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Migraine: A Headache Specialist’s Perspective by Dr Kevin Shields, Consultant Neurologist

When I tell colleagues that I run a specialist headache clinic I am often met with a wry smile. I have always been perplexed by this curious reaction, as headache is one of the most common neurological complaints encountered in daily practice. Getting the management right can make a big difference in quality of life to many patients. This is because headache disorders represent a huge burden in terms of disability and lost economic productivity. Migraine may affect up to 1 in 6 of the population at some stage while potentially 4% of the population suffer from chronic daily headache. Analgesia overuse is a major problem and many people who would benefit from headache preventive treatments are not receiving them. In this article I am going to briefly cover some of the issues I encounter in managing migraine, one of the leading causes of neurology referrals.


Genetic and Environmental Influences

Patients often ask me why they have migraine. For the majority it is something they were born with. If you dig deeply enough there is often a history of a first-degree relative who also suffered from migraine and that can help with the diagnosis. There may also be a history of motion sickness or unexplained abdominal pain in childhood. Migraine has a genetic basis and it probably represents the end product of a complex interaction between a number of genes and the environment. Individual genes have been identified as causing hemiplegic migraine but this represents only a small proportion of the total number of people with migraine. The role that the environment plays in triggering migraine is poorly understood. As a general rule people who have migraine prefer routine. Change seems to be a trigger for attacks. A regular sleep pattern is important – too much sleep can be just as much of a trigger as too little. Hunger rather than exclusion of specific food groups in the diet per se seems to be more of a provocation. Hormonal fluctuations as part of the menstrual cycle or menopause may also be a significant determinant in females. Common sense behavior modification may therefore help with preventing some headaches. If a reliable trigger can be identified then it is best to avoid it if possible, but generally speaking I find that dramatic life-style changes are neither warranted nor particularly beneficial.


Migraine Aura

Migraine aura can often be a source of diagnostic confusion. Aura is experienced by a minority of migraineurs, perhaps only 15% of patients. It is important because though relatively uncommon, it may trigger unnecessary investigations for stroke. The history is crucial to avoid misdiagnosis. There is good evidence to suggest that aura corresponds to the experimental phenomenon of cortical spreading depression. Most commonly it manifests as a visual disturbance such as fortification spectra or a shimmering scotoma. It can also cause motor, sensory or speech symptoms depending on the area of cortex involved. Aura typically precedes the onset of the headache but this is not always the case. Isolated aura is well recognized and is perhaps more common in older males. Aura symptoms evolve slowly over minutes unlike the sudden instantaneous onset experienced during an ischaemic event. They may last for some time, but often no more than an hour, before they resolve. Once again this is often a gradual process. Patients often feel tired and “washed-out” following an isolated aura and this can be an additional clue in the history.



The treatment of migraine can be divided into two arms: a) acute treatment to alleviate the immediate pain, b) prophylactic to reduce the severity and number of attacks.


Acute Treatment

Acute treatment may involve a combination of medications, depending on the severity and constellation of symptoms. The important thing is to treat the pain aggressively from its onset. Leaving treatment until the pain becomes intolerable is not a good strategy. It is my experience that this approach only allows the pain to become more entrenched and difficult to treat. Simple analgesics such as paracetamol, NSAIDs or codeine can all be used and may be adequate for many patients. Patients should also be offered an anti-emetic as gastric emptying is delayed during a migraine attack.

Triptans can be an invaluable acute treatment option for some, though not all, patients. Seven triptans are available. Each has its own particular characteristics in terms of speed of action, efficacy, side effect profile and risk of headache recurrence. They also come in a variety of formulations e.g. an intranasal sprays can be helpful if a rapid speed of onset is required or early onset of vomiting prevents enteric absorption. A given triptan should be used to treat at least three attacks before deciding if it is effective. Failure to respond to a triptan does not mean that the entire class will be ineffective. It is always worthwhile trying an alternative to see if it is better tolerated or more efficacious. The triptans can have unpleasant side effects including chest/neck tightness or excessive sedation. They are contraindicated if there is a history of coronary artery disease, coronary vasospasm or uncontrolled hypertension. Later generation triptans such as almotriptan may be better tolerated but they tend to be more expensive than sumatriptan. It is worth remembering that a triptan can be taken in combination with analgesics, especially NSAIDs. The combination of the two drugs can be synergistic. Some patients may be able to sense at the onset of a migraine whether or not it is going to be a severe attack. If so, I would suggest they take a triptan and a NSAID such as naproxen (provided it is not contra-indicated) together in an effort to terminate the attack.

A novel recent development in the acute management of migraine is the use of neurostimulator devices. Transcranial magnetic (TMS) and vagal nerve stimulation (VNS) are two methods of neuromodulation that are non-invasive and generally well tolerated. Their precise mechanism of action is not clear. TMS delivers magnetic pulses to the occipital cortex using a hand–held device while VNS delivers electrical pulses to the vagal nerve in the neck.


Analgesic and Triptan Overuse Headache

Overuse of acute treatments is a serious and common problem. Any analgesic – even paracetamol – will make migraine worse if used too frequently. Triptans are even more prone to causing over-use headache if taken excessively. Patients may suffer a “double hit” as overuse of acute treatments will not only make migraines worse, but may also block the action of prophylactic treatments. What however constitutes overuse? I consider consumption of painkillers on more than 2 days out of each week, or triptans on more than 6 days per month is too much. Patients will have to stop their acute treatments for at least 4-6 weeks for the effects of overuse to wear off. They may experience a rebound worsening of their headache in that time but there are ways of dealing with this. It is very important to ask specifically about this issue and sometimes a bit of probing is required. Patients may be reluctant to accept this and it often needs to be addressed gently but firmly. It must be remembered that some people have come to rely on their acute treatments. Being told to stop them – even temporarily – because they are making their headaches worse is anathema to them. It is important to stress that they will not improve until the overuse stops. It may help to point out that the very act of acute treatment withdrawal on its own may lead to a 50% reduction in headache days in 50% of patients.


Prophylactic treatments

I generally offer a prophylactic treatment to patients when they suffer four or more debilitating headache days per month. There are numerous treatment options but there are some general principles that must be observed. Firstly, prophylactic treatments may not work quickly. A patient may need to be on an effective dose of a prophylactic agent for up to four months before deciding it is working or not. There are therefore no quick fixes. They are usually started at a low dose but then it must be increased until either:

a) the maximum dose is reached

b) side effects prevent further dose increases

c) the headaches improve


Dose increases should be made every two to four weeks depending on tolerability, but one has to be flexible. Some patients may need to go more slowly but there is little point in maintaining a patient on a low dose if their headaches are not improving. If they get to an effective dose and are maintained on this for 3-4 months without improvement (and they are not overusing acute treatments) then they should be moved on to another treatment. With the exception of the CGRP-antagonists currently in development, no migraine prophylactic treatment was specifically designed for this purpose. Serendipity has played a part and this sometimes needs to be explained to patients. Some may be concerned to learn that they are receiving an anti-depressant or anti-epileptic medication and explaining this early on avoids confusion. Treatments range from Vitamin B2 to botulinum toxin but there is no “wonder-drug”. It may entail a process of trial and error before a preventive is found for an individual that is both tolerable and effective.



Migraine is a very common, debilitating but eminently treatable condition. Acute treatment often depends on using a combination of drugs to bring the pain and other symptoms under control as quickly as possible. Acute treatments may be a doubled edged sword however, and if used too frequently will ultimately lead to a worsening of headache. In such cases prophylactic treatments should be prescribed. Remember that there are a wide variety of prophylactic options but they may not work quickly. Perseverance is required and the dose should be increased if there is no response. It may involve a process of trial and error to find a drug that works and is tolerable. If it becomes apparent that a drug is ineffective, move on to another. It is worth the effort as getting it right can make a big difference to patient’s quality of life.



Dr Kevin Shields currently holds private specialist headache clinics at the Queen Square Private Consulting Rooms (23 Queen Square, WC1N 3AR). If you would like to make an appointment, please contact the Queen Square Private Consulting Rooms on 0203 448 8948.


© Dr Kevin G. Shields 2015.


As QS Enterprises celebrates its 30th anniversary, we caught up with Queen Square chairman of the board, Mr Graham Faulkner.

Q: Hello Graham, thank you for taking the time to speak with us. Please could you tell us a little about your role at Queen Square?

A: I am now the chairman of the board but I’ve been a director with QSE for three or four years. I got to know Anthony Wheatley, the previous chairman, when I was the chief executive of the Epilepsy Society. Anthony was the chairman there as well and we worked together for a number of years. When he was coming to the end of his time at QSE, he got me involved as a board member then I took over as chairman when he stepped down.

Q: What inspired you to work with QS Enterprises?
A: It’s a bit of a cliché but I think what the company does is a tremendous example of private practice and a benefit to the NHS. I thought the way the company is operated, making money through private practice for the benefit of the NHS, is a fantastic model of care.

Q: How has QS Enterprises developed over the last 30 years?
A: Queen Square started just doing optical scans at the National Hospital but then it developed with the heart hospital as well. In the time I’ve been there, we’ve been looking at other ways to bring the QSE model to other areas of activity. At the moment we are discussing new developments to increase the role of QSE both with UCLH and elsewhere in London.

Q: What else can you tell us about upcoming developments at QS Enterprises?

A: Private practice within the NHS is becoming more common and I know UCLH are certainly keen to see the development of private medicine within the hospital environment. We’ve been talking about the role that QSE might have to help with that. We have a proven track record of dealing with private patients, which we think could be helpful to the hospitals on a wider scale. Our chief executive Jodee is going to be doing some work at the Nuffield ward in Queen Square over the next couple of months to look at how we might be able to bring the QSE approach to things within the hospital itself. This approach is gift-aiding the profits back to the hospital via the charitable trustees who then decide how that money’s going to be passed on to the hospital to improve facilities, perhaps to do things that wouldn’t be possible without that additional funding.

Q: With public suspicion of privitisation in the NHS, how does QSE communicate its benefit to the health service?
A: I think QSE is the acceptable face of privitisation. We’re working within the NHS envelope. The financial benefit of private practice is going to be fed back into the NHS to improve services so it’s not as though we are taking things out. It’s working alongside our colleagues at the NHS to benefit the patients, both private and NHS.

Q: What is QS Enterprises’ greatest achievement in your opinion?

A: The sheer amount of money that’s been made by QSE that has been channeled back into the hospital is probably in excess of £25m. This has funded things that wouldn’t have been possible without those charitable funds. A lot of the money for the new NMCCU unit came from QSE so it could be bought earlier in development than would otherwise have been the case. I think the sheer amount of money that’s been pumped into the NHS, long before I was involved, is a fantastic achievement.

Q: What challenges do you see QSE tackling in future?
A: We face the same challenges as the rest of the NHS in terms of funding. There will always be competition out there with other private providers within the health sector. We need to continue to generate the financial return we’ve made up until now.

This month we caught up with Dr Fergus Robertson, Interventional Neuroradiology Consultant at the National Hospital for Neurology and Neurosurgery and Great Ormond Street Hospital for Children, to talk about the work of his neurovascular group. Together with his team, he has been developing new techniques and conducting pioneering research into the treatment a number of complicated conditions.

Q: Thank you for speaking with us Dr Robertson. Please could you tell us a little about about your areas of expertise?

Dr Fergus Robertson: I’m partly a diagnostic radiologist, reporting MRI and CT scans of the nervous system. The rest of my time is spent treating vascular problems of the brain and spine. Often, patients arrive as emergencies to the hospital with brain haemorrhages or strokes but I also treat many with longstanding problems in a more elective, planned way.

Q: How have the facilities at Queen Square Imaging Centre aided your research?

FR: My work is precise, challenging and demands the highest quality imaging when planning treatments. With its state-of-the-art MRI scanner and specialist neuroimaging radiographers, the centre offers a fantastic image quality across the board. From my perspective, the spine and blood vessel imaging really is some of the best I’ve seen anywhere.

Another area where the QSIC staff excel is in their innovation. If I need something new or different, they’ll happily invest time and effort to deliver an imaging solution.

An example of this is the recent introduction of a new MR imaging sequence which can now demonstrate flow through the tiny blood vessels around the spinal cord. These vessels are surrounded by bone and have, in the past, been very difficult to image without directly injecting them in the angiography suite. Now we are able to see them on a non-invasive MRI study, reducing risk to the patient.

Q: How has the work of your neurovascular group been helping patients?

FR: Traditionally, patients with neurovascular problems were treated by neurosurgeons via open surgical operations. But over the last decade we have seen increases in endovascular treatments by neuroradiologists in the angiography suite.

One particular area where there has been a dramatic shift is in the treatment of cerebral aneurysms. These small swellings on cerebral blood vessels may rupture, often causing life-threatening brain haemorrhage. In the past these were predominantly treated with an open operation to place a metal clip across the aneurysm neck. Although the procedure is usually successful, it is lengthy and dangerous particularly in unstable patients.

Now with modern technology  a small tube can be passed via a small nick in the groin, through the blood vessels and into the brain under X ray guidance to pack the aneurysm with tiny platinum coils and prevent further bleeding. These endovascular procedures are generally less invasive, quicker and yield better outcomes than traditional surgery. Now 90 per cent of aneurysm patients at the National Hospital for Neurology and Neurosurgery are treated by the radiology team.

Q: What other areas of work does the group focus on?

FR: We have led the development of new stent treatments for more complicated aneurysms that were traditionally considered untreatable through endovascular techniques, either in view of their size or shape.

We treat a number of other vascular problems - arteriovenous malformations of the brain and spinal cord and also reduce the blood supply to tumours (embolisation) of the brain and spine, allowing surgeons to remove them more rapidly and with less blood loss.

Perhaps the largest growth area is the treatment of patients with stroke, one of the commonest problems in the UK. Many patients come to hospital with a blocked brain artery which leaves them with weakness, disrupted speech, loss of balance or other problems. Those who reach hospital in time are treated with clot-busting drugs. However, if these fail to open the blockage  or if they cannot be administered, an increasing number of patients are being transferred to the angiography suite at Queen Square where we are now able to open the blockage mechanically by removing the clot through the blood vessels. There are real challenges in selecting which patients are likely to benefit from treatment and in getting the blood vessel open before the brain is permanently damaged.

In addition we’re also able to treat patients who experience symptoms from narrowed blood vessels in the head (intracranial stenosis) by opening up the vessel with balloons or stents, also delivered via tubes from the groin. This helps to restore arterial blood flow to areas of the brain and prevent strokes. We’re also helping people experiencing venous pressure problems in the head (idiopathic intracranial hypertension) by opening up narrowed veins improving drainage of the brain and preventing disabling headaches and blindness.

We also work closely with our spinal surgeons performing minimally invasive, image-guided surgical procedures, such as vertebroplasty and kyphoplasty, in which we inject cement to strengthen diseased areas of the spine.

Q: What is the neurovascular group doing to share its work with other medical professionals and improve best practice in the field?

We have an active research programme that has matured over the last ten years to match a workload which has grown from a handful of cases in the early 2000s to nearly 500 procedures now carried out at Queen Square and Great Ormond Street each year. We were finally able to expand our consultant numbers in 2011 to cope with the clinical workload, allowing a greater focus on research themes. We regularly present our experiences at local, national and international meetings.

We operate in a high risk field and work continuously to improve the quality and safety of our service. We have an active, rolling program of audit and neuroradiology leads the National Hospital in this field. With the ongoing restructuring of Neurosurgical services across north London we are working more closely than ever with our colleagues at linked trusts such as the Royal Free Hospital, and Bart’s and the London.

I work in an exciting and rapidly-evolving field with constant opportunities to develop and improve our service. The first class support provided by all the staff at Queen Square is integral to our ongoing success.

On Tuesday 7th October Queen Square Imaging Centre welcomed GPs to its educational evening at the National Hospital for Neurology and Neurosurgery.

This month we caught up with Mr Andrew McEvoy, world-leading Consultant Neurosurgeon at The National Hospital for Neurology (NHNN) and Neurosurgery and Institute of Neurology (ION) in London. Mr McEvoy has been referring to Queen Square Imagine Centre for eight years and uses QS Enterprises' new Private Consulting Rooms.

Q: Thank you for speaking with us Mr McEvoy. Please could you tell us a little about about your areas of expertise?

A: I have the largest adult epilepsy surgical practice in the UK and do a huge amount of brain tumour surgery. I actually do the largest number of ‘awake’ craniotomies in the UK - for surgeries like this, the high-level of work done at Queen Square Imaging Centre (QSIC) is absolutely essential. Although my expertise is in brain tumours and epilepsy I also do more general neurosurgical work on spines, backs and the like.

Q: What keeps you coming back to Queen Square Imaging Centre?

A: I keep coming back to the QSIC for a number of reasons. One is that geographically it is obviously very helpful as it is located in the same square as me. Another is its excellence. If you were to ask anyone in the UK where the experts in neurosurgical and neurological illness are, then they would say here in Queen Square. The third is the quality of the staff doing the reporting - they are second to none. They are also extremely responsive and, especially when working in the private sector, people are likely to turn up and ask for a scan that morning and want the results immediately. The staff are very good at facilitating that and getting you a report very quickly.

The imaging centre’s facilities are also superb, as it has forms of private imaging that others don’t, such as functional imaging and diffusion tensor imaging.

Q: Why do you use Queen Square’s new Private Consulting Rooms?

A: I use the PCRs on a Tuesday morning. They are excellent - a really first class facility. They are well managed with good secretarial support. Patients have a lot of choice with private practices and sometimes as doctors you forget the little things that make a difference. I know where I would go to seek the most expert opinion, but patients look at other factors such as whether they are given a coffee or how quickly the staff answer the phone. I think sometimes doctors forget that and think, “but I’m the best”, forgetting that the patient does actually have a choice and their decision depends on the facilities too.

Q: How much of a role do you think patients play in the decision of which scanning facilities they will be referred to?

A: A lot of clinicians have been attracted to the new PCRs because of the work that comes from being associated with Queen Square. When someone is diagnosed with something like a brain tumour, the first thing they will do is search the internet and many of the people talking and writing about neurology and neurosurgery are at Queen Square. The patient will then seek a second opinion or a consultation with these people which will of course generate more imaging work for QSIC as they will send them to the people they trust to get the imaging done.

Q: You spoke at the second of QSIC’s educational events for GPs, which was held in February, how do you think GPs benefit from attending these events?

A: I don’t think GPs appreciate how much more effective surgery is at treating certain forms of epilepsy when compared to drugs. And often GPs worry too much about the perceived risks without considering the advantages. With refractory epilepsy there is a 70-80 per cent chance of curing patients with surgery, however by giving the patient another drug, the chances of  a cure are more like 3-4 per cent.

The key is for the surgeon to select patients who will benefit from surgery well and to have a good multidisciplinary team.

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