Niamh Flynn describes the treatment options available for patients suffering from the various types of migraine

Migraines are unlikely to spur action to call one’s dentist but many orofacial surgeons will be familiar with patients complaining of this debilitating disease. While it is estimated that 95 per cent of orofacial pain will result from dental causes such as toothache or dental abscess (Scully 2008), migraine can present too and knowing the treatment options available for patients could save potential headaches for patients and dentists alike.

The likelihood of a patient presenting with migraine is not too surprising given the burgeoning number of individuals who suffer with the condition. The International Association for the Study of Pain (2011) found that approximately 5 to 10 per cent of men and 13 to 18 per cent of women suffer with migraine. Approximately 20 to 30 per cent of these individuals will experience aura and neurological symptoms such as visual disturbances.

Approximately 20 to 60 per cent of female migraineurs have migraine attacks associated with their menstrual cycle (MacGregor, 2010). Hormones clearly play a role in causing migraines, particularly in the days prior to menstruation when the oestrogen levels drop. This likely explains why women are up to three times more likely than men to suffer with migraine.

Migraine is different to other types of headache. It is a complex condition typified by severe pain. Some migraine sufferers will also experience sensitivity to light, sound and smell. There are four stages of a migraine episode which have been identified by the International Headache Society (IHS). Not every migraineur will experience all four stages and the number of stages can vary from one migraine to the next. Initial changes of mood and very high or very low energy levels with intense food cravings are typical of the first stage, which is often referred to as the prodrome stage. The aura stage is stage two and occurs approximately 20 to 60 minutes prior to the migraine. Sufferers will report seeing zigzag lines or other visual hallucinations. Other senses can be affected also. Stage three is the migraine itself and that can last between four and 72 hours. The postdromal stage, stage four, is typified by fatigue, difficulty concentrating and gastrointestinal symptoms.

Migraines are painful, debilitating and absolutely disruptive. There is no one definitive explanation for the pathogenesis of migraine although there are several theories which have been put forward. These include a vascular theory, a neurotransmitter theory and a brain stem theory. However, no one theory accounts for all the symptoms which occur in a single attack (Goltman, 1936) which presents a challenge for individuals treating the disease.

Migraine stages
	Stage 1	Stage 2	Stage 3	Stage 4
	Prodromal	Aura	Headache	Postdromal
Duration	Hours-days	5-60 minutes	4-72 hours	Hours-days
Symptoms	Fatigue Poor concentration Neck stiffness Photophobia Phonophobia Irritability Yawning	Visual hallucinations Hemiplegia Hemihypoesthesia Dysphasia	Throbbing headache Photophobia Phonophobia Nausea/vomiting Otonomic dysregulation Allodynia	Fatigue Difficulty concentrating Gastrointestinal symptoms

Caroline Kinane, a chronic migraine sufferer, has had migraines since she was ı6 years of age. She explained how migraines can have a debilitating effect on the day- to-day activities which many of us take for granted. She said: “They (the migraines) started in leaving cert year. Living and working can be challenging. Cooking dinner, answering e-mails and the telephone for example. They all set my head bananas – even thinking to be honest at the moment.”

Like many migraineurs, Caroline tries to fight through the pain but anyone who has ever had a migraine will know that this is not an easy thing to do and recently she has had to take time away from work.

“I have suffered from migraines for many years,” she said, “but since last March my migraines have become a nightmare affecting my every day life and work, making the simplest plans and tasks impossible to do, which leaves you feeling vulnerable and frustrated. It’s my first time ever using a sick cert as I always struggled through, but just not able to this time.”

Caroline’s migraines last a few days and, while tiredness and pressure have historically been the culprits for triggering her migraines, hormones have started to play a part. She said: “For the past seven months I feel it’s hormones which are my main trigger point. I just turned 50.”

Whether you suffer with chronic migraine (15 or more migraines a month for three or more months) or episodic migraine (fewer than 15 migraines a month) there are several treatment options available. Traditionally, medication has been prescribed for migraines. More recently, psychological interventions have been considered. A variety of drugs in the level A category, which satisfy the FDA criteria for having established efficacy in two or more class one trials, include antiepileptic drugs such as Topiramate, beta-blockers such as Propanolol and triptans such as Frovatriptan. Other drugs which have been established as effective from one class-one trial or two class- two trials are anti-depressants such as Amitriptyline, and triptans such as Zolmitriptan. These are termed ‘probably effective’ by the FDA (Silberstein, Holland, Freitag, Dodick, Argoff & Ashman, 2012).

Only 22 per cent of people with chronic migraine use migraine specific medications and the remaining 78 per cent rely on opiates such as Tylenol or on barbiturates (Bigal, Borucho, Seranno & Lipton, 2009). There are two matters to consider in particular with this approach to treatment. One is the possibility of addiction to opiates and the second is the possibility of hyperalgesia – a condition where the pain killers actually make the pain worse because of increased sensitivity to pain.

For many, orthodox treatment has struggled to provide a complete and effective solution. Heavy duty drugs such as beta-blockers, anti-epileptic drugs and triptans are most often prescribed for migraine and sometimes they are effective. Unfortunately, they also bring complications. The known side-effects of beta blockers, for example, include tiredness, impotence and depression to name but a few. With anti-epileptic drugs, weight gain, difficulty concentrating, dizziness and nausea are just a few of the associated side effects.

Fortunately, there is an effective alternative option with no negative side effects – hypnosis. For centuries, hypnosis has been used to treat every type of pain condition imaginable (Pintar & Lynn, 2008). It is also effective. A meta-analysis of ı8 studies found a moderate to large hypnoanalgesic effect of hypnosis for pain management (Montgomery, DuHamel & Redd, 2000). These findings were valid for both clinical and experimental pain. Understandably, the preliminary focus of treatment is most often pain management but disability and pain catastrophising are also very often a major concern for migraine sufferers and are frequently neglected in migraine management programmes.

In my own PhD research, I designed, applied and investigated the impact of specific MP3s delivered online to address headache disability and pain catastrophising. Over 10 weeks, a control group and an intervention group were assessed on a weekly basis. The results were significant. A 48 per cent drop in headache disability and a 60 per cent drop in pain catastrophising after ı0 weeks. Pain catastrophising refers to negative pain-related thoughts which are defined by rumination, magnification and helplessness (Sullivan, Bishop & Pivik, 1995). The intervention involved listening to the specifically designed hypnosis MP3s three times a week over the intervention.

Proponents of hypnosis will often report side-effects of complete relaxation, feelings of being more in control, reduced pain, and being more positive to name but a few. Some of the concerns people have about hypnosis include fears of being under another person’s control, that they will say something they don’t want to say and that there is a possibility of not coming out of trance. It is safe to say none of these things are going to happen. In a state of hypnosis you will hear everything that is being said, you will not say anything you don’t want to say and you can come out of trance any time you choose to.

Nothing is a panacea for all ills and all individuals but the evidence-based research is certainly something to consider for those who have no desire for medication or who have found medication unable to provide the relief which they are seeking.

The prevalence of migraines and the disability that they cause demand that we sit up and take notice of them. An awareness of how others experience migraines can help shine a light on an otherwise lonely existence when one feels they have no recourse but to bury their head in a dark room for hours, and sometimes days, on end.

Armed with knowledge of the stages of migraine and the various treatment approaches, informed decisions can be made.

About the author

Niamh Flynn is a sport psychologist specialising in hypnosis and is based at the Galway Clinic, a private hospital in the west of Ireland. She has a masters in sports medicine (MMedSci) from the University of Sheffield, a masters in business administration (MBA) from Michael Smurfit Business School UCD, a bachelor of arts in psychology (BA), a diploma in hypnotherapy and psychotherapy (DHP) and is a certified instructor (CI) with the National Guild of Hypnotists (NGH). Her book End Migraine Fast and clinically proven audio hypnosis programme for migraines, are available to buy via the website www.bodywatch.com

References

Bigal, M.E., Borucho, S., Serrano, D., & Lipton, R.B. (2009). The acute treatment of episodic and chronic migraine in the USA. Cephalagia. 29(8), 891-897.
Goltman, A. (1936) The mechanism of migraine. Journal of Allergy. 7(4), 351-355.
MacGregor, A. (2010). Prevention and treatment of menstrual migraine. Drugs. 70(14), 1799-1818.
Montgomery, G.H., Duhamel, K.N. & Redd, W.H. (2000). A meta-analysis of hypnotically induced analgesia: How effective is hypnosis? International Journal of Clinical and Experimental Hypnosis, 48(2), 138-153.
Pintar, J. & Lynn, S.J. (2008). Hypnosis: A Brief History. Wiley-Blackwell.
Scully, C. (2008). Oral and maxillofacial medicine : the basis of diagnosis and treatment (2nd ed.). Edinburgh: Churchill Livingstone. pp. 98–108
Silberstein, S.D., Holland, S., Freitag, F., Dodick, D.W., Argoff, C. & Ashman, E. (2012). Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 78(17), 1337-45.
Sullivan, M.J., Bishop, S.R., & Pivik, J. (1995). The Pain Catastrophizing Scale: development and validation. Psychological Assessment, 7(4), 524-532.