Migraine featured in the media again on Monday 1 July, with an item on Seven Sharp, TVNZ’s current affairs and news show at 7pm.
It started well, with Hilary Barry stating that “migraines are not your typical headache and can’t be treated with a big glass of water and paracetamol” but in a bizarre contradiction of what was just said, the intro visuals led with a big glass of water and a ream of Panadol. Crossed wire somewhere, perhaps?
There has been a recent update that the number of people estimated to have migraine in New Zealand has increased from 642,000 to 753,000.
Then there was an interview with GP Dr John Cameron. Hosts Hilary Barry and Jeremy Wells asked an engaging series of questions, some of which we would have answered differently.
What is a migraine?
Dr Cameron mentioned intense pain, that is one-sided, accompanied by nausea and vomiting, intolerance of light and crazy visual disturbances. He was clear that a migraine attack is not just a headache but a neurological event.
We would add that other differences between migraine and a regular headache include the duration of the pain – from 4 hours to 3 days if not treated and sometimes longer. Migraine pain is worse with movement and limits routine activities. Sensitivity to sound is another major feature and people can also be sensitive to smells and touch. The pain is not always one-sided and only 20-30% of people experience crazy visual disturbances or aura. Some people believe that you can’t have a migraine attack if you don’t have visual disturbances but that is absolutely not true.
It’s also important to understand that people experience migraine differently. It’s not the same for everyone and attacks can vary in duration, severity and character even for the same individual.
What causes them?
Dr Cameron said, “We don’t know.” Then went on to explain that it was something to do with chemicals in the brain and the trigeminal nerve.
It’s true that the exact cause of migraine attacks is not really understood but it involves multiple aspects of the brain and nervous system, interacting with the blood vessels in the brain and inflammatory processes. From a review of the pathophysiology of migraine published in April 2024:
“Migraine is a brain disorder involving both headache and altered sensory, limbic, and homeostatic processing. A complex interplay between neurotransmitter systems, physiologic systems, and pain processing likely occurs.”
Yep, that’s hard to explain in a sentence or two on national TV.
Are they hereditary?
Dr Cameron said, confusingly, “Not so much… a little bit.” He conceded that offspring of parents with migraine were more likely to also have migraine but that the “true genetic process” was not yet found and that there was no genetic link from mother to child (note: men get migraine too, so it could come through the father).
In fact, there are types of migraine that run through families and where causative genes have been definitively established. Familial hemiplegic migraine is a rare type of migraine which causes migraine attacks with paralysis of one side of the body. This is an autosomal dominant genetic condition, which means the condition is passed on to children by a single copy of the causative gene from either parent. If a parent has familial hemiplegic migraine, you have a 50% chance of inheriting it.
The genetics of other forms of migraine is more complex but is vital for the understanding of migraine. Dr Desiree Fernandez, headache specialist and neurologist in Nelson, researched migraine genetics for her MD in the UK. She says, “Migraine is a poly-genetic problem, like epilepsy. There are multiple genes involved.” There has been an explosion of research into migraine genetics in the last decade – more than 180 genomic variants have been implicated in increasing the risk of migraine.
Is there anything that helps prevent them?
Dr Cameron said, “Lifestyle things – being fit, being healthy, being non-smoker – getting plenty of rest.. simple basic things.. seems to work.”
This is the kind of advice that people with migraine find victim-blaming and unhelpful. If you people with migraine would just do your exercise, and manage your stress, eat better and get enough sleep, and stop smoking, then you’d be fine. It’s all your fault, because of your bad behaviours.
It’s true, of course, that all these behaviours are important for a long and healthy life, for all people, not just those with migraine. But these things are not a cure for migraine. For people with disabling migraine disease, they can help but they are not enough. It is absurd to concede that migraine is a neurological disease, caused by dysfunction of neurotransmitters in the brain, and then say it will all be better if you just sort out your lifestyle. Do GPs say this to people with epilepsy or multiple sclerosis or Parkinson’s disease? Why would this be the first piece of advice given to someone with the neurological disease of migraine?
That’s a rhetorical question.
He also missed some very significant factors that could help prevent migraine. Don’t be a woman. Don’t get headaches as a child. Don’t be poor or uneducated. Don’t get depression or anxiety. Don’t have other conditions, such as sleep disorders or obesity. Definitely don’t have parents with migraine.
Dr Cameron briefly mentioned preventive medications but spent more time talking about acute medications, including paracetamol, despite the introduction correctly identifying paracetamol as not being very effective for migraine. Most people with a true migraine attack find paracetamol about as helpful as tying a dead mole to their head. (This was a treatment in medieval times.)
How can you help someone who might be suffering a migraine?
Dr Cameron suggested allowing the person to go into a darkened room, helping them take their medicines and getting medical help if attacks aren’t well controlled. He mentioned newer migraine medicines but nothing about their availability, or lack thereof, in New Zealand or that three of these had just landed on the Pharmac funding list.
Dr Cameron also stated, “If you opened up the head of a person with migraine, you would see no difference in their brain – no difference on MRI or CT… nothing that is different from anyone else’s brain.”
Here are some studies that directly contradict this statement:
- Migraine is associated with an increased risk of deep white matter lesions, subclinical posterior circulation infarcts and brain iron accumulation: the population-based MRI CAMERA study
- Structural and Functional Brain Changes in Migraine
- What imaging has revealed about migraine and chronic migraine
- Insights into migraine attacks from neuroimaging
That’s just a small selection. Researchers have clearly demonstrated changes in the brain both during a migraine attack and when comparing the brains of people with migraine to people without.
There is so much more that could be said about how to help someone with a migraine attack. Educate yourself about migraine. Find out what this person needs, which might be different from what another person with migraine needs. Encourage workplaces to be supportive. Tackle the stigma associated with migraine. Make sure they are getting the best possible treatment from health professionals – not something a GP would say, but we know from our own research that migraine health care is not always optimal.
Feedback from the migraine community on this segment from Seven Sharp was “it was a wasted opportunity to educate people about migraines”, “very poor coverage of a medical disability” and “disappointing”. We were disappointed that we weren’t invited to participate in the conversation. We hope that next time they choose to talk to people with lived experience of migraine, experts who are up-to-date with the latest migraine research and those who have a deeper understanding of how to support people with migraine.
References
Karsan N. Pathophysiology of Migraine. Continuum (Minneap Minn). 2024 Apr 1;30(2):325-343. doi: 10.1212/CON.0000000000001412
Sutherland HG, Jenkins B, Griffiths LR. Genetics of migraine: complexity, implications, and potential clinical applications. Lancet Neurol. 2024 Apr;23(4):429-446. doi: 10.1016/S1474-4422(24)00026-7
Grangeon, L., Lange, K.S., Waliszewska-Prosół, M. et al. Genetics of migraine: where are we now?. J Headache Pain 24, 12 (2023). https://doi.org/10.1186/s10194-023-01547-8
Kim J, Chu MK. Genome-Wide Architecture of East Asian Patients With Migraine: A Genome-Wide Association Study Based on Familial History. J Clin Neurol. 2024 Jul;20(4):351-352. https://doi.org/10.3988/jcn.2024.0241
Kruit MC, van Buchem MA, Launer LJ, Terwindt GM, Ferrari MD. Migraine is associated with an increased risk of deep white matter lesions, subclinical posterior circulation infarcts and brain iron accumulation: the population-based MRI CAMERA study. Cephalalgia. 2010 Feb;30(2):129-36. doi: 10.1111/j.1468-2982.2009.01904.x
Kruit, M. C. (2010, January 20). Migraine and brain lesions. Data from the population-based CAMERA Study. Department of Radiology, Faculty of Medicine, Leiden University Medical Center (LUMC), Leiden University. Retrieved from https://hdl.handle.net/1887/14585
Ashina, S., Bentivegna, E., Martelletti, P. et al. Structural and Functional Brain Changes in Migraine. Pain Ther 10, 211–223 (2021). https://doi.org/10.1007/s40122-021-00240-5
Messina R, Filippi M. What imaging has revealed about migraine and chronic migraine. Handb Clin Neurol. 2023;198:105-116. doi: 10.1016/B978-0-12-823356-6.00011-1.
Messina R, Rocca MA, Goadsby PJ, Filippi M. Insights into migraine attacks from neuroimaging. Lancet Neurol. 2023 Sep;22(9):834-846. doi: 10.1016/S1474-4422(23)00152-7
