We are four headache specialists. Ask us anything about migraine and headache!

Asa nurse, what are some things I can ask to accurately assess and evaluate a pt’s headache/migraine? I usually ask location, intensity, character, accompanying signs like auras, & have them rate the pain at its best and worst.

Love this question! Thank you for asking it. All of those things you mentioned are important - location, intensity, quality, and other associated symptoms like aura, nausea, vomiting, and sensitivity to light and sound. Frequency is also very important - how many days of headache the person is experiencing helps to differentiate treatment options to pursue. Also important are to ask about potential triggers, and think about lifestyle - like sleep habits, diet and exercise, and asking about stress. A thorough headache history is crucial! -AP

How can we combat changes in the weather as triggers, short of moving?

Unfortunately we cannot control the weather, though sometimes I wish we could! Sometimes it is best to try to be vigilant about other lifestyle behaviors and reducing other triggers (like lack of sleep, dehydration, stress, missing a meal, etc) to make your brain as resilient as possible to the weather change. It's often the combination of triggers that can lead to a migraine; reducing others can help. -AP

How common is weather as a trigger?

There is varying incidence reported - somewhere between 30 - 50% depending which artical you are reading

here is an interesting paper

https://doi.org/10.2169/internalmedicine.50.5640

- BN

Chronic daily migraine sufferer here. Thank you for doing this AMA and bringing awareness to this topic. My neurologist had me tested for autoimmune diseases recently and although I had a high RF, everything else was normal, so yay...? Anyway, it was never made clear to me what the link is between autoimmune disease and migraine. Can you please explain? Thanks!

Good question! Data does suggest a correlation between autoimmune disease and migraine, but not that one necessarily causes the other. The exact mechanism for the link is not completely understood, but one way to think about it is that if there is inflammation in the body, as in autoimmune disease, there may be an uptick in certain pro-inflammatory chemicals circulating that make the environment more likely to lead to a migraine, and vice versa. Migraine is a complicated biological process that is sensitive to many circulating pro-inflammatory chemicals, so if there is more around, you have a higher likelihood of experiencing a migraine. -AP

Is there a major distinction between a headache and a migraine? For some people, "migraine" seems to refer to a severe debilitating condition that renders one unable to do anything else; others seem to use the term loosely as interchangeable with bad headaches. Does the term migraine denote a clinical diagnosis, or can one simply decide if their headache counts as a migraine?

You are right in that some people use these terms interchangeably, but migraine is a clinical diagnosis with a clear neurobiological and electrochemical process that underlies it. A migraine is not "just a headache". Some people use the term headache to mean a tension type headache, which is very different from a migraine. Migraines can be disabling and often include other symptoms besides pain. -AP

Are there any indicators for oneself to distinguish between a headache and migraine?

As a Headache specialist I use the International Classification of Headache Disorders to help there are very specific guidelines/criteria. They are available for free from the International Headache Society:

https://www.ihs-headache.org/ichd-guidelines

​

- BN

Not sure if this is something you’ll be able to answer, but a lot of us face quantity restrictions on abortive meds like triptans. I specifically take sumatriptan injections. Can you maybe explain how sumatriptan works and why it’s not good for the brain all the time (rebound headaches aside)? Maybe it’ll help me be less angry when I have to fight with insurance.

This is a common frustration on both the patient and provider side of things!

The question about restrictions varies by the medication being prescribed. For the use of triptans as you already stated there is a risk of rebound when used more then 2 days a week. There is also a concern because the one of the 2 receptors that this medication targets is located on your blood vessels and this medication causes the blood vessels to constrict. There is a concern that too much constriction and causing a vascular problem such as a stroke if the medication is overused. The risk of stroke is likely low in young healthy patients with normal blood vessels, but the risk change with age and other medical conditions.

As a provider I find that we have a hard time getting the appropriate amount of triptan approved when a patient requires 2 doses in a single day to relive their headache and needs for example 16 does of a medication. this is a problem with the insurance company's algorithm and needs reform. I would NOT advocate for using triptans more then 8 days per month in migraine headache management with very few caveats (there is no such thing as dealing with absolutes in neurology or headache) - BN

My mom use them more than 8 days per month certain months, but she can't do without - she'd be in so much pain she couldn't get up form bed for days. There's no alternative.

There are alternative medications to triptans now for severe headaches as well.

Insurance continues to be complicated. For patients with commercial insurance they can often get them for $0 with the co-pay card that the companies offer. There are also additional programs for patients that can not afford the medications - but there is paperwork and income requirements.

Ditans: Lasmiditan/Reyvow

seratonin 1F receptor antagonist - does NOT constrict blood vessels. It is s schedule 5 medication with the DEA and holds a driving restriction for 8 hours following administration, SE of dizziness for 3-17% of patients depending on the strength

2nd Generation gepants:

small molecule calcitonin gene related peptide (CGRP) receptor antagonist: Ubrelvy/Nurtec and Rimegepant/Nurtec - SE of nausea in up to 3% of patients

recommend a discussion with her provider to see if these are an option

​

- BN

Why do I have a headache if I don't sleep enough or sleep too long?

It is a complicated relationship, but sleep and migraine often affect each other (both positively and negatively). Some people find sleep to be helpful for stopping a migraine attack. Others wake up in the middle of sleep with an attack and migraine disrupts their sleep. Migraine brains seem to like routine - when routine is disrupted somehow, the brain can be more likely to go into the migraine pathway, so it is important to keep a consistent sleep schedule where possible. -AP

If someone has tried all the medicines (triptans, etc), Botox didn’t work, Emgality didn’t work after 6 months, had a clear MRI, and the neurologist says they are out of options what would you recommend for the next step?

Currently on 900 gabapentin a day. Constant chronic painful headache even in a dark room.

Is a headache specialist next and is there hope?

A headache specialist sounds like a good next step. You can use the AMF's resource on finding a doctor here:

https://americanmigrainefoundation.org/find-a-doctor/

There is still hope and many treatment options (medication and nonmedication) to try, with many more continuing to be developed in the pipeline! - AP

If all signs point to migraines being caused by hormones, what is the likelihood of a hysterectomy eliminating migraines?

There are currently NO consensus guidelines that would recommend hysterectomy for the management of migraines. We do however have several strategies to manage headaches that are felt to be triggered by hormones. There are different recommendations and some debate within the headache community about the use of estrogen in patients that have migraine with aura.

Women with menstrual migraine do have a 2 fold increase risk of stroke when compared to their age matched population. There are older studies when women were using higher dose estrogen birth control up to 30 mcg per day that demonstrated as high as a 6 fold increased risk of stroke. We do not have much new data on the same evaluation with the use of our low and ultra low estrogen dosing 15-20 mcg per day. it is likely lower but unclear if it is closer to 2 fold or 6 fold increased risk.

One can use birth control to prevent the menstrual cycle and therefore prevent the drop in estrogen which is felt to be the trigger for menstrual related headaches. There is also a smaller drop in estrogen around he time of ovulation which can be a trigger for some women. There are non-estrogen forms of birth control that can control/prevent you from having a cycle.

Triptan class of medications such a Frovatriptan and Naratriptan can be used as mini-prophylaxis in patients that can predict their menstrual cycles. - BN

Do we know why migraines sometimes get better (less frequent, less intense, shorter) during pregnancy, and is there a way to replicate this when not pregnant? This happened to me, so I'm personally interested.

There is some data suggesting that the changing hormone levels with the menstrual cycle is often a big trigger for many women, so when one is pregnant, those estrogen levels rise and stay level/don't change drastically. It is the constant level, and no up and down or drastic drop, that seems to keep migraines at bay during pregnancy. -AP

What’s the deal with visual migraines? They don’t hurt, but the frequency seems to be moving from a couple of times a year, to weekly.

Migraine can occur with and without aura. Aura is most commonly visual. Only about 25-30% of patients experience aura with their migraines, and for some people over time they may experience aura without the headache phase of migraine.

Aura, does not always have to be visual, and is a series of sensory disturbances that happen shortly before a migraine attack. These disturbances range from seeing sparks, bright dots, and zig zags to tingling on one side of the body or an inability to speak clearly, and usually last 20-60 minutes.

If aura or migraine is significantly increasing in frequency you should visit with your physician to discuss further.

Here is a link to some more resources:

https://americanmigrainefoundation.org/resource-library/understanding-migraine-aura/

-NH

Is having auras without headache after a common symptom of migraines? And is it a concerning symptom?

Migraine aura is an interesting phenomena, it can occur before, during, after or without the presence of a migraine headache attack. The characteristics of migraine aura change change over a patient's life time - in older patients that have previously had migraine with aura they can stop having the migraine and continue to have the aura. Auras can be visual (some changes in vision - often bright zig zags, a growing spot called a scotoma an many other variation), sensory (numbness or tingling of the face, hands or feet) or motor (having weakens in the face, hands or feet).

The important things is for a provider to make sure that the symptoms do not represent a vascular event or a stroke. There are a few key factors we look for in our patient's description of their symptoms when making that evaluation.

Ff the symptoms are progressing or developing over time this is reassuring that the event is an aura: examples tingling that starts in the face and then progresses down the arm on the same side to the finger tips or kaleidoscope vision, zig zags that move across the visual field or a spot that grows and then shrinks.

If the symptoms are sudden in onset and continue to be present this is concerning for a stroke, the motor or strength problems are more difficult to tease out and often require evaluation by a neurologist or headache specialist to help guide the patient's care and if this occurs is often evaluated in the emergency room. IF it is a stroke there is a 3 HOUR Window for giving and important medication that could reduce disability long term called TPA (tissue plasminogen inhibitor).

the younger you are the lower the risk is for stroke, but if you have problems with blood pressure, diabetes and are overweight theses are things that increase risk of stroke.

Finally, patients can develop typical migraine aura without headache, but this is often a diagnosis of exclusion and needs further evaluation. - BN

Many people do experience aura without a headache, especially as you get older it becomes more common. Not everyone with migraine will have aura. It is not usually concerning if it is consistent with prior auras you have had, but it is always good to check with your doctor if you notice any changes or have any concerns about the symptoms you experience. -AP

Okay...serious question here...how does one become a headache specialist?

Great question! Headache specialists complete 4 years of medical school and then a residency, most commonly in neurology, but some can complete a residency in internal medicine or physical medicine and rehabilitation. In the past physicians would treat patients with headache to achieve expertise, but now there are many locations around the country who have specialized fellowships in headache medicine, and this is an extra year, sometimes two, of training where physicians learn how to take care of patients specifically with headache. -AP

this might be a strange thing to ask, but can Migraines be Genetic? Both my Mom and I (male) get Migraines more then anyone else we know, seemingly often for no reason what so ever. It does not happen often, MAYBE once every month or two.

Not strange at all! Yes, migraines can be genetic. There are certain subtypes of migraine that have clear genetic explanations for them, but often migraine can run in families, sometimes skip generations. -AP

How can I avoid as many migraines as possible? Why does vomiting help?

Maintaining a healthy lifestyle is really important to help try to prevent migraines where possible. This includes having a healthy diet of 3 meals a day and trying not to miss meals, staying well hydrated with at least 8 glasses of water a day, minimizing caffeine intake, maintaining good sleep of at least 6-8 hours a night, incorporating exercise into your routine, and combatting stress with things like mindfulness or meditation, yoga, or seeing a therapist. Easier said than done sometimes, but these all really do help. -AP

Does Ketamine infusion helps with migraines?

There is some data suggesting intranasal ketamine may be helpful for people who have prolonged aura with their migraine, but there are many studies currently underway looking to evaluate this further. Hopefully more to come. -AP

How do intractable chronic migraines affect the brain long term? Can they have an impact that is seen on a MRI or similar test?

This is a question that is continuing to be explored with the use of functional MRI and PET scans

​

- BN

Director of the Transgender Headache Medicine Program

That seems oddly specific?

To follow onto this- are there aspects of migraine that are trans* specific or is it more about filling in the gap between “men’s” and “women’s” health?

I have heard that migraine is more common among women, is there something hormonal about migraine that would make transwomen who are taking hormones more susceptible?

Good question. We do know hormones changes can affect cis-gender people, like during a menstrual cycle or pregnancy. We have limited data available thus far, but some transgender patients on hormone therapy may experience different migraine symptoms, or a change in attack frequency, during treatment. Certain migraine-specific medications may work better than others depending on their medical therapy. -AP

Is CoQ10 effective in preventing migraines if taken daily? If so, how much should someone take and how long before it works?

Co-enzyme Q10 (CoQ10)—an antioxidant that, when taken regularly for migraine prevention, has been shown to reduce frequency and intensity of migraine.

The recommended dose is 300 mg daily. Any migraine preventive can take several weeks to months to have an effect. Consider a trial for at least 3 months.

Other natural supplements or nutraceuticals can be helpful in migraine prevention as well and you can read about them here: https://americanmigrainefoundation.org/resource-library/nutraceuticals-for-migraine-treatment/ -NH

yes it has been demonstrated to be effective:

200 mg twice a day is the recommended dose

Please make note that there is NO regulation body for supplements. This means that there is no guarantee of the purity of the contents of the supplements that are being sold. If one supplement/brand does not work it does not mean that this is an ineffective treatment.

- BN

This might seem unrelated but why is the picture on this post of a seemingly random man when the four doctors on this AMA are women?

As an occasional migraine sufferer, thanks for all your work!

Hi Bananabantha,

We actually just noticed that and don't know how that photo of our spokesperson, Jim Cramer is being pulled into the metadata -- perhaps because we linked our website up top? Too funny.

And of course, happy to help! Please feel free to visit our website and peruse the AMA for anything that helps you manage your migraine! - AMF Moderator

What does the latest research show about rebound/medication overuse headaches? There is so much different info out there about medications that cause them and/or the frequency they can be taken. I hear different things from different doctors.

Great question. there was a publication in 2012 looking at patients with fMRI (functional MRI studies) and they found that patients that have medication overuses headache (MOH) have a different network activated and this is likely why they do not respond the same way to medications that have worked for other patients or that may have worked for the patient in the past. An additional interesting finding was that after the discontinuation of the offending medication it to 4-6 MONTHS for the patient's brain network to return to a baseline "migraine brain"

Medications that are know to cause medication overuse headache include:

opiates

narcotics

short acting over the counter medications: tylenol, Ibuprofen and excedrin when used more then 2-3 days per week

Fioricet, fiorinal when used more then 1 day per week

tramadol/Ultram > 50 mg per day

​

Although the International headache classifications define MOH as occurring when a patient is using medications regularly for > 3 months; I find that it happens much faster to migraine patients. - BN

I get severe migraines with nausea and vomiting around once a week, sometimes more depending on my sleep routine. The main, apparent trigger for me is changes in sleep, such as increased or decreased sleep time and disrupted sleep etc. Currently I take propranolol prophylaxis. My question is, even though I do not always have a severe migraine to the point of throbbing, all consuming pain and accompanying nausea and vomiting, I always feel as though I have a low level migraine most of the time. I can feel a feeling in my head like heaviness, and a pulsating feeling. I also feel the tiredness and lethargy that accompany migraines, along with changes in my mood. Is this something that you have came across before and is there a way to treat this? I have days, usually immediately after a migraine when I feel 'normal', with lots of energy and optimism, but this doesn't last and the cycle continues. Thanks :)

associated with chronic pain.

r/IAmA Rules

This is an excellent question and very common complaint that I have seen. It is often something that is teased out over the course of my interaction with my patients because the primary focus initially is on the severe headaches.

I would encourage you to discuss with you doctor and put it in terms of headache days - this means mild and severe headache days. Likely you need to increase, change or add to your migraine prevention regimen. If you are having 15 or more headache days per month then you have chronic migraine and there maybe medications that are more effective then the propranolol. For chronic migraine Topiramate has level A evidence of efficacy, Botox and the new monoclonal antibodies have FDA approval for the management of chronic migraine and have level A evidence of efficacy as well. You need to discuss this all with your provider and they will need to take into account other factors in your medical history and prescriptions that you are currently taking. - BN

How can migraine be tested? Is it just based on symptoms or is there a way to have a definite answer.

Migraine is a clinical diagnosis that is made based on the signs and symptoms you experience. Things like an MRI will not be able to give you the diagnosis. -AP

Is that Jim Cramer in the picture? I guess this market must be really hitting him hard.

Hi! Yes, that is Jim Cramer, we didn't know the meta data would pull him in just because we linked the AMF website in our post. Mr. Cramer lives with migraine and actually is our spokesperson. You can learn more about Mr. Cramer in this article if you'd like! - AMF Moderator

Why does cardio exercise cause migraines but weight lifting does not?

Some people experience something called Primary Exercise Headache, which is headache provoked by cardio. Many people who have migraine can experience this, and this headache often resembles migraine. We published this patient education piece for the American Migraine Foundation a few years ago on this topic: https://americanmigrainefoundation.org/resource-library/understanding-migraineprimary-exertional-headache/ - RHS

I've had one instance of what I think was a migraine in my life; visual aura, nausea, vomiting, and then a splitting headache for most of the day. It was years back in college and I've never had anything like it before or since. Are isolated cases like that normal? My understanding was always that someone is either "wired" to getting occasional migraines or they're not.

My dad used to get the same exact types of migraines extremely frequently, so when it happened to me I assumed that I'd inherited it and would start getting them occasionally, but that doesn't seem to be the case.

That's a great question! Migraine is a complex genetic neurologic disease process, and many different factors can influence its frequency. Furthermore, epidemiology studies have shown that migraine frequency can change throughout a person's lifetime, too. The American Migraine Foundation has information on different factors that can impact how often you experience migraine attacks, and your risk of developing chronic migraine (defined as the presence of having 15 or more headache days/month): https://info.americanmigrainefoundation.com/are-you-at-risk-for-chronic-migraine

- RHS