By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kuruvilla, MD

As winter progresses, many people notice changes that are difficult to explain but easy to feel.

Energy may be lower. Focus may take more effort. Sleep may feel less restorative. Headaches may become more frequent or more noticeable.

You may often wonder whether this reflects stress, seasonal changes, or simply the pace of daily life. From a brain health perspective, experiences like these are common during late winter and often reflect how the brain responds to changes in routine, environment, and cumulative demands over time.

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The brain responds to context

The brain does not function in isolation. It continuously integrates signals from the body and the environment to regulate energy, attention, sleep, and stress responses.

As winter continues, several subtle shifts often occur at the same time:

• Daylight exposure remains limited
• Sleep timing may drift
• Physical activity often decreases
• Work and personal demands continue without a natural pause

Individually, these changes may seem minor. Together, they can influence how efficiently the brain functions day to day.

This does not indicate that something is “wrong.” It reflects the brain adapting to its current context.

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Understanding brain fog

“Brain fog” is a term many people use to describe slowed thinking, difficulty concentrating, or reduced mental clarity. While it is not a medical diagnosis, it is a real and commonly reported experience.

Brain fog can be influenced by sleep quality, stress levels, hydration, physical activity, and routine consistency. Because the brain is highly energy-dependent, even small disruptions in these areas can affect overall cognitive functioning.

Experiencing brain fog during late winter does not necessarily signal long-term cognitive decline. In many cases, it reflects temporary strain on attention and processing systems.

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Headaches as a signal, not just a symptom

For individuals with a history of headaches or migraine, late winter can be a time when symptoms feel more frequent or more disruptive.

Headache pathways are sensitive to changes in sleep, stress, hydration, and sensory input. When several of these factors shift at once, headache patterns may change as well.

Recognizing headaches as part of overall brain health — rather than isolated events — can help patients approach symptoms with more clarity and less frustration.

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Why pushing harder often doesn’t help

When symptoms increase, it is natural to respond by trying to push through fatigue or cognitive difficulty.

However, for many people, increased pressure and reduced recovery can make symptoms more noticeable over time. The brain benefits from balance — between activity and rest, focus and recovery.

A gentler, more flexible approach is often more supportive of brain health during periods of increased demand or seasonal change.

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A supportive way to respond

Rather than viewing late-winter changes as something to overcome, you may consider treating them as information.

Helpful areas to reflect on include:

• Sleep consistency and quality
• Stress levels and opportunities for recovery
• Hydration and regular meals
• Daily movement
• Changes in headache or cognitive patterns

Small, thoughtful adjustments are often more sustainable — and often more effective — than dramatic changes.

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A seasonal view of brain health

Brain health is not static. It naturally fluctuates with seasons, routines, hormonal changes, and life demands.

Late winter can be a time when the brain requires additional patience, support, and flexibility. Recognizing this can reduce unnecessary self-criticism and encourage a more compassionate response to symptoms.

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Optional supportive tools

As part of a broader approach to brain health, some patients find it helpful to use tools that support awareness and consistency over time.

Our clinic offers the Brain Health MD app as an optional resource for patients who are interested in reflecting on sleep, stress, and symptoms between visits. Tools like this are not a replacement for medical care, but they may support ongoing self-awareness and communication as part of comprehensive brain health care.

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In the weeks ahead, we’ll continue sharing clear, patient-centered brain health education and addressing common questions through our Ask the Medical Director series.

Supporting brain health often begins with understanding where you are — and responding with patience.

By: Dr. Deena Kuruvilla, MD, and Brooklyn A. Bradley, BS

Although migraine can have many causes, many patients can attribute their headaches to the auriculotemporal nerve. In this article, we will briefly talk about why it is important to learn about this nerve and discuss how it influences headaches.

Q1: What is the auriculotemporal nerve?

The auriculotemporal nerve is a nerve in the face. More specifically, it’s an end part of the trigeminal nerve. It has been identified as one of the peripheral trigger sites for migraine headaches [1]. As one can see in Figure 1 [3], the auriculotemporal nerve typically runs on the top part of the jawbone, travels up near the ear, and goes up to innervate the scalp. Thus, this nerve helps you feel things on the front part of your ear, the back part of your temple, and even on your scalp [2]. It also helps your body with some special functions, like controlling sweat on your scalp and helping your parotid gland work (gland in your cheek that produces saliva) [2]. 

Figure 1. Diagram of facial nerves [3]. 

Auriculotemporal Nerve Entrapment | SpringerLink [3]

Q2: What does the auriculotemporal nerve do?

The primary function of the auriculotemporal nerve is to carry sensation from the ear and the skin on the temple [2]. This is particularly important for migraine headaches, since irritation, inflammation and compression to this nerve, known as auriculotemporal neuralgia, can be very painful. The auriculotemporal nerve has other lesser functions, like controlling the blood vessels around the ear and jaw. It also helps your body with some special functions, like controlling sweat on your scalp and helping your parotid gland work (gland in your cheek that produces saliva) [2]. 

Q3: What causes auriculotemporal neuralgia?

Auriculotemporal neuralgia can be caused when the auriculotemporal nerve is compressed by fascial tissue bands (layers of connective tissue that surround and support the auriculotemporal nerve), squeezed by an overlying blood vessel, or damaged by parotid surgery [4, 5]. Damage to the auriculotemporal nerve can trigger headaches or facial pain [1, 4]. Pain may be felt around the temporomandibular joint near the ear. This pain is typically worsened by opening the mouth widely, or pressing hard on the temporomandibular joint.

Q4: How can auriculotemporal nerve headaches be treated?

It is important to first rule out any dangerous secondary causes of headache such as blood clots or aneurysms. Once these causes are ruled out,  there are several treatment options for auriculotemporal nerve headaches, including nerve blocks using local anesthetics [6], trigger point injections, or BOTOX therapy. The exact mechanisms of how these treatments are still being investigated. However, these treatments can decrease muscle contractions overlying the nerve, reduce neurogenic inflammation, and decrease the release of pain-inducing neurotransmitters like CGRP and substance P [7].

Q5: How is BOTOX administered to the auriculotemporal nerve?

Although a BOTOX treatment typically consists of many small injections around the scalp, face and neck, special care is made to inject near the distribution of the auriculotemporal nerve. After checking to find the location of nearby blood vessels, we carefully identify a reference point based on an orthogonal reference line based on the eye and ear and inject a tiny dose superficially above the temporalis muscle.

While it’s possible to have headaches from isolated damage to the auriculotemporal nerve, it’s more common to see headaches present as a result of migraine. In this scenario, auriculotemporal nerve discomfort is coupled with discomfort from other peripheral facial nerves, including the occipital, supraorbital, and supratrochlear nerves. It’s also common to see headaches associated with muscle tension in the surrounding head and neck muscles, including the frontalis muscle, temporalis muscle, occipitalis muscle, trapezius muscle, and the cervical paraspinal muscle group. In future articles, we’ll walk through the previously listed muscles and nerves and present research how these structures influence headaches.

Although this particular article focused on addressing nerves individually, it’s important to note that the most successful approach to headache involves a multi-pronged approach that integrates wellness, mindfulness, stress and trigger reduction, and medications when indicated. At the Westport Headache Institute, we believe that knowledge is power, and we hope to give you the tools and treatment to live a life free of headaches! Stay well!  – Dr. K

References:

1. Chim H, Okada HC, Brown MS, et al (2012) The auriculotemporal nerve in etiology of migraine headaches: compression points and anatomical variations. Plast Reconstr Surg 130:336–341. https://doi.org/10.1097/PRS.0b013e3182589dd5
2. Janis JE, Hatef DA, Ducic I, et al (2010) Anatomy of the auriculotemporal nerve: variations in its relationship to the superficial temporal artery and implications for the treatment of migraine headaches. Plast Reconstr Surg 125:1422–1428. https://doi.org/10.1097/PRS.0b013e3181d4fb05
3. Trescot AM, Rawner E (2016) Auriculotemporal Nerve Entrapment. In: Trescot AM (ed) Peripheral Nerve Entrapments: Clinical Diagnosis and Management. Springer International Publishing, Cham, pp 105–115
4. Greenberg JS, Breiner MJ (2024) Anatomy, Head and Neck: Auriculotemporal Nerve. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
5. Bertozzi N, Simonacci F, Lago G, et al (2018) Surgical Therapy of Temporal Triggered Migraine Headache. Plast Reconstr Surg Glob Open 6:e1980. https://doi.org/10.1097/GOX.0000000000001980
6. Fernandes L, Randall M, Idrovo L (2021) Peripheral nerve blocks for headache disorders. Practical Neurology 21:30–35. https://doi.org/10.1136/practneurol-2020-002612
7. Scuteri D, Tonin P, Nicotera P, et al (2022) Pooled Analysis of Real-World Evidence Supports Anti-CGRP mAbs and OnabotulinumtoxinA Combined Trial in Chronic Migraine. Toxins (Basel) 14:529. https://doi.org/10.3390/toxins14080529

By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kuruvilla, MD

Positioning can play a significant role in migraine symptoms; for example, proper positioning can help minimize pressure on sensitive areas of the head and neck. Implementing ergonomic principles at home and in the workplace may be a potential non-pharmacological option for managing migraine. Ergonomics is the science of designing and arranging objects and environments to fit the people who use them, aiming to optimize comfort, safety, and efficiency while minimizing the risk of discomfort, injury, and fatigue [1]. In today’s blog post, we will dive deeper into the role of trigger points in migraine and how positioning has an impact on migraine specifically. 

Myofascial trigger points are defined as hyperirritable spots in skeletal muscle that have been suggested to have a role in primary headache disorders [2]. In tension-type headache, tenderness in pericranial myofascial tissue is correlated with the intensity and frequency of headache [3, 4, 5]. These points are areas of increased sensitivity within muscles, often associated with tension and stress. When these points are triggered, they can lead to the beginning of a migraine episode, or even intensify an already existing episode. Common myofascial trigger points for migraine include the upper trapezius muscle (base of the skull and upper part of the shoulder blade), sternocleidomastoid muscle (sides of the neck), and temporalis muscle (in the temples along the sides of the head) [2]. Identifying and managing trigger points through relaxation techniques, physical therapy, and stress reduction strategies can be integral in the holistic management of migraine.

Ergonomics considers proper positioning of the head, neck, and spine, and can be helpful at home and in the workplace [6]. The position of your computer screen can impact your occurrence of migraine attacks due to its impact on eye strain and overall ergonomic comfort [6]. If your computer screen is positioned too high or too low, it can cause you to tilt your head upward or downward. This can lead to neck strain and exacerbating migraine symptoms. In addition, if the screen is too bright or too close to your eyes, it can cause eye strain, and fatigue, and serve as a migraine trigger. Positioning your computer screen in a way that minimizes glare and reflections is vital for migraine prevention [6]. Further, adjusting the distance and height so that it is at a comfortable viewing distance will help promote good posture and reduce strain on your neck and shoulders.

Comfortable seating can also play a major part in migraine episodes experienced while at work. Oftentimes our work requires us to sit for long periods in an uncomfortable chair, leading to muscle tension and stiffness [6]. This tension can exacerbate migraine symptoms. It is recommended to use chairs that have armrests, adjustable seat height, and support for your spine to encourage good posture and support your spine. While having good seating at work can influence migraine, stretching and taking regular breaks can be just as helpful to alleviate tension and improve circulation. Taking breaks from work can provide relief from eye strain, reduce muscle tension, refresh your mental focus, and serve as a source of stress relief [6]. Incorporating regular breaks into the workday and participating in stretching breaks can not only encourage a healthy work-rest balance but also support a more migraine-friendly workplace.

There are a few adjustments to create a migraine-friendly workspace [6]. Using ergonomic chairs and arranging workstations for proper alignment can help promote better posture. By maintaining good posture, individuals can reduce tension in the muscles of the neck and upper back, alleviate strain on the nerves and blood vessels, and decrease the risk of migraine occurrence or intensity. Organizing your workstation so that your items are within easy reach and will not cause you to strain yourself can be helpful. In addition, as previously mentioned, it is recommended to take regular breaks throughout the day to minimize tension and strain [6].

The perception of migraine headache is exacerbated by exposure to light as compared to the pain level felt in the dark [7, 8]. In recent years, some glasses have been designed specifically to alleviate migraine symptoms, gaining attention as a potential non-pharmacological intervention. These glasses typically feature precision-tinted lenses that filter certain wavelengths of light [9, 10]. These wavelengths typically include blue light, which is emitted by electronic screens (i.e., smartphones, computers, televisions). In a study determining the wavelength of light that patients with migraine and tension-type headache find uncomfortable between attacks, there were significant differences between the groups in terms of the specific wavelengths they experienced discomfort at [9]. Further, certain glasses may filter out fluorescent or harsh artificial lighting, which can emit wavelengths in the blue-green range [9]. The goal of these glasses is to block or reduce exposure to these specific wavelengths and alleviate migraine symptoms triggered by light sensitivity [10].

By implementing some of the tips listed above, individuals can potentially reduce the occurrence of migraine attacks and improve their overall quality of life at work by utilizing proper positioning techniques. It is important to remember that small adjustments to your workspace can make a big difference in preventing migraine attacks and enhancing your comfort and productivity at work.

References:

1. Edwards C, Fortingo N, Franklin E (2024) Ergonomics. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
2. Do TP, Heldarskard GF, Kolding LT, et al (2018) Myofascial trigger points in migraine and tension-type headache. J Headache Pain 19:84. https://doi.org/10.1186/s10194-018-0913-8
3. Lipchik GL, Holroyd KA, O’Donnell FJ, et al (2000) Exteroceptive suppression periods and pericranial muscle tenderness in chronic tension-type headache: effects of psychopathology, chronicity and disability. Cephalalgia 20:638–646. https://doi.org/10.1111/j.1468-2982.2000.00105.x
4. Buchgreitz L, Lyngberg AC, Bendtsen L, Jensen R (2006) Frequency of headache is related to sensitization: a population study. Pain 123:19–27. https://doi.org/10.1016/j.pain.2006.01.040
5. Fernández-de-Las-Peñas C, Cuadrado ML, Arendt-Nielsen L, et al (2007) Increased pericranial tenderness, decreased pressure pain threshold, and headache clinical parameters in chronic tension-type headache patients. Clin J Pain 23:346–352. https://doi.org/10.1097/AJP.0b013e31803b3770
6. Mansoor SN, Al Arabia DH, Rathore FA (2022) Ergonomics and musculoskeletal disorders among health care professionals: Prevention is better than cure. J Pak Med Assoc 72:1243–1245. https://doi.org/10.47391/jpma.22-76
7. Noseda R, Kainz V, Jakubowski M, et al (2010) A neural mechanism for exacerbation of headache by light. Nat Neurosci 13:239–245. https://doi.org/10.1038/nn.2475
8. Kawasaki A, Purvin VA (2002) Photophobia as the presenting visual symptom of chiasmal compression. J Neuroophthalmol 22:3–8. https://doi.org/10.1097/00041327-200203000-00002
9. Main A, Vlachonikolis I, Dowson A (2000) The Wavelength of Light Causing Photophobia in Migraine and Tension‐type Headache Between Attacks. Headache 40:194–199. https://doi.org/10.1046/j.1526-4610.2000.00028.x
10. Artemenko AR, Filatova E, Vorobyeva YD, et al (2022) Migraine and light: A narrative review. Headache 62:4–10. https://doi.org/10.1111/head.14250

By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kuruvilla, MD

Headaches can be debilitating, impacting our daily tasks and productivity levels. While there is the option of mainstream medical therapy, there are also complementary and integrative approaches that can offer additional relief. In today’s blog post, we will dive deeper into the world of aromatherapy – the therapeutic use of essential oils from plants for the improvement of physical, emotional, and spiritual well-being [1].

Aromatherapy is a division of herbal medicine, which is a subset of complementary and integrative medicine (CIM) therapies. Essential oils are volatile liquid substances extracted from aromatic plant material typically by steam distillation or mechanical expression [1]. Aromatherapy is claimed to be useful for a vast array of symptoms and conditions. Published studies typically focus on the psychological purposes of aromatherapy; for example, the use of aromatherapy as a stress reliever or anxiolytic agent. A 2017 randomized controlled trial on the effects of aromatherapy essential oil inhalation on stress, sleep quality, and immunity in healthy adults asked participants to inhale an essential oil blend of lemon, eucalyptus, tea tree, and peppermint at night for four weeks [2]. The researchers found that the aromatherapy group had significantly lower perceived stress levels and depression, in addition to significantly higher sleep quality. However, the aromatherapy group and control group did not differ in activation of their autonomic nervous system (regulates heart rate, blood pressure, respiration) or immune status [2]. 

Strong perfumes and other scents can often be a trigger for headaches. However, certain essential oils can be a great part of your pain management tool kit [3]. Stress is a very common headache trigger, and some studies have shown that certain essential oils can help relieve stress. A 2006 randomized controlled trial identifying the effects of aromatherapy on blood pressure and stress responses of patients with essential hypertension found that the difference in blood pressure, pulse, subjective stress, anxiety, and serum cortisol levels was statistically significant between the essential oil group and placebo and control groups [4]. In this particular study, the participants inhaled a blend of oils, including lavender, ylangylang, and bergamot [4]. Further, headaches and nausea may sometimes occur together. Peppermint oil aromatherapy is known for having potential anti-nausea effects and may be beneficial to those who experience nausea [5].

Some of the top essential oils for soothing headaches include lavender, peppermint, eucalyptus, rosemary, and chamomile. Lavender is a soothing scent that has been used for calming, relaxation, and stress relief [6]. Research suggests lavender may be useful in migraine management and improvement of sleep quality [6, 7]. Peppermint has a cooling effect that can be soothing. This effect inhibits muscle contractions in the head and neck while also increasing blood flow to the area [3]. Eucalyptus is a long evergreen plant and its oils have been used to regulate and activate various systems like the nervous system for neuralgia and headache. It is recommended for those dealing with sinus headaches, as its compounds can be used to clear away nasal mucus [8]. Rosemary is known for its stimulating properties, and can be beneficial during fatigue. Research has illustrated that rosemary oil has anti-inflammatory and pain-relieving properties [9]. Finally, chamomile is known for its calming and mood stabilizing effects. Chamomile has been shown to have anti-inflammatory properties that can reduce head pain [10].

There is a wide variety of ways to incorporate aromatherapy into your daily routine. Some of the most common include diffusers, inhalation, massages, warm compress, and roll-ons. In terms of safety, it is important to dilute essential oils with a carrier oil (i.e., fractionated coconut oil) before applying to the skin. Performing a patch test prior to applying essential oil on the skin will ensure you do not have an adverse reaction to it. Individuals who are pregnant and those with certain health conditions should consult with a healthcare professional before using essential oils.

It is important to understand that individual responses to aromatherapy can vary, and more research is needed to establish clear guidelines for its use in headache management. Always consult with healthcare professionals before relying solely on aromatherapy for treating headaches, especially if you have an existing medical condition or are taking medications.

References:

1. PDQ Integrative, Alternative, and Complementary Therapies Editorial Board (2002) Aromatherapy With Essential Oils (PDQ®): Health Professional Version. In: PDQ Cancer Information Summaries. National Cancer Institute (US), Bethesda (MD)
2. Lee M, Lim S, Song J-A, et al (2017) The effects of aromatherapy essential oil inhalation on stress, sleep quality and immunity in healthy adults: Randomized controlled trial. European Journal of Integrative Medicine 12:79–86. https://doi.org/10.1016/j.eujim.2017.04.009
3. Try These Essential Oils for Headaches and Migraines. https://www.excedrin.com/headaches/treatment/essential-oils-for-headaches/. Accessed 24 Jan 2024
4. Hwang J-H (2006) [The effects of the inhalation method using essential oils on blood pressure and stress responses of clients with essential hypertension]. Taehan Kanho Hakhoe Chi 36:1123–1134. https://doi.org/10.4040/jkan.2006.36.7.1123
5. Joulaeerad N, Ozgoli G, Hajimehdipoor H, et al (2018) Effect of Aromatherapy with Peppermint Oil on the Severity of Nausea and Vomiting in Pregnancy: A Single-blind, Randomized, Placebo-controlled trial. J Reprod Infertil 19:32–38
6. Sasannejad P, Saeedi M, Shoeibi A, et al (2012) Lavender essential oil in the treatment of migraine headache: a placebo-controlled clinical trial. Eur Neurol 67:288–291. https://doi.org/10.1159/000335249
7. ​​Hirokawa K, Nishimoto T, Taniguchi T (2012) Effects of lavender aroma on sleep quality in healthy Japanese students. Percept Mot Skills 114:111–122. https://doi.org/10.2466/13.15.PMS.114.1.111-122
8. Kehrl W, Sonnemann U, Dethlefsen U (2004) Therapy for Acute Nonpurulent Rhinosinusitis With Cineole: Results of a Double‐Blind, Randomized, Placebo‐Controlled Trial. The Laryngoscope 114:738–742. https://doi.org/10.1097/00005537-200404000-00027
9. Takaki I, Bersani-Amado LE, Vendruscolo A, et al (2008) Anti-inflammatory and antinociceptive effects of Rosmarinus officinalis L. essential oil in experimental animal models. J Med Food 11:741–746. https://doi.org/10.1089/jmf.2007.0524
10. Zargaran A, Borhani-Haghighi A, Faridi P, et al (2014) Potential effect and mechanism of action of topical chamomile (Matricaria chammomila L.) oil on migraine headache: A medical hypothesis. Medical Hypotheses 83:566–569. https://doi.org/10.1016/j.mehy.2014.08.023

By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kuruvilla, MD

At the Westport Headache Institute, we often see patients who present with migraine during and after pregnancy. Although it is common knowledge that migraine is associated with changes in hormones, we will take a closer look at what specifically happens to migraine during pregnancy and provide some quick tips on what to watch out for. Below, we will go through our five most frequently-asked questions about pregnancy and migraine.

1. How does migraine evolve during pregnancy?

During pregnancy, estrogen levels steadily increase, with a peak in the third trimester [1].

Rising estrogen levels during pregnancy typically correspond with an improvement in migraine. However, a steep decrease in estrogen levels occurs after delivery. In the postpartum period, nearly 40% of women experience headaches [2]. Furthermore, migraine intensity and duration often spike during the first week postpartum. Headaches are more common in women with a past history of headache, older age, increased parity (number of births (including live births and stillbirths) where pregnancies reached viable gestational age), or a shorter second stage of labor [2,3].

2. Are migraine attacks dangerous during pregnancy?

Retrospective studies have shown that migraine does not have significant negative outcomes on pregnancy. However, untreated migraine severe enough to lead to acute care visits are associated with higher rates of preterm delivery, pre-eclampsia, and low birth weight infants. Furthermore, there are a number of secondary headache causes in pregnancy that can be dangerous, including:

• Pre-eclampsia
• Eclampsia
• Posterior encephalopathy syndrome (PRES)
• Subarachnoid hemorrhage
• Venous sinus thrombosis
• Arterial dissection
• Reversible cerebral vasoconstriction syndrome

History and physical examinations are vital in distinguishing benign from life-threatening headache presentations in the postpartum period [2]. Factors taken into consideration may include time of delivery, vaginal vs. surgical delivery, complications of the pregnancy and/or delivery, use of epidural anesthesia, medication changes, substance use, family history, and chest pain. Further, physical examination findings that raise suspicion for a life-threatening secondary cause of headache include hypertension, decreased urination, swelling in the legs, visual changes, and abnormal neurological examinations [2].

It’s important to record migraine characteristics and not dismiss symptoms as a natural consequence of pregnancy. A 2015 systematic review suggested that women with migraine may have higher risks of cerebrovascular or cardiovascular complications of pregnancy, including gestational hypertension, preeclampsia, ischemic stroke, heart disease, and venous thromboembolism [4].

3. What migraine ‘red flags’ should I watch out for during pregnancy?

Although there are many concerning symptoms that are associated with migraine, there are four ‘Red Flags’ that can signal that a migraine may be caused by a dangerous secondary cause. These red flags are:

• Sudden or unrelenting headache
• Lack of prior headache history
• Hypertension
• Neurologic abnormalities on exam

4. What imaging studies can I take?

There are a number of imaging studies that are used to work up a migraine and rule out a dangerous secondary cause. These imaging tests include brain MRI/MRA head and neck CT/CTAs [5]. It’s important to note that all of these options have their own risks, including ionizing radiation exposure, strong magnetic fields, risk of tissue heating, and in utero exposure to gadolinium. When deciding which imaging modality to use, it’s important to weigh the risks of neuroimaging with risks of a new or worsening headache based on clinical signs and symptoms.

5. What treatment options are available?

Although there are many treatment options for migraine, it’s important to note that some treatments can have adverse effects on babies — for example, third trimester use of ibuprofen can cause impaired renal function and premature closure of fetal blood vessels [6]. Reglan, also known as metoclopramide, is sometimes prescribed for migraine attacks, but its safety during pregnancy may depend on the individual’s health condition and the stage of the pregnancy. Lidocaine nasal spray is sometimes used in migraine during pregnancy due to its potential to provide local anesthesia and reduce pain [7]. In particular, it may be used to desensitize the nerves involved, and the nasal spray form allows for targeted delivery to the nasal passages, where it can act locally. While lidocaine nasal spray may be considered relatively safe in certain situations, its use during pregnancy should be evaluated on a case-by-case basis. Tylenol, or acetaminophen, is often considered a safer option for pain relief during pregnancy, including use in migraine [7]. However, this is at the discretion of the healthcare professional, and on a case-by-case basis. Nerve blocks have been noted to be safe due to minimal placental transfer, but the gold standard in safety are non-pharmaceutical approaches such as education, relaxation training, and biofeedback [7].

We hope this quick article can help you make a better informed decision on how to proceed if you have a headache during pregnancy. As always, stay well! – Dr. K

References:

1. Maternal Changes During Pregnancy, Labor, and Birth | Anatomy and Physiology II. https://courses.lumenlearning.com/suny-ap2/chapter/maternal-changes-during-pregnancy-labor-and-birth/. Accessed 12 Dec 2023
2. Boushra M, Rathbun KM (2023) Postpartum Headache. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
3. reVITALize: Obstetrics Data Definitions. https://www.acog.org/practice-management/health-it-and-clinical-informatics/revitalize-obstetrics-data-definitions. Accessed 12 Dec 2023
4. Wabnitz A, Bushnell C (2015) Migraine, cardiovascular disease, and stroke during pregnancy: systematic review of the literature. Cephalalgia 35:132–139. https://doi.org/10.1177/0333102414554113
5. Holle D, Obermann M (2013) The role of neuroimaging in the diagnosis of headache disorders. Ther Adv Neurol Disord 6:369–374. https://doi.org/10.1177/1756285613489765
6. Ibuprofen Use During Pregnancy. In: Drugs.com. https://www.drugs.com/pregnancy/ibuprofen.html. Accessed 12 Dec 2023
7. Treating Migraine During Pregnancy. In: American Headache Society. https://americanheadachesociety.org/news/treating-migraine-during-pregnancy/. Accessed 18 Jan 2024

By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kuruvilla, MD

Maintaining a headache diary can be beneficial for people with migraine for several reasons. A headache diary can be a useful tool to better understand and manage your headaches. In today’s blog post, we will discuss the tips and benefits of keeping a headache diary.

A headache diary helps you track and identify potential triggers for your headache attacks. By recording information about your daily activities, food intake, sleep patterns, stress levels, and environmental factors, you can pinpoint specific triggers that may contribute to your headache [1]. Over time, a headache diary can reveal patterns in your headache attacks. For example, you may notice that your headache tends to occur at specific times of the day, during certain days of the month, or in response to particular stimuli (i.e. weather changes, changes in lighting, etc.). This information can be valuable for both you and your headache specialist in developing effective management strategies and pinpointing not only the type of headache, but also potential causes.

Another purpose a headache diary can serve is to track the effectiveness of medications. If you are taking medications to prevent or alleviate your headache, you can record when you take the medication, the exact dosage, and how well it alleviates your symptoms [1]. Thus, you and your headache specialist will be able to identify whether the particular treatment regimen works for you, and if there are any adjustments that need to be made. In addition, your headache diary can track lifestyle factors that may have a role in your headache, such as exercise, dietary habits, sleep quality, and stress. Documenting this information can help you identify whether you need to make changes to these areas, and whether they have a role in your headache frequency and severity.

There are many ways to keep a headache diary. First, we recommend finding a notebook or using a digital app for the diary. At the beginning of each entry, record the date and time the headache begins and ends. You will want to describe the headache as best as you can, including details such as the location of the pain, pain level, pain type (i.e., throbbing, dull, sharp), and how long the headache lasts [2]. It is also important to write down any potential triggers or factors that may have contributed to the headache. These factors may include stress, lack  of sleep, and hormonal changes. Further, record your associated symptoms (i.e., nausea, vomiting, sensitivity to light), medications, treatments, and additional notes [2]. All of this information will be relevant to share with your headache specialist – the more details, the better! Lastly, it is key to be consistent as best you can with the headache diary, even when a headache episode seems minor.

Remember, your headache diary isn’t just a record; it can serve as your roadmap to relief. Start writing, start healing, and let your headache-free days begin! – Dr. K

References:

1. Headache journals: tracking your migraine | amf. In: American Migraine Foundation. https://americanmigrainefoundation.org/resource-library/headache-journals/. Accessed 24 Oct 2023
2. Headache Diary. https://stanfordhealthcare.org/medical-conditions/brain-and-nerves/headache/diagnosis/headache-diary.html. Accessed 24 Oct 2023

By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kuruvilla, MD

Migraine is a common and debilitating condition that affects millions of people worldwide. However, accurate diagnosis of migraine is not simple, and there are many individuals who are misdiagnosed.. Understanding the causes, consequences, and potential solutions of migraine misdiagnosis is vital to ensure that patients experiencing migraine are receiving the appropriate care and treatment. . In today’s blog post, we will dive deeper into migraine misdiagnosis and the potential steps we can take to improve the process of migraine diagnosis. 

Many individuals who experience migraine symptoms are often misdiagnosed. As a result, they may experience inadequate treatment and unnecessary suffering. It is important to understand that migraine is more than just a severe headache. Migraine is characterized by a wide variety of symptoms that can be unique to each patient, and even vary from one migraine episode to the next.

Migraine is often attributed to genetic factors, changes in blood flow within the brain, and abnormalities in the activity of the brain. Factors such as stress, hormonal changes, certain foods, and environmental factors can trigger migraine. In terms of pain quality, headache pain is usually described as a constant dull ache. It can range from mild to moderate in intensity and often affects both sides of the head [2]. For migraine, the pain is typically moderate to severe and is often described as pulsating or throbbing. It typically will affect one side of the head and may be accompanied by additional symptoms such as nausea, sensitivity to light and sound, and vomiting. 

These symptoms are not unique to migraine, and can overlap with other medical conditions. Thus, it can be challenging for healthcare providers to distinguish migraine from other headache types or neurological disorders. For example, migraine may cause facial pain and pressure around the eyes and forehead in addition to severe head pain. These symptoms are often misdiagnosed as sinusitis, especially when there is sinus-related discomfort. According to a 2013 study involving a total of 130 migraine patients, 81.5% of these patients were misdiagnosed as sinusitis [3]. In addition, a multicentre study conducted across seven countries found that out of 1161 patients, 64% called their migraine a “headache,” and only 28% of patients were aware that they suffered from migraine [4].

The consequences of migraine misdiagnosis can be dangerous to a patient’s health and quality of life. These consequences include delayed treatment, decreased quality of life, ineffective medications, and financial burden. Patients may be spending a considerable amount of time and effort to find the correct diagnosis and treatment plan.

Improving the accuracy of migraine diagnosis is essential to ensure that patients receive appropriate treatment, care, and support for their condition. While it is not always possible to eradicate misdiagnosis entirely due to the complexity of migraine symptoms and presentation, there are some steps that can help reduce the likelihood of misdiagnosis. Patients should provide their healthcare team with a comprehensive medical history, including a detailed description of their symptoms, frequency, duration, and any triggers or patterns that they have observed. For example, patients can maintain a headache diary to track this information. Having an open line of communication with providers is helpful as patients should feel comfortable discussing their condition openly. In addition, consulting specialists or seeking a second opinion can be especially helpful when a migraine diagnosis is uncertain.

In conclusion, migraine misdiagnosis is a common challenge that can be a burden for patients. By working towards improved communication between patients and providers, in addition to further knowledge on migraine as a disease, we can reduce the likelihood of misdiagnosis and ensure that individuals experiencing migraine receive the appropriate care and support they need. 

References:

1. (2022) Migraine vs. Headache: How to Tell the Difference. https://www.pennmedicine.org/updates/blogs/health-and-wellness/2019/november/migraines-vs-headaches. Accessed 24 Oct 2023
2. Is It a Migraine or Headache? In: Temple Health. https://www.templehealth.org/about/blog/is-it-migraine-or-headache. Accessed 24 Oct 2023
3. Al-Hashel JY, Ahmed SF, Alroughani R, Goadsby PJ (2013) Migraine misdiagnosis as a sinusitis, a delay that can last for many years. J Headache Pain 14:97. https://doi.org/10.1186/1129-2377-14-97
4. Viana M, Khaliq F, Zecca C, et al (2020) Poor patient awareness and frequent misdiagnosis of migraine: findings from a large transcontinental cohort. Eur J Neurol 27:536–541. https://doi.org/10.1111/ene.14098

By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kuruvilla, MD

The pathophysiology of migraine is not yet fully understood. It is well-known that there is the role of inflammatory mediators which are activated by the trigeminovascular system in the brainstem. There are also different chemicals in the brain such as dopamine and serotonin which play a role in changes in the electrical activity of the brain. [1]. Recent research has highlighted the pituitary-derived hormone prolactin and the hypothalamic neuropeptide oxytocin, and their role in migraine. In today’s blog post, we will dive deeper into the relationship between these two hormones and the pathophysiology of migraine.

Prolactin is a polypeptide hormone (chemical messenger), that is secreted (released) from the pituitary gland [2]. This hormone is responsible for lactation, breast development, and ovulation and is released during these times. Prolactin also has a role in metabolism, immune system regulation, and pancreatic development [2]. Oxytocin is a non-peptide hormone produced in the hypothalamus, which is the area of the brain that controls body temperature, hunger, and thirst [3,4]. This hormone also has a role in sexual arousal, trust, attachment, and mother-infant bonding.

Both prolactin and oxytocin operate at peripheral (neuromuscular structures outside skull and spinal column) and central levels (brain and spinal cord); however, prolactin has increased pain processing capabilities, while oxytocin blocks the detection of painful stimuli [1]. For this reason, prolactin and oxytocin are involved in the processing of noxious or harmful stimuli. Research has also shown the role of the hypothalamus as a migraine generator [5]. 

Recently, there have been research efforts focused on prolactin and oxytocin, and their role in migraine. Clinical and preclinical studies reported a pronociceptive (increased pain processing) role of prolactin, which is a sensitizing factor for pain-related areas in the trigeminovascular system. The trigeminovascular system has particular relevance for migraine as it has been shown to be activated during migraine attacks [1]. However, oxytocin seems to have an opposite role in the trigeminal pain system and spinal cord. 

A study compared serum levels of prolactin in female subjects with episodic migraine versus chronic migraine [6]. This study found that prolactin serum levels were higher in women with chronic migraine than those with episodic migraine. However, in another study, lower prolactin serum levels were seen during the acute phase of migraine [7]. In a study of patients with chronic migraine where researchers collected blood every hour for 12 hours to investigate the role of the hypothalamus in chronic migraine, it was reported that nocturnal prolactin peaks were lower in patients with chronic migraine [8]. These studies illustrate a potential link between migraine and prolactin; however, it is not clear why different responses are seen in episodic versus chronic migraine.

Oxytocin has the capacity to diffuse into various brain structures and has local release in the amygdala, which is a structure associated with stress and the reward system [1]. In recent years, oxytocin has been shown to have analgesic and antidepressant effects [9]. There is a major relationship between the trigeminovascular system and the hypothalamus, which both are key to understanding the role of oxytocin in migraine. Studies on menstrual migraine have reported that estrogen regulates oxytocin release, and it is possible that it contributes to the activation of trigeminal nociceptors and thus increases the risk of menstrual migraine [10, 11].  Further, trigeminal oxytocin receptors are a therapeutic target for menstrual migraine.

Research has described the roles of prolactin and oxytocin in explaining sex differences in migraine. However, there are still some unanswered questions and challenges exist to find a treatment targeting oxytocin and prolactin. 

References:

1. Szewczyk AK, Ulutas S, Aktürk T, et al (2023) Prolactin and oxytocin: potential targets for migraine treatment. The Journal of Headache and Pain 24:31. https://doi.org/10.1186/s10194-023-01557-6
2. Al-Chalabi M, Bass AN, Alsalman I (2023) Physiology, Prolactin. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
3. Lee H-J, Macbeth AH, Pagani J, Young WS (2009) Oxytocin: the Great Facilitator of Life. Prog Neurobiol 88:127–151. https://doi.org/10.1016/j.pneurobio.2009.04.001
4. Hypothalamus: NCI Dictionary of Cancer Terms. NIH National Cancer Institute. 2011. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/hypothalamus. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/hypothalamus. Accessed 29 Jun 2023
5. Schulte LH, May A (2016) The migraine generator revisited: continuous scanning of the migraine cycle over 30 days and three spontaneous attacks. Brain 139:1987–1993. https://doi.org/10.1093/brain/aww097
6. Alia S, Ali RS, Nafiseh E, Ehsan K (2013) Comparison the Serum Level of Prolactin Among Patients With Chronic and Episodic Migraine. Journal of Neurology Research 3:68–72. https://doi.org/10.4021/jnr.v3i2.189
7. Masoud SA, Fakharian E (2005) Serum prolactin and migraine. Ann Saudi Med 25:489–491. https://doi.org/10.5144/0256-4947.2005.489
8. Peres MF, Sanchez del Rio M, Seabra ML, et al (2001) Hypothalamic involvement in chronic migraine. J Neurol Neurosurg Psychiatry 71:747–751. https://doi.org/10.1136/jnnp.71.6.747
9. Goodin BR, Ness TJ Oxytocin – A Multifunctional Analgesic for Chronic Deep Tissue Pain. Current Pharmaceutical Design 21:906–913
10. Krause DN, Warfvinge K, Haanes KA, Edvinsson L (2021) Hormonal influences in migraine — interactions of oestrogen, oxytocin and CGRP. Nat Rev Neurol 17:621–633. https://doi.org/10.1038/s41582-021-00544-2
11. Bharadwaj VN, Porreca F, Cowan RP, et al (2021) A new hypothesis linking oxytocin to menstrual migraine. Headache 61:1051–1059. https://doi.org/10.1111/head.14152

By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kuruvilla, MD

Introduction:

This week’s blog post will highlight the use of supplements for migraine prevention. Supplements, AKA nutraceuticals, are a type of complementary and integrative medicine (CIM). CIM is often used in combination with mainstream medical therapy. CIM encompasses a variety of therapeutic approaches such as acupuncture, mindfulness/meditation and supplements. Some of the common nutraceuticals used for migraine prevention include riboflavin, coenzyme Q10, magnesium, vitamin D, and melatonin. It is important to discuss these complementary approaches with your provider to discover which therapy may be most efficacious with the best safety profile.

Riboflavin:

Riboflavin (B2) is a water-soluble B-vitamin with antioxidant, anti-aging, anti-inflammatory, anti-nociceptive, and anti-cancer properties (1). Riboflavin can be found in many foods and natural sources such as eggs, fish, nuts, fruits, rice, and dark green leafy vegetables. It has a role in cellular functions, most importantly, it helps with energy production (2). Brain energy metabolism has been found to be dysfunctional in people with migraine, thus riboflavin has been researched as a potential mediator in this mechanism (1).

In a randomized controlled trial (RCT) evaluating the effectiveness of high-dose riboflavin in migraine prevention, the researchers compared riboflavin (400 mg) and placebo in 55 patients with migraine for 3 months (3). Riboflavin was found to be superior to placebo in reducing frequency of migraine attacks (3). In a study investigating the efficacy of riboflavin for prevention of migraine, patients received 400 mg riboflavin (4). Headache frequency was significantly reduced from 4 days/month pre-treatment to 2 days/month at both the 3 and 6 month mark. However, headache intensity did not change significantly (4). 

For migraine, the most common dose of riboflavin is 400 mg daily. Riboflavin has a favorable side effect profile. When taken orally, riboflavin may cause the urine to have a more yellow color than normal depending on the dosage.

Coenzyme Q10:

Coenzyme Q10 (CoQ10), also known as ubiquinone, is a dietary supplement often recommended by primary care providers and specialists for numerous diseases. It is most often recommended for neurodegenerative diseases, fibromyalgia, mitochondrial diseases, and migraine. CoQ10 is a fat-soluble vitamin found naturally in the human body. It is vital for energy production in the body, and has the capacity to enhance blood flow and protect blood vessels (5).

In a RCT measuring the efficacy of CoQ10 for migraine prevention, 300 mg/day CoQ10 was administered to the treatment group, and their outcomes were compared to the placebo group (6). CoQ10 was found to be superior to placebo for attack-frequency and days-with-nausea (6). In a RCT studying oral CoQ10 supplementation in patients with migraine, these researchers took an interest in the effects on clinical features and inflammatory markers as well (7). Subjects received 400 mg/day CoQ10 or placebo for three months. CoQ10 reduced calcitonin gene-related peptide (CGRP) and TNF(tumor necrosis factor)-alpha levels significantly, which are two inflammatory markers. In addition, the patients in the CoQ10 group experienced improvement in frequency, severity, and duration of their migraine attacks (7).

CoQ10 has a relatively safe side effect profile and is generally well-tolerated. There is no established ideal dose of CoQ10; however, for adults 19 years and older it is recommended to take 30-200 mg daily. Side effects may include upper abdominal pain, nausea, and heartburn.

Magnesium:

Magnesium is commonly used in over-the-counter products for a variety of diseases. Magnesium is the fourth most common cation in the body and has a vital role in metabolism. It is often involved in muscle contraction, neural activity, and cardiac excitability. In addition, ATP, the source of energy use and storage in our cells, needs magnesium in order to function properly (8).

In a RCT studying the effects of oral magnesium in the prevention of migraine, oral 600 mg of magnesium was administered to the treatment group (9). It was reported that between weeks 9-12, the migraine attack frequency was reduced by 41.6% in the magnesium group (9). In a RCT comparing magnesium, sodium valproate, and concurrent magnesium-sodium valproate therapy for migraine prevention, all groups experienced a significant reduction in migraine characteristics (10). Magnesium may enhance the anti-migraine properties of sodium valproate (10).

Magnesium is considered an inexpensive and simple preventive treatment for patients with migraine. The suggested dosage for migraine is 600 mg; however, it is important to discuss this with your provider. Some common side effects of magnesium supplements include abdominal pain, nausea, cramping, and diarrhea. 

Vitamin D:

Vitamin D is commonly known as the “sunshine vitamin,” and it earns this name from its ability to produce the vitamin in the skin following a period of sun exposure (11). Vitamin D is required to maintain serum calcium concentration, which is necessary for musculoskeletal health. It is a hormone that can be obtained through dietary exposure and exposure to the sun. Vitamin D has many functions including myocardial contractility, insulin production, and the prevention of inflammatory bowel diseases (11).

In a RCT evaluating the use of simvastatin and vitamin D for migraine prevention, participants were randomly assigned to either simvastatin 20 mg 2x/day + vitamin D3 1000 International Units (IU) 2x/daily, or placebo tablets (12). The simvastatin + vitamin D3 caused a greater decrease in the number of migraine days in comparison to placebo. In the treatment group, 25% of patients experienced a 50% reduction in the number of migraine days at 12 weeks (12). In a RCT measuring the effect of vitamin D supplementation on symptoms and C-reactive protein (inflammatory marker) in migraine patients, vitamin D was administered for 10 weeks with 50,000 IU / week (13). Following treatment, there was a significant difference in headache frequency between the two groups (13).

The recommended dosage of vitamin D for adults is 1500 to 2000 IU daily. Some side effects of a very high dose of vitamin D include weakness, dry mouth, and nausea. It is important to discuss the dosage of vitamin D with your provider, as taking a high dosage for a long period of time is possibly unsafe and may affect your serum calcium levels. 

Melatonin:

Melatonin is naturally produced in the brain in response to darkness. It plays a role in the regulation of the body’s circadian rhythms, which is our internal clock. Being exposed to bright light often decreases the secretion of melatonin. Melatonin has other properties beyond its usefulness for sleep (14). According to research, melatonin has a role in cancer suppression, bone deposition, metabolic disorders, cardiovascular diseases, GI conditions, migraine, and neurodegenerative disorders (14). Overall, this hormone has anti-nociceptive and anti-inflammatory properties.

In a RCT comparing melatonin 3 mg to amitriptyline (tricyclic antidepressant with multiple purposes) 25 mg for migraine prevention, the mean headache frequency was reduced by 2.7 migraine headache days in the melatonin group, a decrease from 7.3 days to 4.6 days. In the amitriptyline group, the mean headache frequency was reduced by 2.2 migraine headache days, a decrease from 7.2 days to 5.0 days. Melatonin caused a reduction in headache frequency when compared to placebo (15). In a RCT studying the effects of melatonin on migraine prevention, participants in the migraine treatment group received a dose of 2 mg, 1 hour prior to bedtime for 8 weeks (16). The researchers found that the melatonin did not provide any significant effect over placebo (16). 

While there is no official recommended melatonin dosage for adults, a range of 0.5 to 5 mg is safe and effective. The most common side effects of melatonin supplementation include headache, dizziness, nausea, and drowsiness. There is a lack of high-quality RCTs evaluating the effects of long-term use of melatonin on the body. Thus, it is vital to discuss the use of melatonin with your provider so they can recommend the correct dosage based on your medical history.

Conclusion:

In conclusion, the goal of preventive migraine treatment is to reduce migraine frequency, severity, and duration. CIM approaches are often used in combination with mainstream medical therapy to achieve this goal. Supplements may be an efficacious option for patients who do not respond as successfully to mainstream medical therapy or have had side effects to mainstream medicine.

References:

1. Suwannasom N, Kao I, Pruß A, et al (2020) Riboflavin: The Health Benefits of a Forgotten Natural Vitamin. Int J Mol Sci 21:950. https://doi.org/10.3390/ijms21030950
2. Mosegaard S, Dipace G, Bross P, et al (2020) Riboflavin Deficiency—Implications for General Human Health and Inborn Errors of Metabolism. Int J Mol Sci 21:3847. https://doi.org/10.3390/ijms21113847
3. Schoenen J, Jacquy J, Lenaerts M (1998) Effectiveness of high‐dose riboflavin in migraine prophylaxis A randomized controlled trial. Neurology 50:466–470. https://doi.org/10.1212/WNL.50.2.466
4. Boehnke C, Reuter U, Flach U, et al (2004) High-dose riboflavin treatment is efficacious in migraine prophylaxis: an open study in a tertiary care centre. Eur J Neurol 11:475–477. https://doi.org/10.1111/j.1468-1331.2004.00813.x
5. Sood B, Keenaghan M (2022) Coenzyme Q10. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
6. Sándor PS, Clemente LD, Coppola G, et al (2005) Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial. Neurology 64:713–715. https://doi.org/10.1212/01.WNL.0000151975.03598.ED
7. Dahri M, Tarighat-Esfanjani A, Asghari-Jafarabadi M, Hashemilar M (2019) Oral coenzyme Q10 supplementation in patients with migraine: Effects on clinical features and inflammatory markers. Nutritional Neuroscience 22:607–615. https://doi.org/10.1080/1028415X.2017.1421039
8. Allen MJ, Sharma S (2022) Magnesium. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
9. Peikert A, Wilimzig C, Köhne-Volland R (1996) Prophylaxis of Migraine with Oral Magnesium: Results From A Prospective, Multi-Center, Placebo-Controlled and Double-Blind Randomized Study. Cephalalgia 16:257–263. https://doi.org/10.1046/j.1468-2982.1996.1604257.x
10. Khani S, Hejazi SA, Yaghoubi M, Sharifipour E (2021) Comparative study of magnesium, sodium valproate, and concurrent magnesium-sodium valproate therapy in the prevention of migraine headaches: a randomized controlled double-blind trial. The Journal of Headache and Pain 22:21. https://doi.org/10.1186/s10194-021-01234-6
11. Chauhan K, Shahrokhi M, Huecker MR (2022) Vitamin D. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
12. Buettner C, Nir R-R, Bertisch SM, et al (2015) Simvastatin and Vitamin D for Migraine Prevention: A Randomized Controlled Trial. Ann Neurol 78:970–981. https://doi.org/10.1002/ana.24534
13. Mottaghi T, Askari G, Khorvash F, Maracy MR (2015) Effect of Vitamin D supplementation on symptoms and C-reactive protein in migraine patients. J Res Med Sci 20:477–482
14. Savage RA, Zafar N, Yohannan S, Miller J-MM (2022) Melatonin. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
15. Gonçalves AL, Ferreira AM, Ribeiro RT, et al (2016) Randomised clinical trial comparing melatonin 3 mg, amitriptyline 25 mg and placebo for migraine prevention. J Neurol Neurosurg Psychiatry 87:1127–1132. https://doi.org/10.1136/jnnp-2016-313458
16. Alstadhaug KB, Odeh F, Salvesen R, Bekkelund SI (2010) Prophylaxis of migraine with melatonin: A randomized controlled trial. Neurology 75:1527–1532. https://doi.org/10.1212/WNL.0b013e3181f9618c

Migraine can be classified by the frequency of monthly migraine days as episodic or chronic. With episodic migraine, people have less than 15 headache days monthly while with chronic migraine, people have greater than or equal to 15 headache days monthly of which 8 days meet the formal criteria for migraine. Chronic migraine is associated with more limitations on one’s daily life and higher resource utilization such as medications, imaging studies, lab work and visits to the doctor or emergency room. Known risk factors for the progression from episodic to chronic migraine include obesity, frequent acute medication use (especially opiates and barbiturates), depression and anxiety amongst others.

The Role of Acute Treatments for the Prevention of Chronic Migraine

While it is clear that preventive medications play a key role in preventing the progression from episodic to chronic migraine, less is out there about the role of acute treatments in this process. Dr. Kuruvilla reviews the optimization of acute migraine medications as a means to prevent progression to chronic migraine. Acute treatments include medications and devices. The available acute treatment medications are triptans, ergots, non-steroidal anti-inflammatory medications, gepants, ditans and nausea medications. Devices discussed include Cefaly, Nerivio, Relivion, Spring TMS and Gammacore. Often as headache physicians, we find that acute treatments are underdosed or not taken optimally at the onset of an attack and repeated. As a result, a single attack can persist for several hours and days. The same headache can go away the same day but only to return the following day. The dosage of acute treatments at optimal dosages, as you tolerate them is key. In many cases, it is helpful to have a multi step approach and have a plan A, plan B, plan C for a single attack in case you do not have freedom from pain, freedom from associated symptoms and freedom from disability after plan A or B. It is also crucial to include standard migraine preventive medications along with acute treatments.

Every person with migraine is different and therefore deserves a customized approach to treatment. Open communication with your doctor is key!

Read more in the full article below.

The full article may be viewed here

https://link.springer.com/epdf/10.1007/s11916-022-01022-0?sharing_token=Z3dxC9CTvDpAnV5GstWg1ve4RwlQNchNByi7wbcMAY4OHr60R90UALPqejMmblNqMYg6PUsjypvMgsoG5WiHuQkxmycii7Lt2cDCeJx7t1KffiZ16gRwQkydVdz2oog-Lif94pi7BsBvw9xdSkC-mr8YsDW6gbpsLoYpMgEjjm0%3D