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What doctors wish patients knew about living with migraines

May 27, 2022

Headaches in general can be disruptive to a person’s day. But for people with migraines, the discomfort can be so extreme that it blows regular headaches out of the water. While many people may use “migraine” and “headache” interchangeably, not all head pain is classified as a migraine. This neurological condition can cause debilitating pain that can leave a person in bed for days.

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Yet other times, people with migraines may not feel any pain at all. They may experience visual disturbances or other symptoms such as nausea, numbness and tingling, irritability and difficulty speaking, among others. This can lead to confusion over whether it is a migraine or something more serious.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, AMA member Nancy L. Mueller, MD, a neurologist and pain management specialist in private practice in Englewood Cliffs, New Jersey, discusses what patients need to know about migraine—a condition that affects at least 39 million people in the United States. Dr. Mueller also is an associate professor of neurology at New York University Langone Health and a member at-large for the AMA Organized Medical Staff Section.

“The main type of migraine is the one that is with or without a prodrome,” which is an early symptom that indicates the onset of the migraine, said Dr. Mueller. The common migraine also comes “with the pulsatile feeling, with usually photophobia or phonophobia, meaning lights bother you or noise bothers you.”

This common migraine may also be associated with “nausea and vomiting or just nausea,” she said. The second type is “a complicated migraine, which is similar to the common migraine but with the addition of neurological symptoms that mimic a transient ischemic attack or a warning to a stroke.”

There are other types, as well, such as the vestibular migraine, which makes patients dizzy and often leads to neurology referrals. And some migraines affect vision in ocular migraine, and even ophthalmologists will seek out neurologists for help in such cases.

“There are objective changes in a patient's senses that are scary—even for doctors,” she said.

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“A migraine is a headache that also has accompanied signs or symptoms,” said Dr. Mueller. “Either there is a prodrome, or what’s called an aura, where you can see flashing lights, you can have a sick feeling in your stomach, or you can just have this overwhelming feeling of fatigue.

“Then all of a sudden you have a headache that is usually in one place, usually throbbing, and usually a feeling that you want to take your head and put it somewhere else,” she added, noting “that you need to have that throbbing in a single location along with a sense of nausea or vomiting, having sensitivity to light or to noise, to have a real definition of a migraine.”

While many associate a migraine with intense pain, “the kicker is with either a vestibular migraine or an ocular migraine, what you have is eye findings or you have dizziness or ear findings, but you never get a headache,” said Dr. Mueller. “Which confuses people to no end, because how can you have an ocular migraine when you don’t have a headache?

“It’s basically due to what happens in an area in the brain that affects vision or in the ear affects your balance, or your dizziness and so forth,” she added. “Those blood vessels go into a spasm, so you’re not getting blood into that area.”

That is why “you get a neurological symptom,” Dr. Mueller said, “but it doesn’t necessarily have to go into the throbbing, pulsing headache that most people think of as a migraine.”

As patients get a better understanding of their triggers or the initial onset of symptoms, they can often recognize when they are about to get a migraine.

“This is exactly where abortive medication can help,” said Dr. Mueller, noting that “the sooner a patient understands the beginnings of their headache the quicker they can find relief.”

“It may not just be an aura. It may just be a feeling, or it can be a flicker of lights,” she said. “With that, they know that they need to take something immediately so that it doesn’t progress into a migraine.”

If a patient has “a medicine that they use as a preventive, then they need to make sure they are taking it every day,” said Dr. Mueller. “If they have an abortive medication or something they take when they get a migraine, then it is important that you keep that with you.”

“Don’t go anywhere without it because once you get past a certain point, those abortive medications may help, but they certainly are not as effective as if you take them at the beginning,” she said. “People who don’t get a migraine very often don’t think to keep it with them, and they really should because if you haven’t had a migraine for six months and you’re driving down the highway and you’re starting a migraine, what are you going to do?”

“So, have your medication that aborts your headache with you in every situation—in your purse, in your pocket, next to your bed, in the glove compartment of your car,” Dr. Mueller said.

If one or both parents have migraines, there is a 50–75% chance that you will too, according to the American Migraine Foundation.

“My father had it. My sister has it. My son has it and my husband has it,” said Dr. Mueller, of her family history migraine. “I’ve got a skew towards familial migraine, but that’s not the most common.”

One in five women have migraines, while one in 16 men have the condition. Women also experience menstrual migraines, which happen right before or during a woman’s period.

“If you can avoid using hormonal contraceptives, you should if you have migraine” because they can impact severity and treatment, Dr. Mueller said.

“It just makes it more difficult to treat, but doesn’t mean we can’t do it,” she said. “There are enough other ways of contraception that taking a hormonal kind of contraceptive at this point is not the smartest thing to do” for patients who have menstrual migraines.

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Acute and preventive treatments for migraine often include a variety of prescription and nonprescription medications. But there are also some vitamin and mineral supplements that can be helpful with prevention such as magnesium.

“We usually start magnesium 400 mg, with vitamin B2 (riboflavin) 400 mg as the beginning of treatment for most people with migraines,” said Dr. Mueller, noting that from there they will determine if any additional medication is needed. 

“Stress may make you more susceptible to getting a headache, which could—in turn—become a migraine,” said Dr. Mueller. “There are people who have both common headaches and migraines, and they’re the ones who are the hardest to treat because: Are you treating a migraine? Are you treating a headache?”

“And there are patients who you literally are treating for two types of headaches—the migraine on one side and the tension or common headache on the other side,” she said.

“I've seen too many headaches after COVID-19 and too many longstanding headaches after COVID-19,” said Dr. Mueller. “There’s a huge number of headaches, increased migraine and what they call ‘brain fog’” in patients with long COVID.

“It’s going to be a whole new ballgame with that because we’re not sure if our usual treatments and preventives are going to help with this or not, or if they’re going to get better over time as the virus finally leaves the person’s brain and nervous system,” she said. “The sooner you start looking for what works for you, the better off you’re going to be.”

“My son’s first migraine was when he was 6 years old,” said Dr. Mueller. “If I hadn’t had family history of it, even though I didn’t have it, I would not have believed him. I would have thought that he didn’t want to go to school.”

“If you don’t know that it can happen to a child, you’re more likely to decide that it isn’t real. It’s a headache. It’s not a migraine. And that’s not true,” she said, noting that children “usually describe their migraine just like an adult.”

“Migraine journals are the best” to identify triggers, said Dr. Mueller. “They also have a migraine buddy app on your phone and patients just use that like crazy because what a trigger is for you is not a trigger for someone else.”

“Time between meals, how much sleep you’ve had, all of those things help put together a picture for the patient and the doctor to talk about lifestyle changes that may be needed as a preventative rather than medication,” Dr. Mueller explained. “But getting somebody to keep a diary or journal is difficult because no one wants to do that, so that’s why the app on the phone has made it much easier—they can just check something off or write something in and then we can just review it at our next visit.”

“The biggest thing that people should do is, if they think they have a headache, they need to let their physician talk to them about that headache,” said Dr. Mueller. That’s “because a headache versus a migraine is not something that the patient should make that decision on.

“The treatment and the living with a headache or a migraine should be a topic of discussion so that you can see if there's something that can be done,” she added.

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