We are an internist, a neurologist, and a migraine researcher. Ask us anything about migraine headaches.

Is there any proof, or strong anecdotal evidence, that CBD oil or marijuana relieves the pain or reduces/prevents migraines

CBD products can help with pain and nausea/vomiting, so it makes sense that we’re all interested in whether it can help with migraine pain and symptoms. Unfortunately there’s not much research about the effectiveness of marijuana for migraine treatment to reference, and there’s a lot of controversy anecdotally among doctors and patients about their experiences. If you’re interested in trying CBD oil you’ll need to check your state laws regarding medicinal use and I’d highly recommend you find a doctor to work with. It’s important to have a comprehensive plan to treat acute migraine attacks and prevent future migraines. - Dr. Arefa Cassoobhoy

What is one of the most surprising correlations you’ve found within migraine research?

There are so many important correlations that it is hard to pick one! ...so I will mention a couple of them.

1 - There are strong genetic correlations to migraine. We are able to follow migraine within families and we are also able to see evidence of some of the cellular abnormalities that cause some specific types of migraine and are passed down through families.

2 - One of my other favorite “surprising correlations” is associations between migraine and the weather. Although the evidence for this is inconclusive, I am a believer that weather is a factor that can influence migraine. I have seen it in so many patients. - Bert B. Vargas, MD

On item 1, does identifying the specific cellular abnormality guide treatment of the migraine?

On item 2, is this weather association specifically the change in air pressure associated with changes in weather, or are their migraine-weather correlations that couldn’t be associated with the change in pressure?

Edit: many typos - thanks migraine!

At the moment, identifying these specific cellular abnormalities does not change (or guide) the treatments that may or not be more effective… but they COULD in the future! With more study on the genetics of migraine and the specific cellular/metabolic issues that we see with its subtypes it is my prediction that we will one day have treatments that are more individualized. Regarding weather - yes… it seems that most people correlate their attacks to changes in barometric pressure. - Bert B. Vargas, MD

are people who get migraine headaches prone to brain aneurysms?

Many times, people with migraine fear that they have an underlying cause for their headaches and other symptoms due to things like aneurysms, tumors, or other similar issue. The fact is that most of the time, things like aneurysms are not to blame. Most people with migraine will have a normal MRI and vascular imaging. Interestingly, though, the correlation does seem to work in the opposite direction where a significant number of people with KNOWN aneurysms have a history of migraine - but rest assured that only a small fraction of people with migraines will be found to have an aneurysm. - Bert B. Vargas, MD

What are your best (evidence-based) recommendations for lifestyle modifications to reduce headache frequency in people with migraines (beyond medication management)?

This is a terrific question and I’m glad you asked it! Scientific research has established that the most important lifestyle habits include maintaining a regular sleep/wake schedule, practicing good sleep hygiene, eating healthy regular meals, staying hydrated, getting regular exercise/movement, and managing stress. The nervous system is calmed by regular routine and following our natural circadian rhythms and this is especially important a hyper-responsive nervous system as is seen in migraine. “All things in moderation” is a very good adage for living well with migraine. These actions can raise the threshold for attacks. Other important healthy habits include not smoking, moderating caffeine use, engaging in personally meaningful activities (hobbies, time with family or friends if that is uplifting, volunteering, and learning something new). Practicing relaxation techniques such as meditation, guided visual imagery, yoga, or other ways to quiet the mind can also have beneficial effects. There are many wonderful free or low cost apps and websites teaching these skills.
Non-medication (behavioral) treatments for migraine management are valuable and important in managing migraine. They may be used in conjunction with pharmacologic therapies or alone. They are safe for all life stages including during pregnancy and nursing. The big three behavioral treatments with strong evidence for migraine management are biofeedback, relaxation training, and cognitive-behavioral therapy. We have been doing research on Acceptance and Commitment Therapy (ACT) and Mindfulness Based Therapies like Mindfulness Based Stress Reduction and Mindfulness Based Cognitive Therapy. So far the research into these two therapies seem to show that they help reduce disability associated with migraine and improve quality of life and psychological well-being but do not reduce the number of headache days.
I always want to stress that if stress, depression, anger or anxiety seem unmanageable on one’s own it is important to talk to your doctor or a mental health professional for help. Thank you and best wishes to you. - Dawn Buse, PhD

Are migraines linked to or correlated with future neurological issues?

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That is, if someone suffers from migraines, are they more likely to have other issues, especially in old age?

Migraine is associated with several medical and psychiatric comorbidities. “Comorbidity” is the occurrence of two conditions at rates higher than expected by chance. Medical comorbidities of migraine include epilepsy, cardiovascular disease (stroke, hypertension), sleep disorders (e.g., insomnia, restless leg disorder, and sleep apnea), musculoskeletal disorders, chronic pain conditions (e.g., fibromyalgia, chronic back pain), obesity, respiratory disorders (e.g., asthma, allergic rhinitis), irritable bowel disease, Crohn's disease, cervical dystonia, celiac disease, chronic fatigue and other conditions. Common psychiatric comorbidities of migraine include depression, anxiety, panic disorder, post-traumatic stress disorder, adverse childhood experiences (e.g., physical, emotional and sexual abuse) and suicide attempts. All of these conditions are even more prevalent among people with chronic migraine.
I know that sounds like a lot and I do not want to alarm you. It is not clearly understood in many cases whether one condition causes the other, or they both develop out of shared underlying genetic or biological predispositions (like they both run in a family, or they both involve the same systems in the body that are affected or the same neurotransmitters that are affected). Most of the comorbidities show up closer to the same time, and do not come much later in life, other than perhaps cardiovascular disease (stroke, hypertension) because it naturally tends to be something that happens later in life.
If you have any of these comorbidities or risk factors for them now, talk to your doctor about treatments and preventive lifestyle habits that you can engage in now. The good news is, for most of these conditions, it seems that treating either the migraine or the condition may help both and of course it is best to take care of both conditions both medically and with behavioral treatments (like biofeedback, cognitive behavioral therapy, relaxation therapy) and healthy lifestyle habits like exercise, maintaining a healthy weight, eating well, sleeping well, and staying mentally active both now and as one ages. The other good news is the migraine is one of the few diseases that tends to naturally get better with age. That is not always the case for everybody, but it is the case for most people. Best wishes to you. - Dawn Buse, PhD

I have a headache (migraines/tension/clusters) at least 15-20 days out of the month. When should I be concerned enough to really pressure my doctor? They usually ask how much Excedrin I'm taking, tell me to drink more water, etc. It's frustrating that I can't seem to find relief, and I'm wondering if I should go in with suggestions for treatment or how to go about working on a treatment plan.

Also, I find it much more difficult now to differentiate my migraines with tension headaches since they seem to happen on top of each other - how can I manage that pain and tell the difference between all of the aches...in my head.

Lastly, I take CBD/THC to help mitigate the pain, but people always express concern it may be causing rebounding, any thoughts?

With the frequency of headaches you’re getting, I’d recommend you see a headache specialist (neurologist) to get evaluated and develop a treatment plan. It’ll be important to take a headache diary. There are migraine apps and online diaries to record the frequency of the headaches, the quality of the pain and other associated symptoms, what your triggers might have been, and what helped you get over the headache. If these are chronic, rebound headaches it’ll take some time (weeks to months) to significantly reduce the frequency of your headaches wit acute and preventive therapy. Don’t give up. Hang in there. As far as CBD/THC products there’s not much research on how it can help migraine for me to comment on. It might help as a topical for muscle pains related to the migraine. Let your doctor know everything you’ve tried and what has worked so she can advise you on what to continue or stop. - Arefa Cassoobhoy, MD

Are there triggers for migraines or other causes?

Hi, yes, there are definitely triggers for migraines you should know about including stress, hormones, lifestyle changes, weather changes and food sensitivities. Stress can be positive or negative - from the let down after a joyous event like a wedding, to a crisis at work. Hormones can impact women’s migraine patterns throughout their life. Some women have more migraine headaches around their menstrual period, during their pregnancies or when they’re perimenopausal. For the most part, migraines tend to improve as women get older during the menopause period. To prevent migraines, it’s also important to eat regular, healthy meals, exercise, and get enough quality sleep. Some people notice foods are a migraine trigger - including caffeine, alcohol, cheeses, nitrates found in deli meats, and even aspartame. - Arefa Cassoobhoy, MD

I used to get extreme migraines all of the time and they always started with a visual distortion at the center of my vision that would spread outwards. I always knew that when it got to the edge of my vision, I'd be hit my crippling pain that could last for hours.
I still get those distortions, from time to time, but it's been decades since they were followed by any pain. Is this at all a common evolution of symptoms?

Good news! Yes, migraines tend to occur less frequently and be less severe the older you get. People with migraine also tend to be less sensitive to light, noise, and smell. And, while stress and hormones are major triggers in early adulthood, those in their 50s and 60s tend to name pain, alcohol and smoking as their triggers. - Arefa Cassoobhoy, MD

Why is caffeine such an essential component of the migraine meds I find effective for me, eg Ergotamine/Caffergot?

Caffeine can be a great treatment for migraine and certain other headache disorders - but it can also be a sign of overuse/withdrawal! If you are one of those patients who get migraine only a few times a year, and caffeine helps, caffeine can be a very useful treatment and there is no harm in using the medications you listed)... but when attacks come more frequently (including just a few times per month), response to caffeine can indicate that perhaps withdrawal from caffeine might be partially to blame! I have a number of patients who feel their headaches are worse in the morning after they have gone through a period of fasting without caffeine (while they are asleep) - but once they get that first cup of coffee, they feel much better. This is a red flag for me and I might have them go through a period without caffeine to help eliminate that as a possible contributor. In fact, just 2 cups of coffee per day increases the risk of transitioning from episodic migraine to chronic migraine by 2x! There are also other risks from taking some of the medications you list if they are being used more than just a couple of times per week. This includes medication overuse headache. - Bert B. Vargas, MD

As an audiologist and the head of a tinnitus clinic, I see a lot of people with migraine symptoms (e.g. tinnitus & dizziness secondary to chronic/frequent migraines). However, many have never been diagnosed with migraine, and many have not tried preventative treatment options (including medication and lifestyle modification). Why do you feel that migraine headaches are underdiagnosed? How can practitioners and researchers better educate primary and specialty care providers on migraine?

Migraine is frequently underdiagnosed because of several factors - the main one, IMHO, is that there needs to be more awareness of how prevalent migraine is. One BILLION (with a B!) people worldwide… and 1 in 4 households in the U.S. have at least one person with migraine. Many times people assume that their headaches (or other symptoms) aren’t “bad enough” to be called migraine, or that their symptoms are because of sinus disease when in fact they are frequently undiagnosed migraine. In addition to educating about how prevalent the problem is, I find that it is important to educate people about the hallmark symptoms that define migraine, things like light sensitivity, sound sensitivity, nausea/vomiting, and smell sensitivity. For people with frequently occurring headache, sometimes they also forget to count the mild headache days because this has become their “new normal.” In a clinic like yours, I imagine that you see a lot of tinnitus and also “dizziness” - I imagine that you are in a unique situation to teach your patients about things like vestibular migraine and get them to someone that can help. I feel like PCPs are fabulous at diagnosing migraine - when they have the time to spend with their patients to unravel their symptoms. Unfortunately many of these frontline providers have to evaluate several problems in a short amount of time - that's why I am a big fan of educating the patients so they come to their visits armed with all the right information to make that diagnosis! - Bert B. Vargas, MD

What have you found is the most promising solution to "curing" migraines for those who are highly susceptible? Either in preventing them all together or stopping them once they have started.

So there’s no real cure for migraines. I wish there was! The best solution is finding a doctor you can work with closely to tackle the symptoms you have related to migraine. It can take some time to find a treatment plan that includes acute medication for when you have a migraine and preventive medication that reduces the frequency and intensity of migraine headaches you get. You may have to try a few treatments before you find something that works well. Also it’s just as important to work on lifestyle changes you can make to reduce your threshold for getting a migraine. A headache diary can help identify triggers that you can work to eliminate. You may notice you’re more likely to get a migraine when you haven’t slept well, or you’ve drank alcohol. If stress is a trigger for you, you could benefit from relaxation techniques or biofeedback, for example. The main takeaway I’d say is that treating and preventing migraine requires a multi prong approach. Don’t hesitate to follow up with your doctor to fine tune your treatments. - Arefa Cassoobhoy, MD

What are your thoughts on alternative medicines, such as acupuncture, to treat migraines as compared to western medication? Is there a “best” route of treatment?

I am a big believer in incorporating complementary and alternative therapies in a sensible manner. Something that is “complementary” is frequently a great “complement” to traditional Western therapies. In fact, many treatments considered to be “alternative” have great evidence for treating migraine. These include magnesium, riboflavin (Vitamin B2), and CoQ-10. I incorporate acupuncture frequently and even learned how to do it. Even though the evidence is inconclusive, there are a lot of studies which show it can be helpful. I am also a believer that large studies give you a snapshot of how a treatment works for large populations and does not give you great information about “individual” responses… so I NEVER tell someone that a particular treatment definitely won’t work for them - until they try it. I am always ok with trying alternative treatments (even those without great evidence) as long as the potential for harm is very low. - Bert B. Vargas, MD

I have suffered from chronic debilitating migraines for the past 18 years of my life and nothing has worked. I am very excited about drugs like Amovig and others like it.

My questions are, why did it take so long to come out with Migraine specific meds and why are these drugs so expensive and not covered by insurance?

For someone like me who suffers as much as I do, this is so FRUSTRATING.

This is a very complex question - but a great one! Part of the reason it takes so long for medications like Aimovig to come to market is that there is a lack of funded headache research. In fact, migraine is among the least funded neurologic diseases taking into account the number of people affected. This makes it difficult too for scientists and clinicians to do the studies needed to find newer and better medications. The other issue is that there are a number of safety checkpoints that need to be addressed when it comes to new medications released in the US. Some people think the FDA delays these new treatments too much - but others think that they do not go far enough. Nonetheless, it is important to make sure that everything released is effective AND safe. The other issue about cost is just as complex and a lot of it has to do with insurance companies and other agencies trying to keep healthcare costs low. New medications are expensive because they cost a lot to develop and bring to market. Insurance companies frequently deny these medications until other, frequently effective, and cheaper medications are attempted. Most of the time an insurance company will at least “consider” a new medication like this if several of the others have been ineffective. - Bert B. Vargas MD

I've been a migraine sufferer my whole life, and I know my big triggers, MSG, nitrates, and nitrites.

How exactly do these cause migraines, and why does it not cause them for everyone?

Migraine is a chronic disease with episodic manifestations (attacks). Someone with migraine has a hypersensitive nervous system. We believe that a migraine attack can happen when the combination of biological and environmental factors (i.e., triggers) exceeds a certain biological threshold. (Although sometimes is seems to happen for no noticeable reason at all!) This threshold can change based on various factors. There is some excellent new research on triggers but much is still unknown about them. There are probably fewer triggers than we thought and they vary from person to person and also from attack to attack for the same person. Triggers can include stress, OR relaxation after a stressful period, too much or too little sleep or changing sleep patterns (for example: on the weekend or a change in time zones), hunger, fasting, skipping meals or dehydration, bright or flickering lights, sustained loud noise, strong odors, weather changes and certain foods such as aged cheese and some alcoholic drinks among other factors. In many women, hormonal changes may trigger migraine (specifically the drop in hormones that happen between ovulation to the start of the next period for most women who are hormonally susceptible). A combination of triggers may set the perfect stage for a migraine attack. For example, a college student may feel stress studying for finals week, then not get enough sleep and skip some meals, leading to an attack. Triggers vary from person to person and from attack to attack. The best way to identify triggers is to keep a headache diary and note all factors are related to an attack but may have just been chance. They are lots of great diaries available in headache apps as well as a good old-fashioned paper and pencil diary. My advice is that if you know something is a reliable trigger for you to avoid it and to strengthen your reserves by getting enough sleep, eating healthy and staying hydrated, exercising and managing stress (all to the best of your ability! I know life gets busy and some of these can be tough to fit in, but are great habits.) Good luck to you. - Dawn Buse, PhD

Any ideas why daith piercings are known to cure chronic migraines?

Daith piercings do seem to help SOME people, but certainly not all (unfortunately we live in a time where we don’t have any treatments that work 100% of the time on 100% of the population). Like other injectable treatments, sometimes it is felt that they are hitting specific acupuncture points. I would also be cautious about using words like “cure.” At the time, there is no cure for migraine. Even the medications we use work by adjusting how the body responds to triggers or the underlying pathophysiology of migraine - but they don’t address the genetic root causes. Someday, we hope to have a legitimate “cure” though! - Bert B. Vargas, MD

Any truth to chugging a sugary caffeinated beverage when you start to notice migraine symptoms?

Caffeine is interesting because it can help an acute migraine like you’ve noticed, and there are even medications that include caffeine to treat migraine. But too much daily caffeine is associated with chronic migraine and rebound headaches. And, caffeine withdrawal can trigger a headache. You may need to evaluate your daily caffeine intake in relation to your headache patterns to decide if you need to reduce your caffeine intake (slowly), or try soda/tea/coffee the next time you have a migraine. - Dr. Arefa Cassoobhoy