Migraine misconceptions

Being absent with a migraine is something of an office joke. Sufferers often
wrongly assume no treatment is available, and they are all too readily labelled
malingerers. A knowledge of the facts will help OH practitioners deal with the
problem, by Helen Healy

For their awareness campaign this year, The Migraine Trust chose the theme
‘One in six’, to highlight that recent research has shown the number of people
who have migraine in the UK has increased to one in six.

This makes the incidence of migraine more common than many other conditions.
But despite this, there remain misconceptions about migraine and what it is
like to be a migraine sufferer.

Migraine can affect any person of any age, sex or ethnicity but it is
predominantly the working age group that seems to suffer the most frequently
and the most severely.

Surely then it is important for occupational health practitioners to have some
of the myths dispelled and the facts set out so they know how best to advise
and assist the sufferers.

What is migraine?

Migraine is defined as "an episodic primary headache disorder" –
episodic because it comes and goes, with complete freedom from symptoms between
attacks, and primary because there is no underlying disease causing the

Far from being "a bad headache" as is often assumed, a migraine
attack can include a wide range of symptoms and the attack itself typically
consists of a series of five stages:

– Prodromal or premonitory stage. This first stage is comprised of certain
physical and mental changes such as hyperactivity or fatigue, loss of appetite
or craving for specific foods, mood change, fluid retention, thirst, yawning.

These symptoms may last for several hours, up to a day. They may be vague,
particularly at first, and therefore may be mistaken for migraine attack
‘triggers’. For example, fatigue felt at this stage might lead migraineurs
(those who suffer from migraines) to think that getting overtired prompts or
triggers an attack or a craving for chocolate may suggest that chocolate is a

– The aura stage. This second stage can last between five and 30 minutes. It
may occur before a headache or may accompany a headache.

Aura, meaning additional neurological symptoms, may include visual
disturbances – the most common being flickering zig-zag lines, gaps in the
visual field, blurring or loss of vision.

Migraineurs may encounter speech problems: they may sound drunk, get words
mixed up or know what they want to say but be unable to verbalise. Disturbances
of hearing, distortions of reality, confusion, pins and needles, tingling,
numbness, partial paralysis or passing out may also be experienced.

– The third stage, the headache, involves head pain that can be of moderate
intensity or so severe it is totally incapacitating. It is often pulsating or
throbbing in nature and aggravated by physical exertion or movement. However,
it may also be pressing or tightening. It is typically one-sided – although it
does not have to be and the side that is affected may vary. The head itself can
feel so tender that a sufferer cannot even bear it to touch a pillow. The pain
can be totally incapacitating.

There may be no headache or the headache may not be the predominant symptom.
Migraine is a gastrointestinal disorder so nausea, vomiting, diarrhoea or
constipation may be present. Sensitivity to light, sound or smells are other
symptoms that migraine sufferers experience.

– At the fourth, resolution, stage most attacks slowly fade away although
some end violently. Sleep, even an hour or two can be enough to end an attack.

– The fifth, postdromal or recovery, stage can take hours or days. In this
final stage the symptoms may be the opposite of those experienced during the
first stage. For example, someone who felt lethargic may feel full of energy.

While an attack may have these five stages, migraine is an individual
condition and will vary from one person to another. There is no ‘standard’,
‘typical’ or ‘normal’ migraine. Symptoms differ between individuals and may
change from one attack to the next. One reason for this is that there are
several types of migraine and headache.

It is important that anyone who has not already done so seeks an accurate
diagnosis in order to ensure the most appropriate treatment, because different
types of headache require different treatments.

It is not unusual for symptoms to change at different stages of a patient’s
life, e.g. during pregnancy or at the menopause. However, any change in pattern
should be checked with a doctor.

Migraines and work

Some of the symptoms of migraine make it impossible for the sufferer to
work. This causes frustration when it is viewed by those who do not know any
better that migraine is just given as an excuse by malingerers who are
reluctant to fulfil their work obligations. Equally frustrating for migraine
sufferers is the scenario where someone will say they have a migraine when they
do not. Migraine sufferers contacting The Migraine Trust helpline repeatedly
report anxieties about letting down work colleagues.

Flexible working time systems can therefore be enormously beneficial in
reducing such pressure on migraine sufferers as they can enable them to ensure
their work is completed while they are well enough to do so.

Another problem that migraineurs face when trying to pursue a career is the
limitations imposed by their condition. This can be either because employees
themselves or their employers are hesitant to assign a particularly important
project, that has to take place on a certain date, to a migraine sufferer
because they fear an attack will strike and make it impossible for them to
carry out the job.

Yet while many migraine sufferers are aware there is as yet no cure for
migraine, the message has not yet reached them that migraine is a condition
that can be successfully managed and seems to respond well to self-help. Access
to appropriate information is the key, and is one of the important ways in
which occupational health advisers can help.

So what is migraine management? What could you say to someone who asked for
information or advice about migraine?

As mentioned above, the first step is to get an accurate diagnosis. Many
people say they have not visited their doctor about migraine because of the
inaccurate assumption that nothing can be done. But the role of the GP can be
crucial, so patients should be encouraged to work in partnership with their
doctors in tackling their migraine. A patient may also want to consider
visiting a specialist migraine clinic – further information about this is
available from The Migraine Trust. For some sufferers an appointment with a
headache or migraine specialist can be a life-changing experience.

Migraine sufferers are advised to think about when their attacks start or
increase and to consider carefully whether that coincided with any other change
in their lives. It may not necessarily be a negative change such as a stressful
event – any change in the living/working environment or routine could be
significant for a migraine sufferer.

If there is no obvious link, sufferers are advised to keep a migraine diary.
By recording information on a daily basis they may be able to spot a pattern of
when the attacks occur, e.g. do they wake up with their attacks, do the attacks
seem to occur at the weekend or at a particular time of the month?

The exact mechanism of migraine is still unknown, however it appears that
sufferers are particularly susceptible to specific triggers, or a combination
of triggers that are individual to each sufferer. Anything can trigger an
attack if a person is prone to that trigger – some are dietary or hormonal,
others are environmental.

Common triggers include dehydration, low blood sugar levels, stress or
temperature. Identifying an individual’s trigger factors and tackling them can
be the key to successful management of migraine. For example, someone who wakes
up with a migraine attack may be doing so because of a drop in blood sugar
levels during the hours between eating in the evening and waking up in the
morning. By eating a slow-release food such as a banana before going to bed,
the attack may be staved off. There are also factors in the workplace, which,
if properly addressed, can help prevent attacks.

Treating migraine

Another part of successful migraine management is treatment. There is a wide
range of treatments available for migraine, the effectiveness of which will
vary from one individual to another. For some migraine sufferers, medication is
the answer. Treatments are available to abort an attack before it happens or to
relieve the symptoms of pain and nausea if an attack does strike.

Prophylactic treatments may be taken, on a daily basis, by those whose
attacks are so frequent, severe or disruptive to life that they want to prevent
attacks occurring. Finding the right treatment, at the right dosage, in the
right format (e.g. tablet, injection, nasal spray, melt-in-the mouth) can take
time, so it is important that migraine sufferers keep a record of what they use
and accurately report this information to the doctor.

Other treatments such as acupuncture, massage, osteopathy and reflexology
are reported by some migraine sufferers to be effective. Botox, using a
lightmask or magnetic therapy have also been said to give relief to migraine
sufferers. Herbal treatments are another option.

The management techniques outlined above can help reduce the frequency or
severity of attacks. If attacks still occur, ‘migraine-friendly policies’ may
help employees deal with the practicalities of having attacks in the workplace.
For example, early action by a migraine sufferer can help to halt an attack,
hence the importance of migraine sufferers learning to recognise the ‘warning
signs’ or first stages of an attack.

What action is appropriate will vary from one individual to the next but may
include having a short sleep or rest in a dark, quiet room where they will not
be disturbed, or by taking medication. For this reason, migraine sufferers
should always have their medication with them.

Access to information is a crucial part of self-management and that is where
occupational health advisers, along with medical professionals and migraine
information specialists, can help. As well as providing information themselves,
OH advisers can signpost migraineurs to organisations such as The Migraine
Trust which offers support and up-to-date information via its newsletter.

OH departments may also be able to help with practical arrangements such as
initiatives to arrange fast-track appointments to therapists.

The attitude of employers and other employees to migraine can be vital in
encouraging migraine sufferers to manage their condition successfully thereby
maintaining their efficiency and effectiveness at work.

Helen Healy is Support Services Development Manager for The Migraine
Trust, a registered charity that promotes medical research into the causes and
treatment of migraine and provides a full information service, including a
helpline, free literature and regular newsletters.

The Migraine Trust

Tel: 020-7831 4818, Fax: 020-831 5174

Common workplace triggers

– Inadequate or inappropriate
lighting of work area. Strip lighting, spot lights, lights with an electronic
starter or natural light are the most migraine friendly

– Inadequate breaks for eating and drinking so an employee
becomes dehydrated and blood sugar levels drop

– Poor ventilation or a humid atmosphere

– Workstations leading to poor posture

– Stress brought about by tight deadlines, lack of support,
staff shortages, etc

– Fatigue due to inadequate breaks   

– Smells such as smoke, varnish, oil, perfumes

– VDU screens

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