1. Migraines in the UK Mohammad Moazzam Fazlee & Punnam Mittu

2. Migraine in the UK  WHO has classified headache as a major health disorder and has rated migraine amongst the top 20 most disabling lifetime conditions.  1 in 7 people in the UK suffer from migraine.  Twice as many women as men.  All age groups (even young children) and all social classes.  Migraine costs the UK around £2.25 billion per annum.  One attack can last for between 4 and 72 hours (with an average of 13 attacks each year).  Around 60% of sufferers never consult their GP because they mistakenly think that nothing can be done to help them.  For most people there is not just one trigger but a combination of factors which individually can be tolerated but when they all occur together a threshold is passed and a migraine is triggered.

3. Types of Headache  Tension - the common "everyday" headache most people will experience at some point in their lives. In some cases people have tension headaches on most days of the month.  Migraine - severe headache that can last for several days. It gets worse with activity and often comes with nausea as well as sensitivity to light and sound.  Cluster - extremely severe pain around the eye and side of the face, also includes swelling and a red watery eye. Some people report eight attacks a day, which can last up to three hours.  Medication overuse - feels like a tension headache or a migraine, but is due to taking too many painkillers.  However, there are more than 200 types of headache.

4. How do you know when it’s a Migraine?  Assessment Is it a primary headache (tension, migraine or cluster? Is it secondary to an underlying cause?  Headache History Time  Onset (recent or long time sufferer)  Frequency (daily? Quantify)  Patterns  Duration of attack  Character  Site (where does pain start, does it spread)  Intensity (scale of 1-10)  Duration of pain

5. Causes  Family history?  Triggers/aggravating factors/relieving factors Response  Patients actions during attack – what they do to relieve headache i.e. medication used  Limitations during an attack – does medication work completely/partially/make it worse?  Is patient symptom free between headaches Intervals  State of health between attacks – concerns, anxieties and fears about attacks?  How does patient feel between attacks? How do you know when it’s a Migraine?

6. Migraine  Typically recurrent, episodic  Moderate or severe pain  May be unilateral/and or throbbing  Duration – from 4 hours up to 3 days  GI + visual symptoms common  Activity limited  Dark/quiet preferred  Free from symptoms between attacks

7. Phases of Migraine Attack  Prodrome  60% migraine sufferers experience  Occurs within hours or up to days before an attack Physical symptoms: stiff neck, cold, ↑ thirst, ↑ urination, loss of appetite, diarrhoea, constipation, sensitivity to light/sound Psychological symptoms: Depression, Euphoria, Restlessness, Drowsiness, Fatigue, Irritability, Impaired concentration, Scalp tenderness, Mood changes

8.  Aura  20% sufferers experience right before an attack  Develops 5-20mins before attack, lasts no longer than 1 hour Symptoms:  Numbness or tingling of the face arm, or hand on one side of the body, Muscular weakness  Mild paralysis on one side of the body  Difficulty speaking or loss of speech

9. Analgesics  Aspirin 75-900mg  Paracetamol (little efficacy on own) 125 – 500mg  Ibuprofen 100-600mg Common side effects  Drowsiness  Flushing (redness of face)  Dizziness  Feeling sick (nausea), being sick (vomiting)  Pain sensations  Tingling and Heat sensations

10. ‘Brain gets used to painkillers’ Warwick Medical School  “Anyone taking painkillers for more than 15 days during a month were likely to suffer from analgesia-induced headaches’. Dr Brian Hope  "This can end up getting into a vicious cycle where your headache gets worse, so you take more painkillers, so your headache gets worse and this just becomes worse and worse and worse’’ Prof Martin Underwood  This is a huge problem in the UK population. The figures in terms of the number of people who have medication overuse headache are one in 50, so that is approximately a million people who have headaches on a daily or near daily basis because they're using painkillers.

11. Trigger or predisposing? TriggersPredisposing Psychological Depression, anxiety, anger, tiredness, etc, relaxation after stress: weekends/holidays Stress Change in Habit change in sleep patterns e.g. missing sleep, lying in, missing meals, long distance travel Depression/anxiety Environmental Smoking, smoky rooms, VDU screens, bright/flickering lights/loud noise/strong smells, weather extremes Menopause Diet + foods (alcohol, cheese, citrus fruits – foods containing tyramine) possibly chocolate; missed or delayed meals, dieting too fast, Menstruation Medicines HRT, some sleeping tablets + contraceptive pill Head or neck trauma Other Menstruation, menopause, shift workers, Strenuous unaccustomed exercise

12. Management strategy  Stress: Relaxation and coping strategies may help with specific stress or anxiety present.  Yoga and meditation.  Alter poor sleep or eating patterns.  Diet: Exclude suspected food from diet for several weeks to see an improvement, and consult a dietician to avoid malnutrition.  Avoid particularly energetic sessions. However, maintain good physical fitness.  Migraine related to menstruation can be more difficult to treat than migraine related to other factors i.e. hormonal factors.

13. Advice  Diary to monitor patterns + triggers – review after at least 5 attacks  Improving physical fitness  Physiotherapy (but no evidence)  Acupuncture  Psychological therapy –Relaxation (yoga + meditation) –Stress reduction –Coping strategies –Biofeedback 1 st line if underlying cause e.g. anxiety/stress

14. Things to include in diary…  Date of Attack  Date of Attack  Time Started  Time Started  Time Finished  Time Finished  Aura – Yes/No  Severity – severe/moderate/mild  Time needed off school, work or other activities – Yes/No  Other Symptoms  Feeling Sick – Yes/No  Feeling Sick – Yes/No  Vomiting – Yes/No  Vomiting – Yes/No  Other

15. Things to include in diary…  Medication  Dose  Time Taken  Relief - yes/partial/no  Time to Relief  Possible triggers  Food and drink taken 6-8 hours before attack  For women: record periods

16. References  http://www.bbc.co.uk/news/health- 19622016 http://www.bbc.co.uk/news/health- 19622016 http://www.bbc.co.uk/news/health- 19622016  http://www.migraine.org.uk/index.php?sect ionid=11 http://www.migraine.org.uk/index.php?sect ionid=11 http://www.migraine.org.uk/index.php?sect ionid=11

17. Thank You For Listening