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Risk of high frequency migraine increases by 40-60% during perimenopause and menopause - "Are you ready for the ride of your life?" -What you need to know 

"Do not become alarmed when you experience yourself in totally new ways," sighs Grandmother Growth, tenderly. "You are changing, getting ready to be initiated into the third stage of your life. Are you ready for the ride of your life? -Susan Weed, Menopausal Years the Wise Woman Way

Menopause marks a major life transition for women, an end to our reproductive years and the cessation of menses. While the end to menstruation and the fear of an unwanted pregnancy may be welcomed by some, others may experience a sense of loss as their last opportunity for conception disappears. Many women may have concerns about cognition and memory, mood disorders, weight gain, increased signs of aging like wrinkles, curtailed sexuality, and decreased libido.

For those of us with migraine, "the ride of our lives" may come with additional challenges. A new study reported at the 56th Annual Scientific Meeting of the American Headache Society found the risk of high frequency migraine attacks increases by 40-60% during perimenopause and menopause for some women.

Data from the 2006 American Migraine Prevalence and Prevention (AMPP) Study survey was used for the analysis (Poster Presentation, Martin et al, 56th Annual Scientific Meeting of the AHS, 2014):

  • Women between ages 35-65 years who met the modified ICHD-3 beta criteria for migraine were included.
  • Women who had never menstruated, were pregnant, breast feeding or using exogenous sex hormones were excluded. Other exclusions included polycystic ovarian syndrome, hysterectomy, or oophorectomy.
  • Women with migraine were classified into a high frequency group if they experienced 10 or more headache days per month and into a low or moderate frequency migraine group if they had less than 10 headache days per month based on responses to the Migraine Disability Assessment Scale (MIDAS).
  • Women were classified as premenopausal (regular menstrual cycles without variation in cycle length), perimenopausal (cycle lengths varied by 7 or more days or periods of amenorrhea lasting 2-11 months) and postmenopausal (absent menstrual periods for at least 12 months) based upon responses to the questionnaire.
  • Women also completed the Patient Health Questionnaire Depression module (PHQ-9) and 3) and Allodynia Symptom Checklist-12 (ASC-12).  

The study authors conclusions were as follows:

  • To our knowledge, ours is the first study to demonstrate that high frequency headache is increased by 40-60% in women during the perimenopause and postmenopause compared to the premenopause.
  • The effect of the menopause and postmenopause on headache frequency is robust to adjustment by depression and allodynia.
  • The strongest predictor of high frequency headache was depression, with odds of high frequency headache being 131% higher for those with depression than without.
  • It is quite likely that the changes in ovarian hormones that occur during the perimenopause and the early postmenopause trigger headaches in these women.

"Persistance in scientific research leads to what I call instinct for truth." -Louis Pasteur

In a press release from the  AHS, Dr. Martin, study lead author, is quoted as saying, "These results validate the belief by many women that their headaches worsen during the transition into menopause." He adds, "We hope our work spurs researchers to develop novel treatments for migraine during this period given that many of the headaches encountered are thought to be hormonally triggered." Dr. Richard Lipton, study co-author adds, "We believe that both declining estrogen levels that occur at the time of menstruation as well as low levels that are encountered during the menopause are triggers of migraine in some women."

To appreciate the significance of the results and conclusions in this study, as well as the implications these findings have for our unique journeys with migraine, this article addresses:

  • the influence of estrogen on migraine.
  • depression and migraine.
  • association of allodynia in migraine with mood disorders and other chronic pain conditions.
  • perimenopause, menopause and migraine.

The influence of estrogen on migraine

Although the association between estrogen and migraine warrants further research, some of the explanations of how estrogen influences migraine that we need to be aware of include:

  • Genetic predisposition (MacGregor, 2010, Sacco et al, 2012). 
  • Estrogens may interfere with cellular excitability (MacGregor, 2009, Sacco et al, 2012). 
  • Estrogen is thought to influence the pain pathway associated with migraine by binding to its receptors on the trigeminal nerves. The trigeminovascular system consists of a network of cranial vessels and their trigeminal innervations that convey pain information to the central nervous system where pain is perceived. The pain response increases by the release of vasodilating neuropeptides especially calcitonin gene-related peptide-CGRP (Milan, 2012, and Sacco et al, 2012).
  • There is an interrelationship between estrogen and brain neurotransmitters, including serotonin, dopamine, norepinephrine, and endorphins. In particular, estrogen is believed to have a potent effect on the serotonergic system (Sacco et al, 2012).
  • Estrogen is associated with increased production of serotonin, reduced serotonin reuptake and decreased serotonin degradation (MacGregor, 2010).
  • Low serotonin levels have been linked to migraine.
  • Because serotonin enhances endorphins (natural analgesic found in the gray matter of the brain), low levels can increase sensitivity to pain. 

Depression and migraine

At this point, it is helpful for us to take a quick look at serotonin. Serotonin is a neurotransmitter in our brain important for managing mood, appetite, sleep and dreaming. For example, high levels make make us feel full, calm, relaxed and even drowsy. Low levels may cause us to feel anxious, irritable and depressed. 

Given the strongest predictor of high frequency headache in this study was depression, we need to know that several studies have linked migraine with mood and anxiety disorders. Some studies suggest mood and anxiety disorders are 2-10 times more prevalent among persons with migraine (comorbid) than in the general population. As well, increased migraine frequency (chronic migraine) is associated with higher rates of depression. (Buse et al, 2012). It has been suggested:

  • serotonergic and dopaminergic dysfunction underlies the comorbidity of depression and migraine (Buse et al, 2012), and
  • "conditions that are comorbid with migraine such as depression and anxiety have presumptive serotonergic mechanisms "(Shapiro, 2008, p 29).

Keeping these things in mind, we also need to be aware that a recent study on "Depression in women: windows of vulnerability and new insights into the link between estrogen and serotonin", (Lokuge, 2011), suggests the effects of estrogen on serotonin may have implications on female mood disorders such as premenstrual disorders and depression during pregnancy, postpartum, and during the menopausal transition.

Association of alloydynia in migraine with mood disorders and other chronic pain conditions

Now, let's peek at cutaneous allodynia (CA). CA is thought to be a result of central nervous system sensitization, which makes us hyperresponsive to otherwise innocuous tactile stimuli. For example, it may hurt to brush our hair or try to put it into a ponytail. As an attack progresses, we may experience sensitivity on extracranial locations such as the arm (Shapiro, 2008, p. 30).  Here, we should be aware that in an estimation of the prevalence and severity of  CA in headache sufferers, results of the AMPP Study (2008) showed CA was more common among migraineurs with female sex, high attack frequency, increased body mass index, disability and depression. 

That said, in a study examining the relationship of migraine with comorbid mood disorders and other chronic pain conditions, (Tietjen et al, 2009), results demonstrated symptoms of CA in migraine were associated with current anxiety, depression, and several chronic pain conditions, including irritable bowel syndrome, fibromyalgia and chronic fatigue syndrome.   

Peri-menopause, menopause and migraine

Holding on to what we have learned so far, it's time to review some general information about perimenopause, menopause, and migraine. To begin with, let's take a brief look at what happens to every women during perimenopause and menopause.

We need to know that as we age and enter perimenopause, our ovaries lose their ability to undergo ovulation and produce estrogen and progesterone. Our pituitary gland, via the hypothalamic-pituitary-ovarian axis, attempts to compensate by releasing follicle-stimulating hormone (FSH) to stimulate an ovarian follicle to produce estrogen. Transient increases of estrogen can occur during this time as FSH surges to stimulate remaining follicles. Menstrual irregularities occur, with sometimes prolonged and heavy menstruation mixed with periods of amenorrhea. When no more follicles remain for stimulation, estrogen levels dramatically decline and menstruation ceases.

Approximately 75-80% of women experience perimenopausal and menopausal symptoms.  Sources vary, but, in general, symptoms are thought to emerge up to 4 years prior to cessation of menses (perimenopause) and may persist for several years postmenopause. Symptoms are believed to be related to the withdrawal of estrogen. Many of them are thought to be associated with resultant changes in the central nervous system neurotransmitters, including serotonin, dopamine and norepinephrine.; and, serum electrolytes, including calcium, magnesium, sodium and potassium. They include:

  • Vasomotor disturbances ("hot flashes", "night sweats"). Although the exact cause is not known, vasomotor disturbances are believed to be caused by a narrowing of the thermoneutral zone in the brain related to the central nervous system neurotransmitters (Archer et al, 2011). In other words "our thermostat is broken". The feeling of intense heat that begins in our upper chest or neck, proceeds up to our face and head and may spread throughout our body, can last for several seconds or minutes and be accompanied by profuse perspiration. When "hot flashes" occur at night, they interrupt our sleep (insomnia). We need to know that they can be precipitated by heat, alcohol, spicy foods, and stress.
  • Sleep impairment.
  • Fatigue.
  • Depression, irritability and other mood disturbances.
  • Cognitive difficulties (loss of concentration, poor memory).
  • Weight gain. Numerous factors may be involved, including decreased metabolism; decreased serotonin levels, with resultant increase in food cravings; and, increased sympathetic nervous system activity, with resultant fluctuation in hormones like cortisol. It is important for us to know that weight gain during this period is often associated with fat deposit in the abdomen, which can increase our risk for developing insulin resistance, diabetes, hypertension and heart disease. Hypothyroidism may become prevalent and exacerbate symptoms like fatigue, weight gain, and mood changes.
  • Sexual dysfunction, including decreased libido.
  • Urinary incontinence.
  • Musculoskeletal pain.
  • Osteoporesis.

Now, let's relate these symptoms to migraine. As you can see, many of these symptoms are the same as (and may be easy to confuse with and exacerbate) migraine triggers (e.g., sleep impairment and fatigue), migraine symptoms (e.g. cognitive difficulties, musculoskeletal pain), and comorbidities (e.g. depression and anxiety).

To add to our discomfort, perimenopause and menopause are the very busiest years of our lives. Many of us are juggling family and career responsibilities, or perhaps, financial worries about college for our children and retirement for ourselves and our partners. The added stress can contribute to migraine as a trigger and a factor that makes us more susceptible to all of our triggers. When chronic, stress can deplete our estrogen levels, decrease our serotonin levels, increase anxiety and depression, and increase the frequency of our attacks. In addition, chronic stress may precipitate an earlier perimenopause and menopause.

"Are you ready for the ride of your life"?

Given I went through a surgical menopause at the age of 42 because of an ovarian cancer scare, I was not prepared for the "ride of my life". Twelve years later, I was diagnosed with chronic migraine, accompanied by medication overuse headaches.

Acknowledging surgical menopause has more severe consequences, to help you prepare and "cushion your ride" through a natural perimenopause and menopause, along with an accurate diagnosis for migraine, it would seem appropriate for you to know where you sit in the menopausal transition:

  • "Despite the increased prevalence of headache and migraine in women in their 40s, migraine is underdiagnosed in this population" (MacGregor, 2009).
  • If you have symptoms suggestive of perimenopause and menopause, along with headaches and other symptoms of migraine, it is important to talk to your doctor about all of your symptoms so they can be managed effectively, with the potential to reduce progression to chronic migraine, comorbidities like depression, unpleasant symptoms such as allodynia, and resultant disability. Blood tests to measure FSH and estrogen levels can determine where you are at in the menopausal transition.
  • The lack of an accurate diagnosis for migraine has been shown to be a barrier to our care,  which may include pharmacological and non-pharmacological interventions. (Buse. et al, 2014).

That said, while we wait for novel treatments to emerge, current pharmacological and non-pharmacological  management of migraine in perimenopause and menopause addresses the same issues as management of migraine at any time, with perhaps the addition of hormone replacement therapy (HRT) at the lowest dose possible to maintain a stable estrogen environment (MacGregor, 2012). It is important for you to know that the benefits and risks of HRT vary with the individual and warrant a thorough discussion with your physician.

In  conclusion, keep in mind our migraine brain likes peace and harmony (homeostasis). Avoiding your other migraine triggers, maintaining a healthy diet and lifestyle habits, and participating in a regular exercise program, along with stress management strategies like mind-body and relaxation techniques, and other modalities like acupuncture, can help you decrease the influence of perimenopause and menopause on your migraine attacks, take control of your attacks and, as I do now, assist you to live a happy and healthy third stage of your life, with migraine.

Sharron :)


American Headache Society. "Women With Migraine Experience More Headaches During The Menopausal Transition: Results From The American Migraine Prevalence And Prevention (AMPP) Study." Press Release: Wednesday, June 25, 2014, !2:01 a.m. EDT

Archer, D. F., Sturdee, D. W., et al (2011). "Menopausal hot flushes and night sweats: where are we now?" Climateric.  Oct 14;(5):515-28 doi: 10.3109/13697137.2011.608596. 

Bigal, M. E., Ashina, S., et al (2008). "Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology. Apr 22;70(17):1525-33. doi: 10.12/01.wnl.000031064

Buse, D. C., Silberstein, S. D., et al (2013). "Psychiatric comorbidities of episodic and chronic migrane." J. Neurol. Aug;260(8):1960-9. doi: 10.1007/s00415-012-6725-x.

Buse, D. C., Lipton, R., et al (2014). "Barriers to Chronic Migraine Care: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study." Poster presented at the 66th Annual Academy of Neurology Annual Scientific Meeting, Philadelphia, PA. April26-May 3.

Edyta, J. Frackiewicz, N. R., Cutler. (2000). "Women's Health Care During the Perimenopause." J Am Pharm Assoc. 40(6).  

Lanje, M. A., Dr., Bhutey, A. K., Dr. et al (2010). "Serum Electrolytes During Different Phases of Menstrual Cycle." International Journal of Pharma Sciences and Research.  Vol.1(10), 435-437. ISSN: 0975-9492.

Lokuge, S., Frey, B. N., et al (2011). "Depression in women: windows of vulnerability and new insights into the link between estrogen and serotonin." J Clin Psychiatry.  Nov;73(11):e1563-9. doi: 10.4088/JCP.11com07089.  

MacGregor, E. A. (2009). "Estrogen replacement and migraine." Maturitas. May 20;63(1):51-5. doi: 10.1016/j.maturitas.2009.03.016.   

MacGregor, E. A. (2009). "Migraine Headache in perimenopausal and menopausal women. " CurrPain Headache Rep. Oct;13(5):399-403.

MacGregor, E. A. (2010). "Menstrual Migraine: Therapeutic Approaches." Ther Adv Neurol Disord.  May;3(3):197.

MacGregor, E. A. (2012). "Perimenopaual migraine in women with vasomotor symptoms." Maturitas. Jan;71(1):79-82. doi: 1016/j.maturitas.2011.11.001.

Martin, V. T., Pavlovic, M. J., et al (2014). "The menopausal transition is associated with higher headache frequencies in women with migraine: Results from the American Migraine Prevalence and Prevention (AMPP) Study." Poster presented at the 56th Annual Meeting of the American Headache Society. Los Angeles, CA. June 25-29th. 

Milan, A., Puri, V., Puri, S., PhD.(2012). "Effects of estrogen on the serotonergic system and calcitonin gene-related peptide in trigeminal ganglia of rats." Ann Neurosci. Oct;19(4): 151-157. doi: 10.5214/ans.0972.7531.190403.

Murray, S., M.S., R.N. Migraine: Identify Your Triggers, Break Your Dependence on Medication, Take Back Your Life-An Integrative Self-Care Plan For Wellness. San Francisco: Conari Press, 2013.

Sacco, S., Ricci, S. et al (2012). "Migraine in women: the role of hormones and their impact on vascular diseases." J Headache Pain. Apr;13(3): 177-189. doi: 10.1007/s10194-012-0424-y.

Shapiro, R. E. (2008). "Pathophysiology and Genetics of Migraine and Cluster Headache." In M. Levin (Ed.), Comprehensive Review of Headache Medicine. (pp 21-32). New York: Oxford University Press.

Tietjen, G. E., Brandes, J. L., et al (2009). Allodynia in migraine: association with comorbid conditions." Headache. Oct;49(9): 13333-44. doi: 10.1111/j.1526-4610.2009.01521.x.

Sharron is a health and wellness author. A person with migraines herself, her most recent book is, "Migraine..."

Follow Sharron on twitter @murraysharron, her Facebook page SharronMurray, MS, RN, and her website

This article is not intended as a subsitute for medical advice. If you have concerns about your health or nutrition, please see a qualified professional.

Copyright, October: 2014, Sharron E. Murray 


Family Burden of Chronic Migraine - Heartbreaking results of the CaMEO study - And hope for change


"The practice of patience toward one another, the overlooking of another's defect, and the bearing of one another's burdens is the most elementary condition of all human and social activity in the family, in the professions, and in society." - Lawrence G. Lovasik 

An estimated 37-38 million Americans live with migraine, a debilitating neurological disease with episodic manifestations known as migraine attacks, which may become chronic. Although the frequency and duration of our attacks varies between us as individuals, those of us who have migraine are familiar with the personal and family burden of our disease.

However, given migraine is often referred to as "just a headache" that will disappear if we take a "pill", it is believed that the burden of migraine is not well understood by many who do not experience it. Keeping this in mind, this article addresses the: 

  • personal burden of migraine,
  • family impact of migraine, and
  • the results of a new study, "Family Burden of Chronic Migraine to the Migraineur".  

Personal burden  

In a review of the literature, "The burden of migraine to the individual sufferer: a review," (Dahlof and Solomon (1998), the authors report, "Migraine attacks can have a profound effect on the day-to day lives and well-being of the sufferer." They go on to say, "In the long term, migraine may cause profound emotional changes and result in coping strategies that interfere with working, social and family life and many normal activities. These effects are apparent in quality of life studies on migraine patients."

Family impact of migraine

To assess the impact of migraine on family life both from the perspective of those with migraine and from the perspective of their partners (Lipton, Bigal et al, 2003), individuals in the USA and UK with six or more migraine attacks per year and living as married with partners were asked, along with their partners, to participate in a computer-assisted telephone interview. Results of the study showed: 

  • 85% reported substantial reductions in their ability to do household work and chores.
  • 45% missed family social and leisure activities.
  • 32% avoided making plans for fear of cancellation due to headaches.
  • 50% believed that because of migraine, they were more likely to argue with their partners, 52% children.
  • 52-73% reported other adverse consequences for their relationships with their partner, and children, and at work.
  • 36% believed they would be better partners but for their headaches.

Of the participating partners, 29% felt that arguments were more common because of headaches and 20-60% reported other negative effects on relationships at home.

Another study on the impact of migraine on work, family, and leisure among women 18-35 years of age in Israel and eight European countries (Dueland, Leira, et al, 2004), found substantial migraine-related impairment of productivity at work and school as well as of family and leisure time.   

Family burden of chronic migraine (CM)

Now, we come to the focus of this article. In general, CM is defined as migraine with headache days occurring 15 or more days per month. About 3-7 million people in the US live with this painful and debilitating condition.

To show that CM is a burdensome and difficult condition, not only for the people who live with it but also for the people they love, a web-based study of 994 men and women with CM was used to measure the perceived nature and extent of CM-related burden on family relationships and activities (Buse, Dodick, et al, 2014). The results presented at the 56th Annual Meeting of the American Headache Society revealed:

  • 64.1% of respondents felt their headaches made their partners lives difficult, and 72.5% felt they would be better partners if they did not have headache.
  • 70.2% of respondents reported being easily angered or annoyed by their partners because of headache, and 67.2% stated they avoided sexual intimacy because of their headaches.
  • 64.4% experienced guilt about how their headaches affect their partner.
  • 59.1% felt that they would be better parents if they did not have headache.
  • 20% of respondents reported missing a family vacation within the previous year and 53.6% had reduced enjoyment while on vacation because of headache.

Females consistently reported lower percentage rates of absenteeism because of headaches than males across many activities. The researchers attributed this to possible differences in headache severity between genders, differential denominators in that females may have more activities and responsibilities, or females may feel more obliged to keep commitments despite migraine occurrence. When asked about these findings in an interview, the lead author of the study, Dawn C. Buse, Ph.D., said, " females (mothers and wives) may simply feel they cannot miss a family event and soldier on despite debilitating pain and associated symptoms". 

In the same interview, when asked if the study results surprised her, Dr. Buse replied, "The results are heartbreaking, but not surprising. I hear how difficult CM is on family life from my patients on a daily basis. I have shared the results of this research with several people with CM over the past few weeks and they say that these data describe their lives."

"Families are the heart of our society. We need to do everything that we can to nurture, support, and protect them." - Dawn C. Buse 

As the interview continued, when asked what consumers and health providers should take away from the study, Dr. Buse responded as follows:

"CM is a debilitating disease that affects all aspects of life including roles, responsibilities, and relationships with the family. We hope that people living with CM realize they are not alone in feeling guilty, worried, or sad about how their condition affects their family. We hope that by shedding light on this experience, people with CM and their families will realize that this is a difficult condition for most people who live with it.

We hope that people who do not have migraine may understand a little better the far reaching burden this condition imparts on sufferers, and hope they will be a little more caring and understanding in response to a friend, colleague or family member with CM. We also hope that by shedding light on the normal and common response to this condition, that we can help remove the stigma and shame that those who bravely live with CM may feel.

We also hope that health care professionals will realize the scope of the burden of this condition on sufferers, and be diligent in providing accurate diagnoses and thorough treatment plans, which include both appropriate pharmacological and non-pharmacological (e.g. cognitive behavioral therapy, biofeedback, relaxation training) interventions. We hope that they will recognize that feeling sad, overwhelmed, guilty, frustrated, irritable, depressed and anxious is common for people living with CM and that they will encourage and facilitate patients seeking professional mental help when these feelings become overwhelming.

We hope that third party payers, policy makers, and government agencies who fund research will recognize the serious and damaging effects of this condition on families and put necessary funds towards research and care."

"Hope begins in the dark, the stubborn hope that if you just show up and try to do the right thing, the dawn will come." - Anne Lamott 

For me, I have been on a roller coaster ride with migraine since I was five years old. When I was in my early forties, at the height of my career and deeply involved in family responsibilities, my migraines began increasing in frequency and severity. At the age of 54, I was diagnosed with CM and medication overuse headache (MOH) and my life was put on hold. Like so many others, a career I loved disappeared and I struggled to cope with day-to-day living and several of the findings we have looked at.  

However, I am extremely fortunate and my story is one of hope. With the help of two amazing doctors and a combination of a preventive medication (which I have been able to reduce) and non-pharmacological strategies like biofeedback, meditation, breathing techniques, acupuncture and healing touch, in my mid 60's I was able to remit from CM and MOH to infrequent episodic migraine (EM).  Consequently, my pain, disability and family burden is much, much less and I enjoy a wonderful quality of life.

I share the results of this study, along with Dr. Buse's interview, in the hope that with the assistance of informed health care professionals, increased funding for research and accurate diagnoses and appropriate pharmacological and non-pharmacological interventions, people who have episodic migraine (EM) can be prevented from progressing to CM, those who live with CM have the opportunity to remit, and if remittance is not possible "that those who bravely live with CM" are able to lead a better quality of life, and because of a more compassionate society, without the stigma they may feel.  


Buse, D., C., Dodick, D. W., et al (2014). "Family Burden of Chronic Migraine to the Migraineur: Results of the CaMEO study". Poster presented at the 56th Annual Meeting of the American Headache Society. Los Angeles, CA. June 25th-29th.

Buse, D. C., director, Behavioral Medicine, Montefiore Headache Center and associate professor, Clinical Neurology, Albert Einstein College of Medicine. Interview ( 2014) presented with permission.

Dahlof, C. G., & Solomon G., D., (1998). "The burden of migraine to the individual sufferer: a review." Eur J Neurol.  Nov;5(6):525-533.

Dueland, A., N., Leira, R., et al (2004). "The Impact of Migraine on Work, Family and Leisure Among Young Women - A Multinational Study." Curr Med Res Opin.  20(10).    

Lipton, R.B., Bigal, M.,E., et al (2003). "The family impact of migraine: population-based studies in the USA and UK. Cephalalgia. Jul;23(6):429-40.  

Sharron Murray MS, RN is an author and coauthor CaMEO Study, "Life With Migraine". Currently, Sharron is active in the migraine community as a writer, advocate, American Migraine Foundation Partner, moderator for the American Migraine Foundation "Move Against Migraine" Facebook Group, and member of the National Headache Foundation Patient Leadership Council. 

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN, and her website  

This article is not intended as a substitute for medical advice. If you have concerns about your health or nutrition, please see a qualified professional.

Copyright, 2014, Sharron E. Murray




The spectrum of migraine: Barriers to our care - Gaps in diagnosis, treatment and knowledge of individuals with CM in the US


"Awareness is the greatest agent for change." - Eckhart Tolle

Migraine is a debilitating neurological disease characterized by migraine attacks. The disease affects about 38-39 million of us in the US. 

We need to be aware that as our attacks increase in frequency, so do a host of other problems that can complicate our treatment and contribute to our headache-related disability. In an effort to help us have a better understanding of the challenges we may face and offer suggestions on ways to overcome these burdens and receive optimal care, this article addresses: 

  • the spectrum of migraine and associated characteristics, and
  • results of a new (CaMEO) study: gaps in diagnosis, treatment, and knowledge of individuals with chronic migraine. 


To begin with, let's review what happens as we progress from episodic to chronic migraine in relation to our diagnosis; comorbidities; sociodemographic, disability, and employment characteristics; and, risk factors for progression of episodic to chronic migraine (CM).


In a study that estimated remission rates of subjects with CM, identified predictors of CM remission, and assessed the influence of remission on headache-related disability, (Manack, Buse et al, 2011), our migraines were classified as follows: 

  • Episodic migraine (EM) includes a range of attack frequency with headache days 0-14 per month. If we have headache days 0-9 days per month, we are believed to have low-frequency EM (LFEM). If our headache days occur 10-14 days per month, we have high frequency EM (HFEM). 
  • CM is defined by attack frequency with headache days greater than 15 days per month.

Comorbidities and Sociodemographic, Disability, and Employment Charactersitics  

We need to be aware that, as we progress along the spectrum from LFEM to CM:

  • our comorbidities (obesity, heart disease, angina, high cholesterol, high blood pressure, stroke, circulation problems, arthritis, chronic pain disorders, pulmonary disorders, anxiety and depression) and our individual, family, and societal burdens increase.
  • some psychiatric comorbidities, including depression, are associated with worsening disease progression and disease outcomes, including suicide attempts (possible these comorbidities may be related to shared biological, environmental or genetic risk factors), (Buse, Silberstein et al, 2013).  
  • people with HFEM are thought to share characteristics similar to CM.
  • people with CM are significantly more disabled than those who have EM, have higher levels of unemployment, lower personal and household incomes, increased psychiatric and medical comorbities, and have a greater impaired quality of life both inside and outside the home (Lipton, Serrano, et al, 2014).
  • studies have shown that each year about 2.5% of those of us with EM develop CM.

That said, returning to the study by Manack and Buse, results showed:

  • CM remitted to EM at a 2-year transition rate of 26%.
  • patients with allodynia ( neurons are abnormally excited leading to a reduced pain threshold and hypersensitivity to stimuli); highest frequency of migraines (25-31 days); and, those using preventive medications were less likely to remit (authors mention preventive medications may also increase remission rates but in the study the effects may have been offset by factors like high headache frequency, wrong medication or dose, and poor compliance with regimen).  
  • persistent CM demonstrated increases in headache related disability.
  • remitted CM demonstrated decreases in headache related disability.  

Given this information, it would seem that, as the study authors propose, an accurate diagnosis is necessary to determine where, as individuals, we fit in the migraine spectrum. Once our position is established, the goal of our treatment can be directed toward reducing attack frequency so that:

  • LFEM does not progress to HFEM or CM
  • CM remits to EM.

Risk factors for progression of EM to CM

In line with this approach, a review defining the differences between EM and CM, (Katsarava, Buse, et al, 2011), outlined non-modifiable and modifiable factors that are believed to increase our risk of progression from EM to CM. This is important for us to know because once we identify our personal risk factors, we are able to work with our doctor to improve or eliminate our modifiable ones, decrease the frequency of our attacks and, if we have CM, increase our chances for remission.

Non-modifiable risk factors are reported as:

  • age,
  • female sex,
  • Caucasian race,
  • low education level,
  • low socioeconomic status, and
  • head injury.

Modifiable risk factors are listed as:

  • obesity,*
  • depression,*
  • anxiety,
  • other chronic pain disorders,*
  • stressful life events,
  • medication overuse, and
  • caffeine use/misuse.

*As mentioned above, these risk factors may be comorbid with migraine. Here, it is beneficial for us to know that along with directing treatment towards our personal comorbidities and individual risk factors, preventive pharmacological and non-pharmacological treatments and strategies have been shown to help decrease the frequency of our attacks.  


Now, let's look at CM. About 3-7 million people in the US are believed to live with CM. In an effort to bring more awareness to the individual, society and the health care systems about the burden of CM, a recent study (CaMEO) examined self-reported headache diagnosis rates, health care consultation patterns, and knowledge and use of preventive treatments among a large, US population-based sample of individuals with CM (Buse, Lipton et al, 2014).

Gaps in diagnosis, treatment and knowledge

In this instance, headache types were classified as migraine, CM/transformed migraine (TM), or CM/TM/chronic daily headache (CDH). Results demonstrated:

  • rates of headache subtype diagnosis and consultation for headache were low among individuals with CM (most CM respondents did not receive a diagnosis of CM, even among those consulting  "headache specialists"). This is a barrier to care as diagnosis is necessary for designing an optimal treatment plan, which may include diagnosis-specific treatments.
  • those meeting CM criteria who did seek care from a "headache specialist" were more likely to report being diagnosed with CM, but also with migraine, TM and CDH.
  • awareness of daily preventive medication for headache was high, especially among those currently seeing a "headache specialist", although awareness of injection was low in the same group, and even lower among those who reported they were not under the care of a "headache specialist".
  • knowledge and use of empirically and guideline-supported non-pharmacological treatments for migraine prevention was low among those under the care of a "headache specialist" and very low among those not under the care of a "headache specialist".

Awareness of preventive treatments and strategies among all respondents with CM was as follows:

  • avoiding things or activities that trigger my headaches - 62.7%
  • taking a daily prescription medication - 53.0%
  • receiving injections every few months - 17.4%
  • vitamins or herbs - 33.5%
  • biofeedback - 16.8%
  • relaxation techniques (meditation, visual imagery, diaphragmatic breathing) - 47.5%
  • cognitive behavioral therapy (CBT)/psychotherapy - 12.9%
  • acupuncture - 33.5%
  • yoga - 29.2%
  • exercise - 48.8%
  • weight management/dieting 34.6%
  • not aware of any ways to prevent headaches or reduce their severity - 17.9%
  • don't remember - 1.9% 

The authors conclude these data demonstrate gaps in the diagnosis, treatment, and knowledge of individuals with CM in the US and offer opportunities for improvement in care.

Opportunities for improvement in care

"The natural healing force within each of us is the greatest force in getting well." - Hippocrates

Another finding in the CaMEO study showed more respondents who were under the care of a "headache specialist" consulted a "nonprescribing" health care professional for a headache than those who were not under such care. These "nonprescribing" health care professionals included: chiropractors, massage therapists, acupuncturists, physical therapists, psychologists or other health care professionals, naturopaths, and occupational therapists.

A recent article addressed the use of complementary alternative medicine, "CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don't," (Cowan, 2014). The author suggests "that until such time as the body of scientific literature adequately addresses non-conventional approaches, physicians must acknowledge and understand, as best as possible, CAM approaches which are in common use by patients." 

Given this information, it is important to know that even though more research is necessary to establish evidence-based guidelines for some non-pharmacological therapies, many of us use these treatments and strategies because along with quieting our minds, calming our bodies, combating feelings of hopelessness and despair, and decreasing the frequency and severity of our attacks, they give us a feeling of empowerment. As well, because medications alone do not work for a number of us and lead to medication overuse headaches,  (MOHs) they give us a viable option for therapy.  

"The difference between a stumbling block and a stepping stone is how high you raise your foot." -Benny Lewis.

To overcome barriers to our care, it would seem that those of us with migraine need to:

  • receive an accurate diagnosis within the migraine spectrum, including CM,
  • work with our doctors and other health care professionals to identify and manage our comorbidities and risk factors, and
  • as research continues to unfold, increase our knowledge as we share and explore pharmacological and non-pharmacological treatment options with our doctors and other health care professionals to improve our care.

For me, effective communication with my doctor facilitated my diagnosis of CM and MOHs. And, even though they were foreign to me at the time, non-pharmacological therapies like biofeedback, acupuncture, meditation, diaphragmatic breathing, and healing touch, became instrumental in my remittance to EM. As well, along with trigger management, regular exercise, and a healthy diet and lifestyle habits, they continue to be the foundation of my remission.


Cowan, R.P., M.D., F.A.H.S., F.A.A.N. (2014). "CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don't." Headache Currents.  April, 25. DOI: 10.1111/head.12364.

Buse, D., C., Lipton, R., et al (2014). "Barriers to Chronic Migraine Care: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study" Neurology. April 8, 2014 vol. 82 no. 10 Supplement I9-1.004.

Buse, D., C., Lipton, R., et al (2014). "Barriers to Chronic Migraine Care: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study." Poster presented at the 66th annual Academy of Neurology Annual Scientific Meeting. Philadedelphia, PA. April 26- May 3.

Buse, D., C., Silberstein, S., D., et al. (2013). "Psychiatric comorbidities of episodic and chronic migraine." J Neurol.  Aug;260(8):1960-9. DOI 10.1007/s00415-012-6725-x.

Lipton, R., Serrano, D., et al. (2014). "Sociodemographic, Disability, and Employment Differences Between Persons With Chronic and Episodic Migraine: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study". Neurology. April 8, 2014 vol. 82 no.10 Supplement S41.002.

Katsarava, Z., Buse, D.C., et al. (2012). "Defining the Differences Between Episodic Migraine and Chronic Migraine." Curr Pain Headache Rep. February; 16(1): 86-92.

Manack, A., Buse, D.C., et al. ( 2011). "Rates, predictors and consequences of remission from chronic migraine to episodic migraine." Neurology.  Feb 22;76(8):711-8. doi: 10.1212/WNL.0b013e31820d8af2.

Sharron Murray MS, RN is an author and coauthor CaMEO Study, "Life With Migraine". Currently, Sharron is active in the migraine community as a writer, advocate, American Migraine Foundation Partner, moderator for the American Migraine Foundation "Move Against Migraine" Facebook Group, and member of the National Headache Foundation Patient Leadership Council. 

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN

This article is not intended as a substitute for medical advice. If you have specific concerns about your health or nutrition, please contact a qualified professional. 

Copyright 2014  Sharron E. Murray

Updated February, 2019


Migraine, Comorbidities, and Exercise - A delicate balance


"Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it." -Plato

A number of recent studies have shown aerobic exercise may yield positive outcomes for migraine and consequently regular exercise is recommended as an intervention for migraine management and prevention. However, for those of us with migraine disease, the reality is exercise can be a "damned if you do and damned if you don't" situation. For example, if we have pain and exercise, we may aggravate our pain. If we are pain-free and exercise, we may trigger a migraine attack. On the other hand, if we don't exercise because of pain or fear of a migraine attack, we deny ourselves the option of a preventive treatment for migraine.

In addition, given the role of exercise in the preservation of health and promotion of wellness, lack of exercise deprives us of the health benefits regular activity provides for a number of diseases and disorders shown to be comordid with migraine, including obesity, cardiovascular disease (heart disease, angina, high cholesterol, high blood pressure, stroke), circulation problems, arthritis, chronic pain disorders, anxiety, and depression (Buse, Manack, et al, 2010). This is important for us to know because:

  • an increase in the frequency of our attacks is correlated with an increase in a number of these comorbidities and may contribute to our progression from episodic to chronic migraine; 
  • depresssion, anxiety, and chronic pain disorders have all been associated with chronic migraine at higher rates than episodic migraine (Buse & Silberstein, 2013); 
  • and, the effects of depression, anxiety, and obesity are additive (Katsarava, Buse et al, 2012). For example, related disability increases when obese individuals have comorbid depression or anxiety compared to non-depressed obese individuals.  

How, then, do we effectively incorporate exercise into our treatment plans?

"If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health". - Hippocrates.

Perhaps, for those of us with migraine, our answer lies in the words of Hippocrates. We find the right amount of exercise, not too little and not too much, to suit our individual needs. 

To help us find the right amount of exercise and tailor the activity to meet our individual needs, this article addresses:

  • the health benefits of exercise.
  • the types of exercise we should consider.

The health benefits of exercise

The health benefits of exercise are numerous. As you read through the following list, keep in mind your personal comorbidities and risk factors for progression from episodic to chronic migraine.

Regular exercise can: 

  • improve circulation to our extremities and warm up our cold hands and feet.
  • boost our energy and help with fatigue.
  • promote hormonal stimulation and enhance our sexual function.
  • increase our metabolism, burn fat, help us maintain a healthy weight, and prevent obesity.
  • balance our blood sugar, decrease insulin resistance, and help prevent diabetes.
  • improve our sleep by restoring normal body rhythms.
  • elevate our HDL (good) cholesterol and help protect us from heart disease.
  • decrease or normalize our blood pressure and help decrease the risk of stroke. 
  • improve our muscle tone, strength and endurance.
  • strengthen our bones, cartilage and ligaments and lower our risk for osteoporesis.
  • increase our serotonin and dopamine levels and help reduce anxiety and depression.
  • improve our mental function.
  • raise our endorphin levels (bodies' natural pain reliever).
  • reduce levels of our stress hormones, promote calmness and relaxation, and decrease the effects of stress on our bodies.

Types of exercise we should consider

To begin with, if you haven't exercised in a long time because of pain, fear of a migraine attack, or other health considerations, you should have a physical examination by your doctor or other health care professional. At your appointment, you might want to ask for a consultation with a qualified physical therapist to plan and initiate an exercise program that is best for your situation. Also, if you pick an exercise that is new to you, always seek guidance from a qualified instructor to learn the proper technique. 

Keep in mind, any form of activity that moves our bodies, increases the work of our heart and lungs, and burns calories is considered exercise. These activities include walking, running, gardening, climbing stairs, working out at the gym, sports, swimming, hiking, biking, dancing, yoga and tai chi.   

That said, for those of us with migraine, the type of exercise we choose, apart from the overall health benefits, may be significant in either reducing the frequency and severity of our migraine attacks or precipitating a migraine attack. Low - to moderate - intensity exercises such as walking, cycling, and yoga, as well as sports that rely on endurance rather than power like, swimming, jogging, and tai chi are thought to decrease the frequency and severity of our migraine attacks by:

  • increasing our serotonin levels.
  • raising our endorphin levels.
  • helping in stress reduction.

Here, it is interesting to note, "A Study to Evaluate the Feasibility of an Aerobic Exercise Program in Patients With Migraine", (Varkey et al, 2009), demonstrated moderate-intensity exercise (indoor cycling), including warm-up and cool-down periods, was well tolerated by the patients. Patients were reminded to consider stress, proper sleep, good nutrition and hydration during the study. 

Another study aimed to evaluate the effects of exercise in migraine prevention (Varkey et al, 2011) showed exercise (based on indoor cycling) was found to be equal to the well-documented methods of relaxation and topiramate with regard to the reduction of migraine frequency. The report goes on to say this non-pharmacological approach may be a treatment option for patients with migraine, who do not benefit from or do not want to take daily medication. And, adds "from a wider health-based perspective, it should be stressed that patients with migraine are less physically active than the general population, and that exercise has positive effects in terms of general well-being and the prevention of disease."

In addition, a pilot study, "Aerobic exercise as a therapy option for migraine," (Darabaneanu et al, 2011), showed migraine patients in the exercise group (running program) had both a reduction in the number of migraine days per month and the intensity of attacks. As well, the increase in fitness level resulted in a lowered stress level. 

At this point, we need to know that strenuous and high-intensity exercises such as running, jumping rope, and heavy weight lifting, as well as sports that include short bursts of speed alternated with periods of moderate-intensity like singles tennis, basketball, and soccer, are believed to precipitate or aggravate our attacks because: 

  • although they increase our endorphins, they also increase our epinephrine levels heart rate and blood pressure.
  • if prolonged, the increase in our epinephrine levels may propel our bodies into the "fight or flight response" and decrease our serotonin levels.
  • some exercises, like heavy weight lifting, may cause muscle tightness or spasms in our upper body.

In a recent study that investigated the lifetime prevalence of exercise-triggered migraine (ETM) attacks and if patients with ETM experienced specific prodromal or ictal migraine symptoms (Koppen and vanVeldhoven, 2013), results included

  • life time prevalence of ETM attacks was high regardless of migraine type (with or without aura) or gender.
  • possible rise in cardiac output and systolic blood pressure triggers ETM attacks.
  • those experiencing ETM attacks more frequently had neck pain as the initial symptom explained by activation of upper cervical nerve fibers and release of neuropeptides.
  • higher brain lactate levels were associated with higher migraine frequency and could explain the triggering of migraine attacks by high-intensity exercise.
  • the majority of patients stopped practicing high-intensity exercise, but were able to continue other low-intensity exercise.  

"Movement is a medicine for creating change in a person's physical, emotional, and mental states."  - Carol Welch

Holding on to the delicate balance of migraine, comorbidities, and exercise, in this article, we have learned lack of movement because of migraine attacks deprives us of a valuable health activity, along with participation in the sports we enjoy, and negatively affects our physical, emotional, and mental states. On the other hand, low-to -moderate intensity exercises may decrease the frequency and intensity of our attacks and help us enjoy the benefits of better overall health and quality of life, including enhancing our self-efficacy for migraine management (capability and confidence).

A few other things to keep in mind include

  • if we feel a migraine coming on, a short walk in the fresh air might help.
  • exercising during a full blown attack may be extremely painful and is probably best avoided.
  • *if we can't talk without stopping for a breath during any form of exercise, then the activity it is too strenuous or intense.
  • exercising in the heat is not wise as the activity may trigger a migraine from heat intolerance.
  • stay hydrated, and avoid hypoglycemia.
  • wear a hat and sun glasses when exercising outdoors.
  • should not exercise close to bedtime as it may interfere with sleep.
  • pick something fun.
  • set realistic goals and, given our unique situations, do what we can do to achieve them.

*Aerobic (cardiovascular) recommendations for moderate-intensity exercise include at least 30 minutes of the activity per day, repeated 5 days a week, along with strength and stretching exercises twice a week for flexibility and stamina. However, we can break up our activities into fifteen minute periods, three times a day, and achieve the same benefits. Then, increase the time as we get stronger. As well, walking is a great way to start. 

Finally, we should be aware in a recent publication, "Aerobic Exercise for Reducing Migraine Burden: Mechanisms, Markers, and Models of Change Processes," (Irby, Bond, Lipton, et al, 2016), the authors reviewed 9 studies that incorporated aerobic exercise for migraine. All studies reported a  reduction in headache frequency and/or intensity. Despite the apparent consistency, Irby, Bond, Lipton, et al, report it is a challenge to draw conclusions about the independent effects of exercise as published in most reports to date. The authors then proceed to explore mechanisms and pathways that reduce the frequency, duration, severity or associated disability with migraine in conceptual models linking aerobic exercise and migraine improvement. They articulate a variety of potential mechanisms and markers that could account for the effects of aerobic exercise on migraine; encourage and facilitate further research; and, hopefully benefit migraineurs, including the many who remain suboptimally treated, by providing a new therapeutic avenue to established interventions for migraine. 

*Note: "A systematic review and meta-analysis was performed to investigate the result of aerobic exercise on the number of migraine days, duration and pain intensity in patients with migraine...Read the full review, "The effect of aerobic exercise days on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis", published January, 2019, in the Journal of Headache and Pain.


Buse, D.C., Manack, A., Serrano, D., et al. (2010). "Sociodemographic and comorbidity profiles of chronic migraine and episodic migraine sufferers." J Neurol Neurosurg Psychiatry. Apr;81(4):428-32. doi: 10.1136/jnnp.2009.192492. 

Buse, D.C., Silberstein, S.D., et al. (2013). "Psychiatric comorbidities of episodic and chronic migraine." J Neurol. Aug;260(8):1960-69. doi: 10.1007/s00415-012-6725-x.  

Darabaneau, S., Overath, C.H, et al. (2011). "Aerobic Exercise as a therapy option for migraine: a pilot study". Int J Sports Med.  Jun;32(6):455-60. doi:10.1055/s-0030-1269928.

Irby, Meghan, B., MS,  Bond, Dale, PhD,  S., Lipton, Richard, B., MD, et al. (2016). "Aerobic Exercise for Reducing Migraine Burden: Mechanisms, Markers, and Models of Change Processes". Headache. Feb;56(2): 357-369.

Katsarava, Z., Buse, D.C., et al. (2011). "Defining the Differences Between Episodic Migraine and Chronic Migraine." Curr Pain Headache Rep. February; 16(1):86-92.                 

Koppen, H., & van Veldhoven P., LJ., (2013). "Migraineurs with exercise-triggered attacks have a distinct migraine." The Journalof Headache and Pain. 14:99 doi:10.1186/1129-2377-14-99.    

Murray, S., M.S., R.N., Migraine; Identify Your Triggers, Break Your Dependence on Medication, Take Back Your Life - An Integrative Self-Care Plan For Wellness. San Francisco: Conari Press, 2013.

Ni. M., L.Ac., D.O.M., PH.D. Secrets of Self-Healing. New York: Avery, 2008.

Varkey, E., RPT, Cider, A.,RPT et al. (2009). "A Study to evaluate the feasibility of an aerobic exercise program in patients with migraine." Headache."  Apr;49(4):563-70. doi: 10.1111/j. 1526-4610.2008.01231.x. 

Varkey, E., Cider. A., et al. (2011). "Exercise as migraine prophylaxis: A randomized study using relaxation and topiramate as controls." Cephalalgia. October; 31(14): 1428-1438. doi: 10.1177/0333102411419681.

Sharron Murray MS, RN is an author and coauthor CaMEO Study, "Life With Migraine". Currently, Sharron is active in the migraine community as a writer, advocate, American Migraine Foundation Partner, moderator for the American Migraine Foundation "Move Against Migraine" Facebook Group, and member of the National Headache Foundation Patient Leadership Council.  

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN, and her website

This article is not intended as a substitute for medical advice. If you have specific concerns about your health or nutrition, please contact a qualified professional.

Updated, February, 2019.

Copyright 2014, Sharron E. Murray


Effective use of medications for migraine relief -5 Ways to overcome unmet needs and improve our treatment outcomes


"Half of the modern drugs could well be thrown out of the window, except that the birds might eat them." -Martin Henry Fischer

In the throes of a violent migraine attack, we all want a drug that will eradicate our pain. Unfortunately, for many of us, such a drug does not exist. In an effort to relieve our pain, we plow through unpleasant side effects of our medications, may exceed the recommended dose of one or more of the drugs we take, accidentally take too much of a drug, or take a medication more often than we should and end up with medication overuse headaches (MOHs). We become vulnerable to anything, or anyone, that offers to put an end to our agony in the name of a "cure" and, in our frustration, may feel like tossing the lot of our medications out the window.

In an important step toward reducing barriers to our care and improving treatment outcomes, a recent study examined  unmet treatment needs among persons with episodic migraine (Lipton, Buse, et al, 2013). Results showed the three most common unmet needs were:

  • moderate or severe headache-related disability,
  • treatment dissatisfaction related to efficacy (effectiveness), safety and overall satisfaction of a comprehensive list of acute and preventive medications, and
  • excessive opiods and/or barbiturate use or probable dependence.

To help us overcome these unmet needs and achieve optimal therapy, this article adapts physician guidelines for successful migraine management (American Headache Society, PDF), as patient-centered strategies. Let's take a look:

1. Establish a partnership with our physicians:

  • The role of our physicians is to help us understand the nature and mechanism of migraine disease and the non-pharmacological and pharmacological options that are available for treatment. In other words, our doctors are guides to help us make wise choices for our migraine treatment programs, including how they fit into our overall health.
  • Our role as patients is to reach the best possible decision about choices for treatment through an educated discussion with our doctor. This should involve an evaluation of our lifestyle, as well as attitudes and beliefs about taking medication (side effects), herbs , and supplements .

 2. Educate ourselves:

  • To facilitate an educated discussion, ask questions and encourage a dialogue with our physicians.
  • Listen to the answers with an open mind.  For example, you may want a medication your doctor denies out of concern for your overall health, or that the medication may harm you. In my case, the best thing a doctor ever did for me was tell me he wouldn't refill my Imitrex prescription for 18 pills a month.
  • If you are confused about the information your doctor relays, ask for clarification. Knowledge gives us a feeling of empowerment and helps us actively participate in our management program. In the same example, this stunning news came in a visit to a new doctor. When I asked for clarification, he told me I had MOHs (known as rebound at that time) and we would have to explore other ways to manage my attacks.

3. Work with our physicians to set realistic goals

  • While being completely pain-free might not be an option, decreasing the severity of pain and frequency of attacks is achievable.
  • Given our individual situations, identify ways to reduce the frequency of our attacks and limit the negative effects of migraine on our daily lives. In my case, my doctor and I decided that I needed to be more diligent about trigger management; eating and sleeping habits; participation in the biofeedback and diaphragmatic breathing exercises I had been taught, but rarely practiced; and, give acupuncture a chance. As well as decreasing the frequency of my attacks, this plan allowed me to wean off Imitrex at my own pace, without any harmful effects.
  • If preventive medication is going to be part of our therapies, identify side effects that we find intolerable. In my situation, I have a condition, which makes me blister from many preventive medications, including antiepileptics. As well, I like to exercise, which rules out beta blockers like propranolol. Other examples include, if weight is a problem for you, drugs with a high risk of increasing weight should be avoided.

4. Work with our physicians to establish a tailored, non-pharmacological treatment plan:

  • Keep a diary (notebook, electronic, or you can always mark up a calendar like I did) to help our doctors identify possible triggers and suggest strategies to help us minimize or avoid them.
  • A diary can also help our doctors recognize the frequency and patterns of our migraine attacks, identify the severity of our pain and functional disability; assess the effectiveness of our treatment; and, recognize the need to adjust doses, alter routes of administration, and add, or change our medications.
  • Adopt healthy lifestyle habits, including regular sleeping, eating and exercise patterns. 
  • Participate in stress management  and relaxation strategies such as cognitive behavioral therapy, biofeedback, meditation, and diaphragmatic breathing techniques. Besides helping us relax and decreasing the frequency of our attacks, some of these techniques can reduce gastric stasis and allow our medications to be absorbed faster. 
  • Keep in mind, although non-pharmacological therapies produce a slower response than pharmacological interventions, they allow us to have an active role in our program.
  • Note, non-pharmacological therapies are particularly important when we have comorbid conditions, such as cardiovascular disease, that may limit our drug options. 

5. Work with our physicians to establish a tailored, pharmacological treatment plan:

  • Given our individual situation and the frequency and severity of our attacks, our treatment plan may include acute and preventive treatment.
  • Acute treatment may involve over-the-counter (OTC) and prescription medications to treat our pain and other symptoms during an attack, such as aspirin; acetaminophen; non-steroidal anti-inflammatory drugs (NSAIDs); combination analgesics that contain caffeine, opioids and/or barbiturates*; neuroleptics/antiemetics; and, corticosteroids. As well, we may be prescribed medications to abort an attack at the onset or stop its progression to severe pain, such as triptans and ergotamines. Acute medications have been classified into categories related to their effectiveness (Marmura, M.J., Silberstein, S.D., & Schwedt, T.J., 2015).
  • We need to be aware that excessive amounts of acetaminophen can result in severe liver injury, while over indulgence in NSAIDs comes with increased risk of gastrointestinal and cardiovascular disorders. As well, using multiple drugs at the same time, alcohol consumption, and combining medications with herbs and supplements, without our doctor's knowledge, can increase can our risk for a number of other problems, including bleeding disorders and poor renal function.
  • If we use acute therapy more than 2 days per week, we need to talk to our doctor about preventive therapy to reduce our risk for MOHS, and the chance of progression to chronic migraine. Preventive therapy may be started earlier if triptans and ergots are contraindicated because we have vascular disease, or if our response to acute medication is poor.
  • Preventive treatment may involve long-term therapy with daily administration of prescription medications proven to be effective to decrease the frequency of our attacks. These medications have been classified into categories related to their effectiveness (Silberstein, 2012) and include: antiepileptic drugs, beta bockers, antidepressants, ACE inhibitors and calcium channel blockers. Currently, Botox (botulinum type A) is only approved as a preventive for chronic migraine.  
  • With preventive therapy, we need to be aware that unpleasant side effects may limit our tolerance and decrease our compliance. As side effects are different for every medication, we need to be sure our doctor communicates adverse effects on initiation of each medication. Some of the less tolerable adverse effects you might want to ask about include weight gain, memory loss, depression, and drowsiness. 
  • On the other hand, with preventive therapy, we need to know that if we work with our doctor to select a preventive medication that can work for comorbid disorders we may have, this can treat both (or more) of these illnesses at the same time. For example, if you have sleep disturbances, depression, or neck pain, amitriptyline may be a good choice; or, if you have hypertension and anxiety, a beta blocker may be the best medication for you. As well, a preventive medication should take our lifestyle into consideration; and, our doctor needs to be aware of all the medications, herbs, and supplements we take to avoid potential drug interactions.
  • If adverse effects become intolerable, we need to communicate this to our physician so the daily dose of the drug can be tapered down, eventually stopped and, perhaps replaced with one that is more acceptable.    

*A word about opioids and barbiturates

We need to be aware that recent studies show opioids do not work well in migraine. In assessment of the frequency of opioid use for acute migraine treatment (Buse, Pearlman, et al, 2012), results demonstrated opioids are associated with more severe headache-related disability; comorbidities like depression, anxiety, and cardiovascular disease; increased headache frequency, and, increased headache-related health care resource utilization. Other reports indicate opioids interfere with triptan effectiveness, increase response to pain stimuli (hyperalagesia), prevent reversal of migraine central sensitization and increase the progression of episodic to chronic migraine (Tepper, 2012, Johnson, Hutchinson, et al, 2013). In a review of MOH (Tepper, 2012), use of any opioids and barbiturates was reported to increase the likelihood of transformation (chronification) from episodic to chronic migraine. The report goes on to say opioids and butalbital should be avoided in acute migraine treatment. As well, we should know that data from the AMPP revealed opioid users were more likely to be occupationally "disabled" compared with nonusers and users with probable dependence were more likely to be "on disability" (Lipton, Buse, et al, 2013).       

Given the information addressed in this article, it would seem the role of effective communication between ourselves and our doctors is crucial to help us overcome our unmet treatment needs and achieve optimal therapy. For us, we need to listen to our doctors and respect them for their knowledge. For our doctors, they need to listen to us and know "the most important part of the patient is the person inside of the patient" (Girgis, 2014).    


"To provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults", The American Headache Society published a "Postion Statement On Integrating New Migraine Treatments Into Clinical Practice", Headache: The Journal of Heada and Face Pain/ Volume 59, Issue 1, December 10, 2018. The statement includes a discussion of the emerging preventive options , "the new CGRP drugs". as well as neuromodulation devices and evidence-based complementary therapies like Cognitive Bhavioral therapy , Biofeedback, Meditation and Relaxtion Techniques.  


American Headache Society. "Acute Migraine Treatment." PDF. Retreived May 5, 2014 from

Buse, D.C., PhD.,  Pearlman, S.H., PhD., et al. (2012). "Opioid use and dependence among persons with migraine: results of the AMPP study." Headache. Jan;52(1):18-36. doi: 10.111/j. 1526-4610.2011.02050.x.  

D'Amico, D., Tepper, S. (2008). "Prophylaxis of migraine: general principles and patient acceptance." Neuropsychiatr Dis Treat." Dec;4(6): 1155-1167. Retrieved May 5, from

Girgis, L., M.D., (2014). "Marcus Welby versus the 21st Century." Medcity News.  

Johnson, J.L., Hutchinson, M.R., et al. (2013). "Medication-overuse headache and opioid-induced hyperalgesia: A review of mechanisms, a neuroimmune hypothesis and a novel approach to treatment." Cephalalgia. Jan;33(1):52-64. doi: 10.1177/0333102412467512. Epub 2012 Nov 9.

Lipton, R.B., M.D., Buse, D.C., PhD., et al. (2013). "Examination of Unmet Treatment Needs Among Persons With Episodic Migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study." Headache. Sep;53(8):1300-11. doi: 10.1111/head.12154. Epub 2013 Jul 23.

Marmura, M.J., Silberstein, S.D., & Schwedt, T.J. (2015). "The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies". Headache. 55;(1):3-20.   

Murray, S., M.S., R.N. Migraine:Identify  Your Triggers, Break Your Dependence on Medication, Take Back Your Life. San Francisco: Conari Press, 2013.

Silberstein, S.D., M.D., F.A.C.P., Holland, S., PhD., et al. (2012). "Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults." Neurology.April 24;vol.78 no.17 1337-1345. doi: 10.1212/WNL.ObO13e3182535d20 

Tepper, S.J. (2012). "Opioids should not be used in migraine." Headache. May;52 Suppl 1:30-4. doi: 10.1111/j.1526-4610.2012.02140.x. 

Tepper, S.J., (2012). "Medication-overuse headache." Continum (Minneap Minn). Aug;18(4):807-22.doi: 10.1212/01.CON.0000418644.3203.

Sharron Murray MS, RN is an author and coauthor CaMEO Study, "Life With Migraine". Currently, Sharron is active in the migraine community as a writer, advocate, American Migraine Foundation Partner, moderator for the American Migraine Foundation "Move Against Migraine" Facebook Group, and member of the National Headache Foundation Patient Leadership Council.  

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS,RN, and her website

This article is not intended as a substitute for medical advice. If you have specific concerns about your health or nutrition, please contact a qualified professional.

Updated, February, 2019.

Copyright 2014, Sharron E. Murray

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