The diagnostic criteria: A) At least 5 attacks fulfilling B-D; B) lasting untreated 4-74 hours; C) two of the following: unilateral, pulsating, moderate or severe pain intensity, worsening with physical activity; D) one of the following: nausea and/or vomiting, photophobia or phonophobia; E) not attributed to another disorder. (International Classification of headache disorders, 2004) (go here for one of the most comprehensive sites on migraine)
The main treatment for migraine is to use medication – best evidence to date suggests: “Only two pharmacological treatments have been shown to be effective in placebo-controlled randomized trials: topiramate and local injection of botulinum toxin. Both therapies are effective in patients with chronic migraine with and without medication overuse. “ (Diener, Holle, Dodick, 2011)
As one of the many people who have migraine to NOT find these two medications helpful, and someone who has slightly unusual migraine symptoms (my main symptom is nausea, with headache being secondary), it’s taken a long time for me to reach a clear-cut diagnosis for migraine. In the meantime I’ve had to learn to “live with” my migraines without pharmacology. No easy matter when even the best say “Most of the time migraines resolve with sleep. Occasionally, and especially in children, vomiting stops migraine.” (from Migraine Aura Foundation)
What helps migraine – apart from sleep and vomiting?
I’m going to start with the approaches that I commonly use in the Pain Management Centre for people with migraine. Please note: these are NOT a panacea for all migraines, and they work most effectively in combination. Please don’t use what I’m writing as a substitute for seeing a health care provider – you and your health care provider need to work together.
- Assessment: Step one for managing migraines is carrying out a good assessment to identify triggers (antecedents). This is one occasion when diaries for recording headaches and activities over a month or so. I’m generally not keen on pain diaries because they so often focus the person on their pain, but in the case of intermittent headaches the diary method is really useful. It’s helpful to briefly record activities, “stress” level, aura, headache intensity, sleep and food/drink intake. This might help identify triggers – but having identified them, avoiding them is not always the best approach! Instead, it might be more preferable to consider ways of managing the overall vulnerability to migraine – more on this below.
- Self-regulation training: Self-regulation refers to a wide range of strategies to influence alertness and ability to achieve a given activity. In the context of migraine management, it usually refers to using things like biofeedback modalities to help train the person to up and down-regulate their physiological activity. I find this has to be conducted alongside cognitive therapy so the person remembers to use self-regulation, and to help manage the automatic thoughts that often occur both because of having a migraine and as a response to using different strategies.
- Cognitive therapy: This refers to recognising automatic thoughts, intermediate beliefs/attitudes, and core beliefs, and working with these to interpret events in a different way. This approach helps people to reflect on why they feel the way they do about situations and establish whether these are “working” to help them achieve what is important and valued in their life. Even if an interpretation of a situation is accurate, it may not be helpful.
- Effective communication: This might seem a strange one to put into migraine management, but something I have found is that emotional stress from interpersonal conflict is one of the “hidden” triggers for migraine. Effective communication can be called “assertive” communication, but I find this to be a very value-laden term. Being able to communicate effectively involves listening, hearing, interpreting then developing an honest and respectful response.
- Activity management: Yes, that old standby of timetables, planning, prioritising and putting off – oh, perhaps not that last one! Seriously though, establishing a paced activity pattern that avoids “boom and bust” patterns, or “pain contingent” patterns really helps, especially on a day when a migraine has started. Stopping everything isn’t an option for many people, so maintaining a “minimum” plan for those days can be useful.
Self-regulation training – some details
While learning self-regulation without biofeedback is perfectly fine, for some good reasons, various biofeedback modalities enhance the learning.
Biofeedback involves monitoring physiological processes usually considered involuntary or that are modulated outside of conscious awareness. The three most common forms of biofeedback for headache treatment are: thermal, electromyographic (EMG), and electrodermal. I tend to use Galvanic Skin Response (GSR) rasther than electrodermal, simply because it’s available to me and also because it gives me (and the person I’m working with) a good “overall” assessment of alertness.
There are many things that you can do with biofeedback, but I usually begin by attaching the leads and showing the graphs on the computer monitor. We talk for a while until the person’s graphs show they’re stabilising into a baseline state.
I then usually begin with a Stroop test to establish “working under stress”. This is a test where people are asked to read words for colours, with the words printed in different colours from how they read. For example GREEN RED BLUE. This gives me some information on the parameters the person usually demonstrates “stress”.
I then progress to learning to breathe. “Not so difficult”, you say – well, it’s surprising how few people demonstrate effective breathing and control of breathing. I almost always begin with respiration – to firstly use diaphragmatic breathing, then to slow the breathing down, and finally, with a respiration monitor around the person’s chest, I might help them look at the S pattern they create on the monitor. This helps them to create slow, regular and full breathing that smoothly inflates and deflates the lungs.
Then I often move onto some animated programmes – one of my favourites is the Wild Divine set called “Relaxing Rhythms”. It monitors heart rate, heart rate variability and GSR, and has a number of really good animations that help people to develop control.
More on migraine management soon!
Grazzi, L., & Andrasik, F. (2010). Non-pharmacological approaches in migraine prophylaxis: behavioral medicine Neurological Sciences, 31 (S1), 133-135 DOI: 10.1007/s10072-010-0306-5
Paola Schiapparelli • Gianni Allais • Ilaria Castagnoli Gabellari •
Sara Rolando • Maria Grazia Terzi • Chiara Benedetto (2010). Non-pharmacological approaches in migraine prophylaxis: Part ii Neurological Sciences, 31 (S1), 137-139 DOI: 10.1007/s10072-010-0307-4