Headaches are one of the most frequent reasons people take medication or see a healthcare specialist. But it can be hard to know when you should seek medical attention and how to find the right providers. To determine the best course of action, ask yourself the following questions:

• Does headache interfere with your life, including work, school, family, or social activities?
  Have your headaches become more frequent recently or more severe?
  Are over-the-counter medications no longer effective, or are you concerned you might be taking too much?
  Have you gone to the emergency department for a headache?

If you answered “yes” to any of the questions, it’s time to seek medical attention. A good place to start is by talking to your primary care provider (PCP). They may be able to get the ball rolling, but they’ll probably give you a referral to a neurologist or headache specialist. A headache specialist is a physician, often a neurologist or anesthesiologist, who has expertise in the diagnosis and treatment of head pain disorders that comes from an extra year of training, called a fellowship.

A specialist can best deal with headaches that are severe, incapacitating, or resistant to treatment.

A headache specialist may be listed as “UCNS certified;” you may want to check that they are. If so, it means the United Council for Neurologic Subspecialties (UCNS), an organization that provides accreditation to fellowship programs and certification to individual physicians in neurologic subspecialties, including headache medicine, has certified the doctor is sufficiently trained to be an expert in the field.

“UCNS certified” headache specialists may be neurologists or any other type of physician who has expertise in the treatment of headache disorders. All doctors who’ve taken and passed the UCNS certification exam are legally allowed to call themselves “headache specialists.”

So, other than a PCP referral, how do you find a headache specialist, UCNS certified or not?

The most common source of referrals to any type of healthcare provider is through word of mouth from satisfied patients. Look for testimonials from headache clinics, or ask a physician who they’d go to if they needed to. Oftentimes, that makes for the best fit.

Another way is through your insurance company’s website, which may allow you to search for a headache specialist. Or, you can call their referral service to get more information.

The American Migraine Foundation website has a page called “Find a Healthcare Professional,” where users can search for a headache specialist by name, state, city, ZIP code, distance from your current location, and several other categories.

The UCNS website contains a list of all their certified headache specialists. One caveat, though, is that some of the location information may be outdated, because the doctors were added to the list in the year they took the certification exam, which in some cases goes back as far as 2006.

Depending on where you live, it may be hard to find a UCNS certified headache specialist, as there are only 564 UCNS headache specialists in the entire US. In fact, six states have no headache specialists: Alaska, Delaware, Montana, North Dakota, South Carolina, and Wyoming, and eight states have only one for the entire state: Arkansas, Idaho, Kansas, Mississippi, New Mexico, Oregon, South Dakota, and Vermont.

Finally, if you do find a headache specialist, they may recommend that you participate in a headache program or receive inpatient care to treat your headaches. While your knee-jerk reaction may be an immediate “no,” these approaches can be particularly helpful if you deal with very severe and treatment-refractory headache.

Most specialists also combine pharmacological treatments with scientifically proven non-pharmacologic treatments that include biofeedback, acupuncture, relaxation training, and cognitive behavioral therapy (CBT) for headache.

New daily persistent headache (NDPH) is another type of primary chronic headache disorder. The symptoms start very suddenly and remain moderate-to-severe 24/7/365. NDPH generally only affects your head. However, when it comes with migraine-like features, you may experience light sensitivity, sound sensitivity, vertigo, nausea, and/or vomiting. The pain may occur only on one side of the head, both sides, or move between one side and the other.

Because the symptoms last for months or years, NDPH can greatly impact your daily life. And, unfortunately, most cases also prove difficult to treat.

NDPH has two main forms:

• Primary NDPH: “idiopathic” NDPH, meaning there’s no identifiable cause
  Secondary NDPH: happens in connection with or because of another condition or disease, usually a viral illness

NDPH can affect anyone, but it’s more common in women and those assigned female at birth. It’s also prevalent in children and teenagers, especially between ages 10-18, but you can still develop it no matter what your age.

There’s been only limited research on how common the disorder is, but the available data indicate it’s not that common. The best available studies come from Norway and Spain, and they suggest it occurs in 30-100 out of every 100,000 people.

Causes of NDPH

As we’ve mentioned, experts don’t know exactly why NDPH happens. However, they suspect stress and viral or bacterial infections may play a part in the process. People who develop NDPH often report going through stressful life events before the pain hit. People also report developing NDPH after medical events like having an infection, but there aren’t enough data to confirm if these events  either cause or contribute to NDPH or if they’re just in the wrong place at the wrong time.

What data do exist show that people often develop NDPH while they have either a viral or bacterial infection, including:

• Epstein-Barr virus (a key cause of mononucleosis)
  Salmonella
  E. coli
  Dengue fever
  COVID-19
  Meningitis or encephalitis

NDPH can also emerge as a secondary effect of another medical condition that directly affects your brain or central nervous system. Examples include:

• Subarachnoid hemorrhage (bleeding into the subarachnoid space; often begins suddenly with a “thunderclap headache”)
  Low cerebrospinal fluid (CSF) pressure, usually from a CSF leak
  High CSF pressure that causes a headache
  Post-injury headache (concussion or traumatic brain injury)
  Medication overuse headache (especially for treating headaches or migraine attacks)

Symptoms of NDPH

NDPH symptoms aren’t much different from the other primary headache types, but some happen in an unusual way.

• They’re long lasting: to diagnose, you have to have the headache for at least three months
  The pain is constant: nonstop pain once it starts
  The pain is usually moderate-to-severe: potential to severely disrupt a person’s life and activities

There’s another symptom, but it’s unique to this headache disorder in particular — you remember exactly when the pain started. According to the International Headache Society’s official guidelines, the International Classification of Headache Disorders, a doctor can only diagnose you with NDPH if you can remember exactly when the headache started, including where you were and what you were doing.

Headaches that occur with NDPH can appear just like standard tension-type headaches (TTHs), migraine, or it may have features of both. TTH symptoms can include:

• Pain on both sides of your head
  Pain feels like pressure or a vise around your head
  Pain doesn’t get worse depending on what you’re doing

Migraine symptoms can include:

• Pain on one side of your head
  Pain that throbs, pulses, or pounds
• Sensitivity to light, sound, and smells
  Nausea and vomiting
  Vertigo
  Visual auras
• Pain that worsens with activity

Of course, no two attacks are identical, so which symptoms you get, or how many, depend on your individual physiology and circumstances.

Diagnosing and treating NDPH

No tests currently exist to directly diagnose NDPH. Instead, diagnosis focuses on ruling out other medical conditions that could cause similar symptoms, especially dangerous or life-threatening ones. Common tests include:

• Computerized tomography (CT) scan
  Magnetic resonance imaging (MRI) scan
  Lumbar puncture (spinal tap)
  Blood tests to look for signs of infection

Depending on your health history and the symptoms you present with, doctors may also recommend additional tests to rule out other conditions.

Once you’ve been diagnosed, you hit another bump in the road, as NDPH can be difficult to treat. Cases with migraine-like symptoms are usually easier than those with TTH symptoms, which are more likely to be treatment-resistant. Time, too, plays a role. NDPH is more likely to respond more effectively to treatment when you get to it early in its progression rather than years after symptoms begin.

Medications are usually the primary means to treat NDPH. However, finding a medication that’s right for you and can relieve the symptoms is often difficult. Some possible medications include:

• Antidepressants: amitriptyline, nortriptyline, and venlafaxine, which also treat pain disorders, can sometimes help
  Antiseizure medications: gabapentin or topiramate
  Botulinum toxin injections (brand name Botox®): blocks nerve signals, including pain signals
  Migraine preventive medications: include beta-blockers like propranolol and angiotensin-II receptor blockers like candesartan
  Experimental anesthetic/antidepressants: ketamine, an anesthetic also used for treatment-resistant depression, may help

All of these medications come with side effects or complications, so make sure you understand why your doctor recommends any one in particular to treat you. You may need to play around with the dose to find a level that suits your specific needs while minimizing adverse effects.

You can find more information about this type of headache on the American Migraine Foundation website.

 

A cluster headache is different from both tension-type headaches and migraine. With this type of headache, you experience pain on one side of your head that can last anywhere from 15 minutes up to three hours, then it starts all over again, up to about eight times a day.

The pain occurs daily for weeks to months, most commonly popping up at the same time every day. The entire cycle — eight times a day for weeks or months — is called an attack. After such an attack, the pain goes suddenly into remission, and it may be months or even years before you experience another cluster.

However, about 1 in 5 people with cluster headaches have a chronic form and may never experience a remission.

Cluster headaches aren’t common, only affecting about 1 out of every 100,000 people.

Symptoms of cluster headaches

Symptoms of cluster headaches other than pain happen on the same side as the pain and include:

• Watery eye
  Red eye
  Droopy eyelid
  Runny or stuffy nostril
  Flushing or sweating

The location of your head pain can vary, but it shows up in one of the following regions:

• Orbital: behind your eye or near your temple
  Supraorbital: above your eye, near your forehead
  Temporal: side of your head behind your ear

When symptoms set in, it usually only takes five to 10 minutes for them to reach their worst.

Many people report that these excruciating headaches wake them up one or two hours after going to bed, and they feel more severe than those during the day. Because of the timing, they’re sometimes called “alarm clock headaches.”

Perhaps more appropriately, they’re often called “suicide headaches” because the pain is so severe and unrelenting people feel like dying must be better. If you or someone you know is feeling this way, call the Suicide and Crisis Hotline (in the US) at 988.

Causes of cluster headaches

Researchers don’t know the exact cause of cluster headaches, but studies have shown that they could relate to your body releasing either histamine (a chemical involved in allergy response) or serotonin (a neurotransmitter) near the trigeminal nerve that sends sensations between your face and brain.

In addition, studies indicate that cluster headaches may happen if there’s dysfunction in the hypothalamus, the region of your brain responsible for keeping your body in a steady state and setting your internal clock to respond to the amount of sunlight you receive. The hypothalamus connection may, for many people, explain the link between the start of headaches and the change of seasons, periods when the amount of sunlight changes along with the weather.

Studies are ongoing to pin down the underlying cause more precisely.

Cluster headache triggers

Triggers are things that causes your symptoms to start, even if you’ve been in remission for a while. Specific triggers during a cluster headache cycle vary from one individual to the next but may include:

• Tobacco, alcohol, and other substance use
  Bright lights
  Hot temperatures
  Nitrites in food (preserved meats)
  Certain medications (like sildenafil)

Triggers can also launch a new cycle of attacks after a period of no symptoms.

Diagnosing and treating cluster headaches

Much like migraine, cluster headaches are usually diagnosed by a neurologist or headache specialist after performing physical and neurological exams and combining the information with imaging results. It helps if you see the doctor while you’re in an attack cycle, so they can see the signs and symptoms in real time and understand how they affect you.

There are two types of medications that your doctor might recommend:

Prevention medications

Some medications can shorten a headache cycle and make each of the headaches less severe. The most common ones include those that treat allergies, depression, blood pressure, and seizures. Also, Emgality® is not only an FDA-approved preventive therapy for migraine, but it’s also been approved for cluster headaches. It’s a monoclonal antibody that targets calcitonin gene-related peptide (CGRP), a known player in the pain cascade.

Pain management medications

When a headache occurs, you may experience other symptoms along with the pain; pain management drugs, like triptan medicines (the injectable form of sumatriptan), anti-inflammatory medicines (steroids like prednisone), or dihydroergotamine injections (can’t be taken with sumatriptan), can deal with these along with the pain.

Some people find relief by breathing in 100% oxygen during an attack.

According to Dr. Joanna Kempner at the 2025 Migraine World Summit, low-dose psilocybin (the active ingredient in “magic mushrooms,”) may also be helpful, but because of its Schedule I classification, there’s been little scientific research on the topic.

Generic, over-the-counter anti-inflammatory medications (NSAIDs like ibuprofen) aren’t effective in treating cluster headaches.

Other therapies

If medications don’t help your symptoms, your doctor might suggest surgery to implant a neurostimulator device. It sends electrical signals to specific nerves in your head to manage the symptoms they control.

Some alternative therapies may provide relief from cluster headaches, including:

• Acupuncture: places ultrathin, sterile needles into your skin at various points to relieve pain, nausea, and other symptoms
  Physiotherapy: focuses on stretching, moving joints, and massaging techniques
  Spinal manipulation: realigns your spine with a chiropractic adjustment
  gammaCore: stimulates the vagus nerve externally with use of a neuromodulator

Your doctor may make additional recommendations based on your unique situation.

 

Pharmacological treatments aren’t effective for everyone, and some people prefer not to take medications if they aren’t absolutely needed. For these patients, external neuromodulation devices can help prevent and/or treat a migraine attack.

There are a number of neuromodulators on the market, all of which target different nerves or areas of the brain. Here’s a roundup of what’s available.

Cefaly®

Cefaly is a transcutaneous supraorbital (above the eyes on the forehead) neurostimulation device cleared by the Food and Drug Administration (FDA) in March 2014 for the prevention of migraine headaches in people 18 years and older. It’s the only neuromodulation device available without a prescription.

The device attaches to the forehead with an adhesive electrode. When you switch it on, it generates precise micro-impulses to stimulate the trigeminal nerve, which is known to be involved in most migraine headaches. Stimulation of the trigeminal nerve is believed to suppress activity in the fibers within the nerve that carry pain signals to the brain.

The manufacturer recommends you use Cefaly once a day for 20 minutes to prevent migraine attacks. The device allows you to increase the impulses’ intensity so your sessions become more and more effective as you build tolerance. Unfortunately, you’re not able to reduce the impulse intensity, so if the starting intensity is too high and causes pain, there’s nothing you can do, and you’ll have to look for something else.

You shouldn’t use Cephaly if you have a metallic or electronic implant in your head, if your pain stems from an unknown origin, or if you have a cardiac pacemaker or an implanted or a wearable defibrillator.

Side effects from using Cefaly are rare. The most notable are an uncomfortable feeling of the device on the forehead, allergic skin reaction to the electrode, fatigue both during and after the session, and a headache after the session.

Cerena transcranial magnetic stimulation (TMS)

Transcranial magnetic stimulation  is a noninvasive method of brain stimulation cleared by the FDA on December 13, 2013 for use in patients who have migraine with aura. The device uses electromagnetic impulses to regulate signals in the brain. You need to get a prescription from your doctor to use it.

A plastic-insulated metal coil placed over the scalp generates pulses that can be delivered one at a time or in rapid succession. When  delivered in rapid succession, the treatment is known as repetitive TMS (rTMS).

Recent studies show that single-pulse TMS therapy may be effective in treating acute migraine with aura after the first attack. An attack occurs when bursts of neural activity in the nerves that connect the brain to the face and other parts of the head are followed by a period of inactivity known as cortical spreading depression.

The brain operates through the conduction of electrical impulses, so intentionally introducing mild electrical fields through TMS may modulate the excitability of the brain’s neurons and thereby reduce cortical spreading depression. rTMS may help prevent migraine attacks by producing longer-lasting changes in brain activity.

You may be a good candidate for transcranial magnetic stimulation if your migraine attacks don’t respond to medication.

Side effects of TMS are generally mild-to-moderate and improve shortly after treatment. They may include some scalp discomfort; tingling, spasms, or twitching of facial muscles; and lightheadedness.

You shouldn’t receive TMS if you have a pacemaker, shunt, or spinal cord stimulator.

gammaCore®

gammaCore is a noninvasive vagal nerve stimulator (nVNS) that can be used for acute treatment of migraine and cluster headaches in patients 12 and older. It also comes with dosing regimens for the prevention of migraine and cluster headaches. Patients with hemicrania continua (one-sided continuous headache) and paroxysmal hemicrania (sudden, severe head pain on one side of your head, usually behind the eye) may see benefit with gammaCore as well.

Treatment duration is 4-6 minutes, and it can be repeated throughout the day if you experience additional attacks.

Possible side effects include skin irritation, muscle twitching, pain, and dizziness.

gammaCore shouldn’t be used in pregnant women or those with carotid atherosclerosis, congenital cardiac issues, prior vagal nerve surgeries, high or low blood pressure or heart rate, or an implantable electric stimulation or metallic device.

Relivion®

Relivion is a multi-channel brain neuromodulation system. It targets branches of both the occipital and trigeminal nerves with electrical stimulation designed to treat acute migraine pain in patients at least 18 years old.

As with the other neuromodulators, you shouldn’t use Relivion if you have an active implantable medical stimulator or other metal device.

Side effects may include scalp numbness, tingling sensation, pain, skin irritation, sleepiness, dizziness, and headache.

Nerivio®

Nerivio is unique in that it’s worn on the upper arm instead of the head. It stimulates small nerves that send transcutaneous electrical nerve stimulation to a pain regulation center in the brainstem. That center inhibits pain signals by releasing neurotransmitters.

Nerivio is meant to be used for patients who have episodic migraine and who are at least 18 years old. You shouldn’t use Nerivio if you have an active implantable medical device (e.g., pacemaker, vagal nerve stimulator, spinal cord stimulator). Each treatment lasts for 45 minutes, and the device is thought to be most effective if used within one hour of the onset of the pain phase of a migraine attack. Research is currently underway to determine its efficacy if used during the prodrome phase that precedes the pain.

If you’re struggling with migraine attacks, talk to your physician about which neuromodulator, if any, may be best for your individual circumstances.

If you have migraine, or if you’re simply interested in learning about migraine and other headache disorders, the Migraine World Summit is going on this week, March 20-27, online. There will be 32 speakers over the eight days, talking about every aspect of the disorder, symptoms, treatments, and research that’s currently being conducted.

The Summit has been held every year since its inception in 2015, and registration is free, but you can purchase an All-Access Pass if you’re not going to be able to watch during the week and want to access the interviews, videos, and transcripts later on. Go to migraineworldsummit.com to register.

 

Migraine is one of the oldest medical conditions known to mankind. Some of the earliest cases of painful headaches that we know about were recorded by the ancient Egyptians around 1200 BCE.

Around 400 BCE, Hippocrates described the visual disturbances, now known as an aura, that can precede a migraine attack, such as flashing lights or blurred vision. He also described that patients felt relief if they were able to vomit.

The credit for the discovery of migraine, though, was given to Aretaeus of Cappadocia who, during the second century CE, described the unilateral headaches typical of migraine attacks, as well as the associated vomiting and the periods between attacks where the patient is symptom-free.

The word migraine comes from the Latin word “hemicrania” meaning “half” (hemi) and “skull” (crania). Hemicrania was first used by Galenus of Pergamon to describe the one-sided pain felt by people undergoing an attack.

Galenus also suggested that the pain originated in the meninges and vasculature of the head, as well as suggested a connection between the stomach and the brain due to the vomiting that often comes with a migraine attack.

A popular Islamic philosopher, Avicenna, described migraine in his textbook on medicine entitled “El Qanoon fel teb;” he mentioned how eating, drinking, sounds, and light all worsened the head pain felt during a migraine attack and indicated how patients tended to rest alone in a dark room until the attack passed.

Abu Bakr Mohamed Ibn Zakariya Râzi pointed to an association between migraine and hormones when he mentioned how such intense attacks would often occur during menopause, after childbirth, or during the menstrual cycle.

Not all descriptions or suggestions were favorable for migraine patients. Andalusian-born physician Abulcasis, also known as Abu El Qasim, suggested that the one-sided headache could best be treated by applying hot irons to the head or garlic to the site through an incision in the temple.

The Middle Ages also offered several ineffective treatments for migraine including bloodletting and even witchcraft.

It wasn’t until the “Bibliotheca Anatomica, Medic, Chirurgica was published in London in 1712 that migraine was described along with other major headache types.

In the late 1930s, Graham and Wolff reported that an ergotamine tart (derived from the ergot fungus) could help abort migraine attacks. The tart provided relief by causing vasoconstriction of dilated blood vessels in the brain.

In 1950, Harold Wolff devised an experimental approach to exploring the brain, and he proposed from his research that blood vessel abnormalities were associated with migraine, something we know about today.

Today, we’re also learning about the complex role that neurotransmitters, peptides, hormones, and other molecules play in the cascade that leads to a migraine attack. Researchers are developing more targeted therapies based on our growing knowledge about human pathophysiology.

 

Citation:

Mandal, MD, Anaya. (2025). “Migraine History.” Retrieved from https://www.news-medical.net/health/Migraine-History.aspx.

 

You feel pain and pressure in your face, especially above and around the eyes, and you’ve got a runny nose. Is it migraine (a primary headache), or is it a sinus headache (a secondary headache)?

Especially during allergy season, most people self-diagnose a sinus headache. However, according to the American Migraine Foundation (AMF), studies indicate about 90% of these headaches are actually migraine attacks.

The barrage of marketing for over-the-counter allergy relief medications has reinforced the belief that sinus headache is a common condition; however, sinus headache isn’t as prevalent as you may think.

Here’s how you can tell the difference, so you’ll know what medical attention you need.

Migraine basics

We’ve covered this topic before, but it bears repeating here.

Migraine isn’t simply a bad headache; headache is just one component. Migraine is a chronic neurological disease that comes with a variety of disabling symptoms, including pain, and a number of different approaches to treatment.

Common migraine symptoms include:

• Moderate-to-severe, one-sided head pain
  Pain that throbs, pounds, or pulsates
  Pain that worsens with movement
  Nausea and/or vomiting
  Sensitivity to light, noise, and/or smells
  Nasal congestion and runny nose

The AMF estimates that over 40 million Americans live with migraine. Since many people don’t get either an accurate diagnosis or the proper treatment they need, though, the actual number is likely much higher.

Sinus headache basics

A true sinus headache — called rhinosinusitis — is rare. The real cause of most sinus headaches is an underlying infection of the nasal sinuses characterized by thick, discolored nasal discharge. That makes the pain a secondary headache.

Sinus headache symptoms include:

• Stuffy nose
  Facial pain
  Pressure around the eyes and behind the cheekbones
  Weak sense of smell or inability to smell
  Aching in the upper teeth
  Fever

If your infection is viral, the facial pain and headache should resolve within seven days. If the infection is bacterial, they should resolve after successful treatment with antibiotics. If your pain continues despite treatment, your doctor may review their diagnosis of sinus headache and run additional tests to determine the true cause of your symptoms.

Why is misdiagnosis common?

Research studies show that some common allergy and sinus headache symptoms present along with migraine. One study found that 45% of people with migraine reported either nasal congestion or watery eyes during an attack. In addition, migraine is underdiagnosed and undertreated, meaning self-diagnosing a migraine attack is less likely than a sinus headache.

Another study delved into the frequent complaint of sinus headache by evaluating nearly 3,000 people; none were diagnosed with or being treated for migraine prior to the study. All participants reported a minimum of six sinus headaches in the six months prior to the study’s start. The researchers found, though, that 88% of the participants had migraine and not sinus headache.

A study called the American Migraine Study II looked at nearly 30,000 individuals, and only about 50% who were eventually diagnosed with migraine knew they had migraine before the study began. The most common misdiagnosis for the remainder was sinus headache.

The nerves activated during a migraine attack are the same nerves that also supply the sinuses, ears, eyes, teeth, and jaw, helping to explain why migraine attacks are felt in these regions. When the nerves supplying the sinuses are activated (from migraine or allergies) it can lead to congestion, a runny nose, and watery eyes. Because of the symptom overlap, it’s crucial to get an evaluation from a healthcare provider, so you can receive appropriate treatment.

A quick and easy test

You can also ask yourself the following questions from the ID Migraine Questionnaire developed by Dr. Richard Lipton of the Albert Einstein College of Medicine:

• In the past three months, how disabling were your headaches?
• Do your headaches interfere with your ability to function?
• Do your headaches make you miss work, school, or family activities?
  Do you ever feel nauseous when you have a headache?
  Do you become sensitive to light while you have a headache?

If you answer “yes” to the last four questions, the likelihood of a migraine diagnosis is 98%.

Those with sinus headaches are less likely to answer yes to any of the above questions.

If you believe your sinus headaches might actually be migraine attacks, talk to your primary care provider or see a headache specialist. Your doctor may prescribe a migraine-specific medication to see if it reduces your head pain and related symptoms the next time you have a headache. If necessary, they might also order blood work or a CT scan of your sinuses to rule out an underlying sinus problem.

 

According to the American Migraine Foundation, while studies have shown migraine is a genetically based neurological disorder, factors such as your environment, lifestyle, and diet still play a large role in the frequency of your migraine attacks. You won’t be able to stop all migraine attacks simply by following a trigger-free diet, but you may be able to reduce both the frequency and severity of attacks by tending to your body’s specific dietary and nutritional needs.

Food as triggers

Can food really trigger migraine attacks? It’s actually a lot more complicated than a yes or no. Migraine prodrome can actually cause food cravings — meaning eating a specific food might be a sign that an attack is already underway and isn’t the trigger for the attack. While some foods do trigger migraine attacks, in prodrome-related eating cases, the attack would have happened no matter if the person did or didn’t eat a particular food.

The problem may be one of association. Many of those with migraine think a food or drink is a trigger because, in the past, they started experiencing the pain phase of the migraine attack while eating or drinking it. Therefore, they associate the food with pain, even though their migraine attack had already started by the time they ate the food.

It’s important to remember that migraine attacks develop due to many different factors. If you’re stressed, not sleeping well, or not exercising, some foods can make it more likely to have a migraine attack, but they’re not the sole cause.

Different people have different dietary requirements, so what triggers one person’s attacks may play no role for someone else. If you want to learn if a specific food or type of diet increases your risk of migraine attacks, keep a food diary along with your headache journal to identify consistent patterns that do, in fact, trigger migraine attacks. If you find a pattern, try avoiding the food for a while and monitor your symptoms; if they improve, the food is one of your triggers.

Extremely strict diets, though, don’t work in your favor. You may end up avoiding non-migraine-related foods and missing out on important nutrients.

Caffeine: migraine trigger or reliever?

Caffeine is commonly cited as a migraine attack trigger, together with alcohol, artificial sweeteners, and MSG. Some people, though, find that a small cup of caffeinated coffee during an attack, or a medication that contains a small amount of caffeine, can make the pain and other symptoms better.

While caffeine in small doses may provide mild head-pain relief, people who regularly consume large quantities may be at risk for withdrawal symptoms if they try to quit “cold turkey.” And withdrawal itself can be a migraine trigger.

In a study published in the journal Neurology, the researchers concluded that “Dietary and medicinal caffeine consumption appears to be a modest risk factor for chronic daily headache [emphasis added] onset, regardless of headache type.”

How caffeine affects you as an individual with migraine also depends on how much water you drink between doses, as caffeinated beverages affect migraine symptoms indirectly by causing dehydration. It’s important to drink at least eight, eight-ounce glasses of water every day if you aren’t drinking caffeinated drinks, and add another full glass for each caffeinated cup to offset its dehydrating effects.

If you find your headaches are being triggered by caffeine withdrawal, try to reduce caffeine slowly, by about 25% a week. It’s enough to wean you off of it but avoid the unpleasant withdrawal symptoms that can occur.

Dietary guidelines

The US Department of Health and Human Services’ Dietary Guidelines for Americans (DGA) makes food recommendations to help you lead a healthier life. They’re not tailored to people with migraine, but they’re helpful in maintaining a healthy and balanced diet; this alone can reduce the frequency of migraine attacks.

Some DGA recommendations include:

Aim for half of your daily grains to be whole grains, which contain more fiber and vitamins than grains with the hulls removed. Substitute whole grains for white bread, white rice, and white pasta in your diet.

Eat a colorful diet, maintaining a variety of fresh fruits and vegetables in your diet. At each meal, half your plate should be fruits and vegetables.

Instead of sticking to a low-fat diet, aim to eat healthier fats like olive oil and avocado. Limit “saturated” and “trans fats” (often found in highly processed and/or fried foods) when possible, and increase your seafood consumption to two to three times per week for those healthy omega-3 fats.

Limit sodium to less than 2300 mg per day. Ditch the processed foods like heat-and-eat frozen meals, canned soups, and chips and crackers, which all contain a lot of salt, and cook from scratch or choose foods labeled “low sodium” whenever you can.

In addition to the basics of a healthy diet, if you have migraine, there are a few other things to keep in mind:

• Don’t skip meals; hunger can trigger a migraine attack
  Start your day with fuel. Eat a high-protein breakfast within 30-60 minutes of waking up
  Consider eating five small meals per day; include a carbohydrate, a protein, and a healthy fat in each one to stay full longer
  Stay away from any food or drink that’s a known trigger
  Drink water during the day instead of sugary sodas or juice

The more mindful you are about your diet, the less frequently you’ll experience migraine attacks.

 

Many people with migraine have an adversarial relationship with their gut. During an attack, it can cause stomach and abdominal pain, nausea, an overly full sensation, and more. But why would a disorder that causes crippling headaches affect the gastrointestinal (GI) tract so severely?

Vince Martin, MD, AQH, Director of the Headache & Facial Pain Center at the University of Cincinnati Gardner Neuroscience Institute, spoke at the 2024 Migraine World Summit and explained some of the varied reasons people living with migraine also struggle with gut issues.

The association, he says, relates to the autonomic nervous system, especially the vagus nerve. It’s often called the gut-brain superhighway, since it extends all the way from the brain and down into the GI tract. That means many of the same neurochemicals involved in migraine are also found in the nerve cells of the gut.

Some of the main players are serotonin, which we know is important in migraine; glutamate, another neurotransmitter involved in attacks; and CGRP (calcitonin gene-related peptide, a key component of new preventive treatments). They’re all found in the gut in large quantities.

There are also neurologic connections between the trigeminal system,  the main nerve involved in migraine, and the center in the brain that controls nausea. When that center gets activated, nerves that go to the stomach cause the organ to stop contracting, and that gives you the feeling of nausea.

Gastroparesis, the loss of contraction, is a common side effect of a migraine attack. Normally, the stomach contracts to propel the food into the small intestine. But when someone has a migraine attack, those contractions may stop, and the stomach just kind of sits there. It can lead to issues with nausea, but it can also lead to problems with drug absorption. Some of the oral pills that migraine patients take may not actually be absorbed if the person has gastroparesis.

It’s also possible that these symptoms could manifest outside of a migraine attack. People with migraine may chronically feel full easily or lose their appetite, they may have some pain in their stomach region, and they become easily nauseous.

One lesser-known form of migraine is called abdominal migraine. People develop pain in their epigastrium, which lies just beneath the sternum in the abdomen; they can have recurrent bouts of abdominal pain with or without “classic” migraine symptoms.

This can occur repetitively and may even stump gastroenterologists trying to diagnose the problem. They look for other pathology like gallstones or liver problems, but they don’t find anything significant. And that’s because the diagnosis is really one of exclusion. Once they’ve done their full gastrointestinal evaluation, and particularly if the patient has a history of migraine, then the pain could be called abdominal migraine.

There’s another factor to consider, too, which is the microbiome; it’s basically the collection of all the bacteria that live in your gut. The microbiome changes on a daily basis, as it’s linked to your diet, whether you’ve had any recent antibiotics, and a number of other factors.

The bacteria are a mix of anti-inflammatory and pro-inflammatory types. So, it’s the ratio between the good and the bad bacteria and the substances they produce that may promote or inhibit gut inflammation. And since what happens in the gut can influence what happens in the brain, this balance between good and bad becomes very important.

A lot of healthy lifestyles — diets rich in fruit, vegetables, and fiber — promote the healthy bacteria in your gut. If you eat a poor diet with lots of carbohydrates, sugars, and unhealthy fats, though, it creates an unhealthy environment, and you may struggle with gut symptoms.

And if you’ve been on broad-spectrum antibiotics for a long period of time, they can wreak havoc on the GI tract and the ratio of bacteria in the microbiome. It can throw you into a bad pro-inflammatory state for a long period, and perpetuate the migraine attacks.

More research needs to be done to discover the intricacies of the gut-brain system and how it affects migraine attack symptoms and migraine as a whole.

 

If you think you have migraine (or any other type of ongoing headache), discuss your symptoms with your primary care physician (PCP) first. They may be able to diagnose the condition and start treatment, though most don’t have enough of the proper training to handle more than routine cases. As a result, your PCP will probably refer you to a general neurologist or a headache specialist for follow-up.

The specialist diagnoses migraine after taking a complete medical and family health history and asking you a lot about your symptoms, including:

• What symptoms do you experience during each phase of migraine?
  How severe are the symptoms?
  How long do symptoms last?
  Do you experience an aura preceding the pain?
  How does the pain feel (i.e., shooting, throbbing, aching), and where is it located?
  Does anything make your headache better or worse?
• How long does it take you to get back to normal?
• Do any of the symptoms affect your daily life?

In addition, the doctor performs a physical exam, a neurological exam, and may also order blood tests and imaging tests (e.g., a CT scan or an MRI) to make sure nothing else can account for your headache. An electroencephalogram (EEG) can also help rule out other conditions.

If the doctor can’t find any other condition to explain your symptoms and diagnoses you with either episodic or chronic migraine, the discussion moves to treatment.

There are two types of treatment: preventive and abortive. Preventive treatment is something you take or use every day to prevent a migraine attack from starting up. Abortive (or rescue) treatment is something you take or use at the first sign of an attack to, hopefully, prevent the attack from progressing.

Both the preventive and abortive treatments can be broken down further into two categories: medication and neuromodulators.

Medication

Until recently, most preventive and abortive medications used were drugs repurposed from other conditions that, by chance, also worked on one or more of the migraine pathways in the brain.

Some of the common preventive migraine medications include:

• Antiseizure medications (valproic acid, topiramate)
  Beta-blockers (atenolol, propranolol, nadolol)
  Calcium channel blockers (verapamil)
  Tricyclic antidepressants (amitriptyline, nortriptyline, doxepin)
  Serotonin and norepinephrine reuptake inhibitors (venlafaxine, duloxetine)

Some of the common abortive medications include:

• Triptans (5-hydroxytryptamine)
  Ditans (lasmiditan)
  Dihydroergotamine (DHE) (prochlorperazine)
  Antinausea medications (metoclopramide, promethazine)

Medications come in different forms:

• An injection under your skin (subcutaneous)
  An oral medication
  A nasal spray
  Through an IV (intravenously)
  Suppository

The doctor weighs the risks and benefits of each type of medication before choosing one or more to manage your symptoms. As with any medication, you need to carefully follow their instructions on how to use these safely.

It’s only been in the last few years that research into the mechanisms of migraine has turned up new, migraine-specific classes of drugs. For preventive use are the calcitonin gene-related peptide (CGRP) agonists. These are monoclonal antibodies that prevent the CGRP protein from triggering the cascade that leads to a migraine attack.

The first group of anti-CGRPs released were Aimovig®, AJOVY®, and Emgality®. They come as a subcutaneous injection self-administered once a month. Almost 60% of migraine patients treated with these drugs experienced a ≥ 50% reduction in monthly migraine days at 12 weeks compared to control subjects. Unfortunately, that means over 40% didn’t see that improvement.

For abortive use are a group of short-chain proteins called gepants and ditans, that dock with the CGRP receptor, preventing CGRP from initiating pain signals. Gepants and ditans come as oral pills or dissolvable tablets, not injectables like the monoclonal antibodies. They target very specific receptors on sensory nerves that can resolve migraine symptoms like sensory sensitivity and nausea. Because of their specificity, they come with fewer side effects than the older drugs.

Neuromodulators

The American Migraine Association explains the three noninvasive neuromodulation devices currently FDA-approved for both preventive and abortive treatment.

Transcutaneous supraorbital neurostimulator

Image from American Migraine Foundation

This device is known more commonly as the Cefaly, and it uses electrodes for stimulation. Patients place the electrodes on their forehead, connect the device, and turn it on. It stimulates the supraorbital nerves, which transmit the device’s signal to the brain.

Preventative treatment with the Cefaly lasts for 20 minutes daily. Acute treatment, which uses a different setting on the device, lasts one hour. It takes about three months to determine if the device is effective at preventing migraine attacks.

You buy the device outright, and it’s the only one available without a prescription.

Single Pulse Transcranial Magnetic Stimulator device (SpringTMS or sTMS)
This device simulates nerves using a magnet rather than electrical pulses. You place it on the back of your head, and the device delivers a magnetic charge in about one second. You can rent it in three-month increments.

The preventive dose is four pulses twice daily, with as-needed extra pulses for acute treatment up to 17 pulses per day. Like the Cephaly, it takes about three months of daily use to determine if it has a preventative effect.

Non-Invasive Vagus Nerve Stimulator (nVNS)(aka gammaCore)

Image from electroCore®

This device uses electrodes to treat attacks of episodic cluster headache, but it’s also been FDA-approved for the acute treatment of migraine-related pain in adults. You put gel on the electrodes and then press the device to the side of your neck and turn it on.

It stimulates the vagus nerve in two-minute increments. Two cycles twice a day is the dose for preventive treatment; you can add additional cycles, as needed, for acute treatment.

You do need a prescription for the device, which you rent in three-month installments. Again, it takes about three months to determine effectiveness.

Neuromodulators are a viable alternative for those who either don’t respond to the medications or have unwanted side effects.