Migraines
1. Introduction
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).
Frequently Asked Questions
- A migraine is usually a moderate or severe headache felt as a throbbing pain on one side of the head.
- Headaches affect almost everyone at some time.
- It is more common in women than in men (1).
- Over a 1-year period, approximately 12% of the general population will suffer from a migraine (4).
- No.
- Headaches are generally a normal part of life and will commonly pass on their own.
- Approximately 2% of people seen in UK general practice with headaches are referred to a neurologist to rule out more dangerous causes (4).
- Females are more likely to suffer from primary headaches (a type of disease-free headache) than males (1, 2).
- Those with an unhealthy lifestyle.
- Those under excessive stress.
- Migraines tend to be unilateral, throbbing and disproportionately disabling.
- Nausea is common.
- Migraines can occur with or without aura.
- Visual symptoms are the most common manifestation of an aura and consist of flickering lights, spots or zig-zag lines, fortification spectra or blind spots (1).
- Consider using a headache diary to aid the diagnosis of primary headaches.
- Consider causes/what you are doing during onset, intensity, area of pain, any other symptoms you experience whilst having a headache. Finding any patterns may help your healthcare professional better manage your headache (6).
- This is dependent on the cause and subtype of the headache itself. Many headaches will settle without concern, however some will require further investigation.
- Some headaches may be linked to neck problems and in these cases, treatment and rehabilitation will be helpful.
- We recommend an assessment from a musculoskeletal physiotherapist to determine if this is the case.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Unilateral (one side) or bilateral (both sides) pain.
- Pain quality will be pulsing (throbbing or banging in young people aged 12–17 years).
- Moderate or severe intensity.
- Aggravated by, or causes avoidance of, routine activities of daily living.
- Lasting 4-72 hours in adults or 1-72 hours in young people aged between 12-17 (1).
- Episodic migraine (with or without aura) – less than 15 days per month.
- Chronic migraine (with or without aura) – 15 days per month or more, for more than 3 months (1, 2).
Aura symptoms:
- 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.
- Speech disturbance.
- Fully reversible.
- Develop over at least 5 minutes.
- Last 5- 60 minutes.
3. Causes
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 migraines are 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).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing migraines. It does not mean everyone with these risk factors will develop symptoms.
- Adolescence for the first migraine.
- Family history of migraines.
- Changes in sleep cycles.
- Missed meals.
- Stress (5).
5. Prevalence
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).
6. Assessment & Diagnosis
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.
7. Self-Management
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.
8. Rehabilitation
Rehabilitation will be determined by your symptoms and triggers. Recovery can take some time and should be managed by your GP.
9. Migraines
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
Pain should not exceed 2/10 on your perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
These exercises provide a progression from the previous exercises aiming to progress strength and flexibility around the neck and upper back. Pain should not exceed 2/10 on your perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
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.
11. Other Treatment Options
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).
References
- NICE. (2012). Headaches: diagnosis and management of headaches in young people and adults. NICE Clinical Guideline.
- International Headache Society Classification of Headaches ICHD II; Updated Web-based Version.
- Hale, N. and Paauw, D,S. (2014). Diagnosis and treatment of headache in the ambulatory care setting: a review of classic presentations and new considerations in diagnosis and management. The Medical Clinics of North America 98(3), 505-527.
- Latinovic, R., Gulliford, M., Ridsdale, L. (2006). Headache and migraine in primary care: consultation, prescription, and referral rates in a large population. J Neurology Neurosurg Psychiatry 77(3), 385-387.
- Dodick, David, W. (2018). Migraine. The Lancet. 391 (10127), 1315-1330.
- NICE. (2015). Suspected cancer: recognition and referral NICE guideline. NICE Guideline.
- Disease and Injury Incidence and Prevalence Collaborators. (2015). Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study. Lancet. https://doi.org/10.1016/S0140-6736(16)31678-6.
- Neurological Disorders Collaborator Group. (2015). Global, regional, and national burden of neurological disorders during 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurology. 2017 (16), 877–97.