, the Harley Street Clinic and London Bridge Hospital. An attack typically lasts between four hours and three days, with some sufferers debilitated for longer.
The brain is an electrical organ; electricity flows through it and within it. “A migraine is a build-up of electrical irritability on the brain’s surface,” Gratwicke says. Initially, this “electrical irritability” covers a penny-sized area. “That triggers release of a chemical called CGRP [calcitonin gene-related peptide], and this diffuses across the tiny gap between the brain and the thin membrane that covers it — the meningeal lining — and binds to receptors on that lining.” Classically, the headache of a migraine attack is side-locked as the lining on one side of the brain is irritated more than on the other, though in severe cases the irritation spreads, becoming “global”.
Why do I suffer light sensitivity and nausea?
The core symptoms of a migraine attack, Gratwicke says, are “headache, sensitivity to light, sensitivity to sound, sensitivity to movement and nausea.” All are caused by irritation and sensitisation of the meningeal lining, which also covers the optic nerves. “This is why, when you’ve got a migraine, if you’ve got bright light coming through the pupil in the eye it falls onto the retina and through it, onto the irritated meningeal lining beneath, and makes the pain worse.”
As for the nausea, “There are some quite strong neural connections from the meningeal lining to areas of the brain involved in satiety. And when the meningeal lining is irritated, these pathways become hyperactive.” This generates the sensation of nausea.
Why does noise or strong perfume make it worse?
“The brain areas that process sound and smell become hypersensitive in migraine and consequently their signals are amplified,” Gratwicke says. And motion sensitivity? “If you start moving the head around too much you’re putting shearing forces mechanically across the meningeal lining, irritating it more.”
What is happening to my vision?
Aura symptoms don’t affect all sufferers, but cause most anxiety. As migraines very often occur over our visual processing areas, “that will give rise to some sort of visual distortion”, Gratwicke says. “Blurring of vision, zigzag lines, or what I get — colourful splotches — drifting black dots, drifting white dots, star bursts.”
I tell Gratwicke that if I overdo it at the gym, I get visual disturbances, but no pain. “You’re describing a migraine, with visual aura, without much prominent headache,” he says, adding that exercise is a trigger as it dehydrates you. Meanwhile, if a migraine attack occurs elsewhere in the brain, it can prompt sensory auras — “a tingling, numb or heavy sensation spreading down the side of the face, sometimes into the arm, very rarely into the leg”. Many people fear they’re having a stroke.
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At Pain Spa, Dr Krishna is very experienced in managing various headaches including migraines. Dr Krishna will discuss all the management options including the newer drugs. Please email us for further details at clinic@painspa.co.uk if you are interested in having a consultation with Dr Krishna.