Threshold Theory

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Is there any way to prevent or predict a migraine attack?
Many migraineurs find that over time they can begin to identify factors and or situations which seem to predict or trigger an attack. While it is usually the final trigger that is most obvious, underlying triggers are equally important. For example, if you drink a glass of wine on its own you do not always have an attack of migraine. However, if you drink the same glass of wine on an empty stomach, have had a particularly stressful day at work and have drunk lots of coffee to keep going - an attack is more likely. All those triggers are equally important - stress, coffee, lack of food and the glass of wine. Dealing with any of your triggers may help you have fewer attacks; trying to identify triggers will be time consuming but worthwhile.

The most common triggers are:

  • Lack of food - missing meals (especially breakfast), snack lunches or sugary snacks instead of a proper meal can all result in an eventual drop in blood sugar which can lead to an attack. This is particularly important for children who use up a lot of energy and are growing quickly.
  • Specific foods - a few people notice that certain foods seem to trigger an attack. The most common foods are chocolate, alcohol, dairy foods and citrus fruits.
  • Changes in sleeping pattern - too much and too little sleep - a Saturday morning ‘lie in’ or a run of late nights.
  • Hormonal changes in women - migraine attacks may be made worse by the contraceptive pill; it should not be taken if you have attacks with an ‘aura’.
  • Head and neck pain - muscle tension affecting the neck and shoulder muscles may be a trigger, particularly if you are hunched over a desk or VDU all day or do a lot of driving. Simple neck exercises and awareness of the way you sit and stand or even regular massage can help.
  • In a few cases, migraine can be aggravated by specific dental problems.
  • Environmental changes - bright lights, loud noise, strong smells, travelling etc. can all trigger attacks in some people.
  • Exercise - regular exercise, without overdoing it, can help prevent migraine attacks but exercise done irregularly when you are unfit can trigger an attack.
  • Stress - often in the period of time after the stress including the weekend after a stressful week or the first few days of a holiday.

1. Try asking friends and relatives if they notice any changes in you before the migraine attack starts. Look out for any differences in mood or behaviour in the 24 hours before the headache.
2. Keep a diary. Several triggers are necessary which when added together can result in an attack as the ‘threshold’ is crossed. Sometimes, the attack can be prevented by removing as many of these triggers as possible and keeping below the ‘threshold’. In the diary note:

The date.   How long the attack lasted.
 The day of the week.  What treatment was taken.
 The time the attack started. What time it was taken.
 What symptoms were present and their timing in relation to the headache. What trigger factors were present or had built up.

3. Identify triggers. After you have recorded several attacks in this way, you should have a better idea of your triggers. You can then divide the triggers into two groups - those which you can do something about (missing meals, drinking red wine) and those which are out of your control (menstrual cycle, travelling).
Try dealing with the triggers within your control. Cut out any specific triggers that you suspect, one at time. If you try to deal with too many all at once, you can’t be certain which are most relevant to you. If you know that you have a particularly difficult period at work, be extra careful to make sure you don’t miss meals or have too many late nights. Most people find it difficult to ‘relax’, but an active hobby (playing sports, cycling to work, walking the dog) can help to relieve stress. Hormones are only an additional trigger. Hormonal changes are difficult to control, but attacks may be helped by eating small, frequent meals, avoiding sugary snacks and alcohol, getting adequate sleep etc. in the week or ten days before your period. The diary can help point out less obvious trigger factors. If you find that most of your attacks start late morning or late afternoon, it may be lack of food that is the problem and you can try eating a mid-morning or mid afternoon snack. Attacks on waking may be due to sleeping in, neck problems or again, too long since food (try a late night snack).
4. Take treatment early. During a migraine attack, the body systems shut down and drugs are not easily absorbed. It is important to take migraine treatment without delay as early as possible in a migraine attack. This means that simple treatment can be effective.
5. Carry a dose of treatment about with you. Drugs can be taken without delay if you have them on you. Ideally keep a couple of biscuits and a small carton of drink with you so that you are not taking the tablets on an empty stomach.
But even simple drugs bought from the chemist for migraine may be enough to abort at attack if taken early. 

‘Alternative’ medicine can often help the migraineur. Those with neck tension or back problems may be helped by simple hot or cold pads put on the back of the neck or where it hurts most. You may benefit from a course of treatment of osteopathy, acupuncture or massage. Postural problems may be helped by the Alexander Technique. If stress is a problem, you could try biofeedback or relaxation techniques. Herbs, such as feverfew, have helped some people but they should be used under guidance as they are still drugs. Feverfew can be taken in any form (dried or fresh leaves, tablets etc.) and can take up to 6 weeks before taking effect. One suggested dose is 25mg daily increasing up to 200mg if necessary. Some people notice that they get mouth ulcers or stomach upsets and feverfew should not be taken in pregnancy.

Always remember headaches can also be a symptom of an underlying medical problem. It is very important that you see your doctor to make sure of the correct diagnosis of your headache, particularly if you notice any changes in the pattern of headaches or the symptoms, even if a previous diagnosis of migraine has been made.

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