Around 10 million people in the UK experience migraine attacks regularly. However, according to The Migraine Trust’s survey in July 2021, the proportion of the population living with migraine may be even higher than this: over half said they experienced a migraine attack every month or more, at an average of just over two episodes a month. 

“Chronic migraine is defined as having at least 15 headache days per month, with migraine symptoms on at least eight of these days, for at least three months,” says Ria Bhola, headache nurse specialist at The Migraine Trust. “People who experience fewer headache days than this have episodic migraine. Migraine can change throughout a person’s life, and it is possible for episodic migraine to become chronic migraine at any time.”

According to a review in Frontiers in Pain Research in August 2021, chronic migraine tends to affect more women than men, and the incidence peaks during midlife. It’s not fully understood exactly what causes it, but risk factors include high baseline episodic migraine attack frequency, obesity and stress.

Treatment options

It’s estimated that 190,000 migraine attacks occur every day in the UK. The acute treatment of episodic and chronic migraine attacks is the same and involves taking analgesics and an anti-emetic to stop or shorten an attack. 

“Soluble aspirin is preferred, and ibuprofen’s lysine form may be helpful,” says Dr Katy Munro, GP headache specialist at the National Migraine Centre. “Paracetamol is weaker for migraine pain but is more effective if soluble and combined with a prescribed pro-kinetic like metoclopramide.”

Headache specialists don’t recommend codeine for migraine (even if the product pack states its suitability) as they say it isn’t very effective, worsens nausea, is addictive and can make headaches worse if used regularly. Instead, pharmacists should advise anyone with migraine attacks that don’t respond to simple analgesics in a couple of hours to take a triptan. 

“Triptans are specifically used for migraines as they cause the blood vessels around the brain to contract, reversing the process,” says Sue Swift, Numark Drug Tariff information technician. “Available in tablet, injection or nasal spray form, they should be taken as soon as the pain starts. If the migraine improves but then returns, the patient can have another dose after two hours, but shouldn’t exceed two doses in 24 hours.”

"It’s estimated that 190,000 migraine attacks occur every day in the UK"

Since chronic migraine attacks are so regular, it can be challenging to know when to take analgesics. People with migraine shouldn’t take paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) on 15 or more days a month or take opioids, combination painkillers, triptans or ergotamine on 10 or more days a month. 

“People with migraine need to limit their analgesic use because taking them too often can lead to medication overuse headache,” says Ms Bhola. “Frequent use of painkillers could lead to episodic migraine becoming chronic.”

The Frontiers in Pain Research review found that although appropriate acute treatment may help to reduce the immediate head pain in a migraine attack, the effectiveness and options are quite limited. Importantly, it has been reported that people with chronic migraine respond less well to triptans. Most chronic migraine needs to be treated with preventative approaches.

Lifestyle factors or triggers may contribute to the onset of acute attacks. “Maintaining routine and minimising changes can be very helpful,” says Dr Munro. “A person with migraine shouldn’t skip meals, should try to eat slow-release energy foods like protein, fat and complex carbohydrate every three to four hours, keep a good routine of waking and sleeping, stay hydrated, take moderate regular exercise and try to minimise the impact of stress or excitement if possible.”

Ms Bhola suggests keeping a migraine diary, but this may not work so well for chronic migraine. “As people with chronic migraine experience very frequent attacks,” she says, “it can be harder to identify triggers; many people struggle to identify their triggers until their symptoms begin to improve.”

Red flag symptoms

Red flags that require referral include:

• New onset or rapidly worsening headache (especially in over 55s)
• Abnormal neurological signs
• Fever or signs of infection
• First severe, thunderclap headache
• Vomiting before a headache
• Pain triggered by bending, lifting or straining
• Headache with local tenderness over the temple area
• Secondary risk factors such as cancer.

Non-drug alternatives

Some people with chronic migraine find non-drug treatments are helpful in easing and reducing attacks. “There is some evidence magnesium (600mg), riboflavin (400mg) and co-enzyme Q10 (150mg) can benefit people with migraine,” says Ms Bhola. “It can take six to eight weeks to see any benefit, and interactions with existing medication need to be taken into account. Some people find that applying cold or hot packs to their head or neck can be soothing.”

Neck and shoulder tightness may trigger frequent migraine attacks and make migraine worse. “Frequent gentle stretches can benefit people with migraine,” says Ms Bhola. “Some people with migraine find acupuncture provides some temporary relief as an alternative to medication. Relaxation techniques can reduce the impact of stress and anxiety.”

Prevention

If migraine attacks are regular, a GP may prescribe preventative treatments such as beta-blockers, tricyclic antidepressants, anti-epilepsy drugs or the blood pressure tablet candesartan. 

“Preventive options for migraine are generally considered when a person is experiencing four or more migraine attacks per month,” says Ms Bhola. “People taking preventives should take the medication for at least three months at optimal dosing to assess whether it is having a beneficial effect.”

If initial preventative medicines don’t work, the GP may refer the patient to a specialist clinic that has access to a wider range of treatments. “Botulinum toxin type A is an injectable preventive treatment offered at specialist headache clinics to patients with chronic migraine who have failed three prior preventives,” says Ms Bhola. “Waiting times vary across services and the treatment is repeated every three months to those who meet the criteria.”

CGRP mAbs (erenumab, galcanezumab and fremanezumab) disable the activity of the protein responsible for the pain and nausea associated with migraine. “CGRP mAbs can reduce both the frequency and severity of migraine attacks and cause fewer side effects than traditional migraine preventives,” says Ms Bhola. “Patients can learn to administer the monthly injection, but unfortunately, many are struggling to access CGRP mAbs, despite being eligible for them.”

According to GlobalData in November 2021, low diagnosis is partly to blame for poor access to these treatments. Almost a quarter of people in The Migraine Trust survey had been experiencing migraine attacks for over two years before they were diagnosed.

Refresher: common types of primary headaches

MIGRAINE

Signs/symptoms: A one-sided, throbbing headache, often with nausea and/or vomiting. The head pain may be so bad that people want to lie down. They may be sensitive to light, sounds and smells, and feel very tired. Some people get warning signs for up to an hour before an attack (migraine with aura) – including visual problems (e.g. flashing lights or zig zag patterns), numbness or tingling sensations, feeling dizzy and muscle weakness.

Treatment: Initial analgesics, triptans and anti-emetics for acute attacks, and preventative treatments for regular migraine attacks. Review lifestyle factors that may trigger migraine.

TENSION-TYPE HEADACHES

Signs and symptoms: A tight band around the head, usually on both sides, or across the forehead. This usually gets worse during the day, but most people can carry on with their usual activities.

Treatment: Analgesics such as paracetamol or ibuprofen. Exercise, drinking more water and fresh air may help. Look at lifestyle triggers, such as stress, alcohol, caffeine and poor posture.

CLUSTER HEADACHES

Signs and symptoms: Severe, one-sided headaches, often around the eye. Headaches are disabling and prevent usual activities. They begin quickly and with no warning. People may feel restless and agitated during an attack and want to rock, pace or bang their head against a wall. They may also have a red and watering eye, sweaty face and a blocked or runny nostril.

Treatment: OTC painkillers don’t work. A triptan injection or nasal spray or oxygen therapy may help during an attack. Transcutaneous vagus nerve stimulation (TVNS) may relieve cluster headache by using low-voltage electrical currents to stimulate a nerve in the neck. Preventative treatments may reduce attacks during a cluster. Lifestyle triggers include alcohol, strong-smelling chemicals and getting overheated during exercise. 

Views of the P3pharmacy category panel

“I’m always surprised how many customers don’t keep analgesics at home, but will come to the pharmacy with a headache and ask what they should take. Panadol is our best seller; we stock all the variants to give customers options. Migraleve, Nurofen, Cuprofen sell well. We keep sumatriptan but have had some stock issues recently. Our customers tend to prefer brands to generic alternatives, but it’s good to keep a variety and the different variants within each brand in stock so they have a choice.”

Sarina Mughal, Day Lewis, Knightsbridge

“This fairly important area is helped by the availability of sumatriptan OTC. We get asked ‘headache or migraine?’ but we would direct the customer to their GP for a first diagnosis if they’re not sure. We try to find out whether frequent headaches could be caused by medication overuse – how often do hey take analgesics and for how long? We warn about the addictive potential of codeine. We sell a lot of Numark’s own brand sumatriptan - we tend to sell generic analgesics rather than brands.” 

Lindsey Fairbrother, Goodlife Pharmacy, Hatton, Derbyshire

“This is a steady category; not much has changed in recent years. It’s not one we actively promote, but staff will refer customers to the pharmacist. If customers have a change in headache or migraine pattern we refer them, especially if they are buying painkillers more frequently. Sumatriptan (we stock Migraitan) does really well. Most customers are already prescribed it, but run out. Solpadeine sells well too. We have to keep an eye on customers who buy codeine as medication overuse can be a problem.”

Hardik Desai, Ticehurst Pharmacy, Kent