Migraines are a common, yet very under diagnosed clinical problem. Classic migraines are characterized by episodic attacks of head pain and associated symptoms such as nausea and sensitivity to light, sound or head movement. Migraines are generally thought of as subset of “headache” disorders, with classic migraines typically featuring unilateral (one-sided) headache as a dominant symptom. Through emerging evidence and evolving perspective in recent years, it has become apparent that many migraine sufferers may have little or no headache as a symptom. These “atypical migraine” sufferers may have primary complaints consisting of :



  • Dizziness/ vertigo/ recurrent BPPV (positional vertigo)
  • Ear/ head pain (often “sharp” and “stabbing”)
  • “Sinus” pressure/congestion (seen in 40% of migraine sufferers)
  • Fluctuating hearing loss
  • Ringing in the ears (tinnitus) Visual alteration
  • Gastrointestinal symptoms (cyclical vomiting/ abdominal migraine/ periodic diarrhea)


  • 28 million Americans with “classic” migraine headaches
  • Females are 3 times more likely than males
  • Peak incidence is between 30-50 years of age
  • At age 35, 28% of all females have migraine headaches
  • It is estimated that <50% of migraine sufferers have been diagnosed/treated


Migraine is an inherited problem of ion channels in the brain. Migraine sufferers have a hard time adapting to strong stimuli such as loud noise, bright light, or excessive motion; in essence, migraine sufferers have a relatively “sensitive brain.” These stimuli can produce abnormal electrical activity in, on, or around the brain, which can then result in a migraine attack.

Migraine Triggers

A migraine trigger is any environmental, dietary, or physiologic factor that can provoke migraine activity in the brain.

Environmental triggers:

  • odors
  • bright lights
  • weather (sensitive to cold, wind, barometric changes)

Food triggers: 2 main categories

  • byproducts of food aging (e.g., fermented products such as red wine, aged cheeses, yeast in fresh bread and yogurt)

  • foods with chemicals similar to neurotransmitters (“brain messengers”) (e.g., coffee, chocolate, MSG, nitrates used as preservatives in prepackaged foods)

Physiologic triggers: stress (probably the most important trigger!!!!)

  • fatigue/ irregular sleep patterns
  • hunger
  • pain (e.g., neck injury and spasm, temporomandibular joint (TMJ) pain, sinus pain)
  • hormone changes (e.g., drop in estrogen before menstrual period or after menopause)
  • eye strain


  • Trigger identification and avoidance
    • Migraine diary
    • Dietary changes Main triggers: Chocolate, wines, caffeine, aged cheeses, MSG, yeast, nuts
    • Stress management
    • Improved sleep habits
    • Regular exercise
    • Avoid the “Vicious cycle” (narcotics, caffeine, decongestants (e.g., pseudoephedrine), “catch-up” sleep)

  • Correct the correctable
    • Eye exam
    • Sinusitis management
    • TMJ treatment (soft diet, warm compresses, mouth guard)

  • Medications: 2 categories
    • Medications to elevate the threshold (i.e., make the brain less “sensitive”) Many were originally used to treat depression, seizures, blood pressure Common initial medication is Nortriptyline (main side effects: sedation (so take at bedtime), dry mouth) May often take 6-8 weeks to respond

    • Medications to abort acute attacks Because they can cause rebound, should not be used more than 6-8 times per month

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