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Conari Press, an imprint of Red Wheel/Weiser, LLC  is the publisher of Sharron's book, Migraine: Identify Your Triggers, Break your Dependence on Medication, Take Back Your Life -  An Integrative Self-Care Plan for Wellness," released June, 2013. Follow Sharron on Twitter @murraysharron, and her page Sharron Murray, MS, RN on Facebook, for tips to help you battle your migraines and achieve wellness.



My Migraine Management: Science + Art = "DESSERT"


In this  MHAM 1: Blogging and Social Media Challenge, I share how, in my migraine management, a combination of science and art equals "DESSERT". For purposes of this discussion, I define science as the research and theoretical principles that give scientific efficacy to the ingredients in my "DESSERT". While art, through caring for myself as a whole person, physically, mentally, emotionally and spiritually, adds the flavor.


"Somewhere, something incredible is waiting to be known" - Carl Saga

For many years I believed migraine was a severe headache caused by my inability to cope with stress. To find relief from the agonizing head pain, I consumed volumes of ineffective over the counter and prescription medications. My break through came when my journey with migraine progressed from episodic to chronic, along with medication overuse headache. Through research, I discovered migraine was a disease and today, believed to be a disabling neurological (neurobiological) disease, with genetic and environmental influences. Now, as I wait for a cure to be discovered, I keep up to date with studies that reveal the most effective pharmacological and nonpharmacological (including complementary or integrative) treatments and therapies for prevention and relief of my migraine attacks. As well, I enrich my body of knowledge by learning about other diseases and disorders that may be comorbid with migraine and complicate the course of my disease. 


"Like a work of art, each encounter with a patient is unique." (M.G. Hackney, personal communication, April, 2015).

Like the colors in a watercolor are unique to a work of art, my personal characteristics; risk factors; comorbidities; triggers; symptoms; responses to treatment and therapies; socioeconomic status; and, family burdens that influence the course of my disease are unique to me. And, while I am fortunate to have doctors who know the person inside my migraine and are caring, compassionate, and nonjudgmental in their approaches, I have learned to be caring, compassionate, and nonjudgmental with myself as I make substantial changes in my lifestyle habits such as what I eat and drink, eating and drinking habits, exercise, sleep hygiene, and how I manage my stress levels.  

"DESSERT is like a feel-good song and the best ones make you dance" - chef Edward Lee 

You know that feeling you get when you wake up without a migraine? Yeah, you want to dance! That's what I call DESSERT! Thankfully, I have found with a combination of art and science thrown into a mix of the following ingredients and sweetened with a blend of persistence, patience, and consistency, I can enjoy DESSERT almost every day:   

D = Diagnosis and Diary 

After years of being misdiagnosed, I received my first official diagnosis of migraine from the neurologist at a migraine clinic. As I found out, effective treatment for migraine needs an accurate diagnosis. Shortly after, I learned that one of the most effective ways to help my doctor make an accurate diagnosis, assist with identification and management of my individual triggers, and improve my treatment outcomes was for me to keep a dairy.  To begin with I used a monthly calendar but now I use an electronic diary for a more scientific approach. 

*E = Eating and Drinking Habits 

Keeping in mind, skipped meals (hypoglycemia) and dehydration can trigger an attack, I eat a healthy meal 3 times a day (breakfast before 9 am, lunch before 1 pm and dinner before 7 pm) and drink 8-10 glasses of water (more if I need because of exercise or heat).  

*S = Stress Management 

Because emotional stress can keep me awake at night and/or interrupt my sleep and because I tend to run at full speed, which makes me vulnerable to "let-down" stress, I monitor my stress levels frequently throughout the day, practice mindfulness, and implement stress reduction strategies like meditation and biofeedback as part of my daily routine. As well, I have acupuncture on a regular basis.  

*S = Sleep 

Knowing good quality sleep is protective for migraine, I try to maintain a schedule of 8 hours a night, with a regular bedtime and awake time.  

*E = Exercise

Because exercise can help prevent my migraine attacks and reduce my risk for comorbidities, I attend a gym 3 times a week.

R = Routine 

Knowing my migraine brain does not like change, sticking to my daily routine is essential for living well with this disease.

T = Tender Loving Care 

Perhaps, the most important thing I've learned in this journey with migraine, is to love myself. When I have setbacks, rather than beat myself up, I concentrate on the good days  and what it is like to be migraine-free... You know, "DESSERT.... and move forward again...

 *My guide, "15 steps to create an environment conducive to wellness".   

Warm wishes for great success with your migraine management plan.

Sharron is the author of, ""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.

Follow Sharron on twitter @murraysharron, her FB page, Sharron Murray, Ms, RN, and her website, 

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

Copyright June, 2017. Sharron E.Murray 





Cold Therapy in Migraine: Mechanisms and Methods


Although research about cold therapy (cryotherapy) in patients with migraine is limited, one thing is known, as the pain begins, many of us reach for the cold pack. In an article by Sprouse-Blum, et al., (2013), the authors report, "of all self-administered pain-relieving maneuvers, cold therapy is the most common maneuver applied in migraine without aura and the second most common maneuver applied in migraine with aura second only to compression" (p. 237). Before we take a look at the possible physiological effects of cold therapy, and some of our respective methods of application, let's have a quick review of helpful things to know about headache and neck pain in migraine. 

We need to be aware that migraine is a genetic neurological disease and headache is a phase of a migraine attack (a person may have an attack without headache). Headache is commonly unilateral, pulsating, moderate to severe intensity, and may be aggravated by movement. However, pain may be felt all over the head (on one or both sides and in the middle of the head), including the eyes, frontal, occipital and neck areas (Kelman, 2005; ICHD-3 beta, 2013; Burstein et al., 2015). The headache phase is thought to begin with activation of meningeal receptors at the origin of the trigeminovascular system. As the headache progresses, in activation and sensitization of the trigeminovascular pathway, a number of complicated electrical and chemical events take place, including the involvement of neurotransmitters, neuropeptides and inflammatory mediators. In the process, we may experience a wide variety of autonomic, affective, cognitive, and sensory symptoms, including allodynia. The clinical manifestations of cephalic allodynia may include scalp and muscle tenderness and sensitivity to touch (Burstein et al., (2015)

It is important for us to know neck pain is commonly reported as a symptom with a migraine attack and may be experienced before (premonitory symptom), during and after the headache phase. While not conclusive and further studies are indicated, it is thought that neck pain may be an integral part of the migraine process ( Calhoun et al., 2010; Ashina, et al., 2015; Maniyar et al., 2015; Lampl,et al., 2015). In a population study assessing neck pain in migraine and tension-type headache, (Ashina et al., 2015), the authors report neck pain may play a role in the pathophysiology of migraine and tension-type headache and may arise because of convergent input from the first division of the trigeminal nerve and the upper cervical roots to the trigeminal complex (p. 212). Clinical implications from this study that are beneficial for us to know are:   

  • "Neck pain is highly prevalent in the general population and is more prevalent in individuals with migraine and tension-type headache. 
  • Neck pain has the highest prevalence in coexistant migraine and tension-type headache.
  • Myofascial pericranial tenderness is significantly increased in individuals with neck pain compared to individuals without neck pain.
  • Neck pain may have a shared pathophysiological mechanism with primary headaches. 
  • Neck pain may result in increased disability in headache sufferers and treatment may also be directed to the neck," (p. 218).    

Additionally, we should be aware Maniyar et al., (2015), report "patients with neck stiffness do not respond as well to triptan treatment as patients without neck stiffness during acute migraine headache, suggesting a phenotype-mechanism dissociation" (p. 611). And, Lampl et al., (2015), indicate "prevention and treatment of neck pain could be important in the prevention of future chronic migraine" (p. 6/9). 

Now, keeping these things in mind, let's take a look at the possible physiological effects of cold therapy for symptomatic relief in migraine. In general, local cold therapy is thought to cool skin, decrease temperature, decrease blood flow (vasoconstriction), reduce inflammation in adjacent tissues, relieve pressure on affected nerves, decrease muscle spasm and muscle tension, and numb pain. That said, let's review some of the proposed pathophysiological mechanisms of action in migraine. 

In a study by Robbins, (1989), where a cold wrap was placed around the head with an elastic bandage and in a study by Ulcer et al., (2006), where cold was administered by gel cap, in a discussion of effectiveness, both study authors report, local anesthesia is important in the use of cold therapy in migraine. They go on to suggest cold sensations overwhelm and block transmission of the pain stimuli into the cerebral cortex and ice reduces the release of some substances including histamines, vasoactive substances and enzymes that stimulate nerve endings. Robbins adds a more thorough discussion, including the conduction velocity of peripheral nerves is decreased as the temperature is lowered. As well, Robbins mentions the major effect of ice is to decrease blood flow to the area (vasoconstriction) and a further effect is to reduce metabolism and oxygen demand. More recently, in a study by Sprouse-Blum, et al., (2013), where an adjustable wrap containing two freezable ice packs targeting the carotid arteries at the front of the neck was used to evaluate targeted cooling in the migraine patient by cooling the blood passing through the intracranial vessels, in a discussion of effectiveness, the authors report:

  • it is possible blood passing through the carotid arteries was cooled enough to decrease release of inflammatory mediators from the walls of the intracranial vessels, decrease vascular permeability, and decrease local pain stimulation;
  • there may have been a contribution of cold induced physiologic vasoconstriction similar to that observed with triptan type medications albeit through a different mechanism (the authors note the role of vasoconstriction in migraine remains unclear);
  • a minimal contribution of analgesia associated with the small diameter myelinated fibers located around the cranial vessels is proposed, and
  • there may be a minimal contribution of decreased metabolic activity in locally cooled areas (page 239).

Little is written about the contraindications of cold therapy in migraine. In the study by Ucler et al., (2006), the authors report one patient could not use cold therapy because of cold intolerance and another patient due to vertigo. Robbins, (1989), reports contraindications may include Raynaud's phenomenon and cold sensitivity. As well, Robbins, (1989), notes ice may cause some problems in rheumatoid conditions and in patients with paroxysmal cold hemoglobinuria. Taking these factors into consideration, in addition, if you have circulatory problems, are diabetic, are pregnant or are nursing, you should discuss individual concerns about cold therapy with your doctor.  

Today, there are a number of products on the market designed to meet our individual cold therapy needs and comfort levels, including gel packs, pillows, caps, hats, and collars. For example, a hat that covers the entire head may be appropriate for one person, while another person may like something that covers the eyes.

In my case, since my migraines escalated to chronic migraine and then remitted to infrequent episodic migraine, I have become increasingly sensitive to hats or anything tight around my head, or neck, because of allodynia. As well, when I do have an attack, neck pain has become a troublesome symptom for me in the premonitory phase, throughout the headache phase, and into the postdrome.

Recently, I was introduced to the Migraine Hat by Lisa Jacobson, founder of The Daily Migraine, who created the hat at a good price point, with the intent of using the proceeds to raise migraine awareness. My first impression was that along with being adjustable so I could regulate the pressure, it was light enough that I could use it for a head wrap and flexible enough that I could use it for my neck. That said, I have been using the hat for the last few months, mostly for neck pain. I find if I catch the neck pain early enough, along with breathing, slow and easy, in and out, some biofeedback exercises, and meditation, I can often prevent or lessen the severity of an impending headache. To get the maximum benefit from the Migraine Hat, when I apply it to my neck I: 

  • fold the Cryo-gel ice pack in half,
  • insert it into the cloth cover and close the Velcro  tabs,
  • with the the seam side of the cloth cover down and Velcro closure to the front of my neck, where I can easily access it for adjustments, I turn the two top corners down and fasten the lower portion just at, or slightly below, the level of my clavicle . 

This way the contact of the Cryo-gel ice pack is at the back of my neck and base of my skull, not the sides and front of my neck. If the pain moves to my head, I can remove the hat from my neck, readjust the Cryo-gel pack to its original size, and place it where it hurts, including around my head, top of my head, or over my eyes.

In addition to the flexibility of the Migraine Hat, I am impressed with the versatility of the well designed cooler, which comes as a gift. Because I don't eat fast food and avoid foods with MSG, preservatives and artificial ingredients, I often take a healthy snack or sandwich with me when I am away from home. Along with two Cryo-gel ice packs, I am able to tuck in my food choice and keep it cool for the day. 


Ashina, S., Bendtsen, L., Lyngberg, A., C., et al., (2015). "Prevalence of neck pain in migraine and tension-type headache: a population study." Cephalalgia. Mar;35(3):211-9.

Burstein, R., Noseda, R., & Borsook, (2015). "Migraine: Multiple Processes, Complex Pathopysiology." The Journal of Neuroscience. April;35(17):6619-6629.

Calhoun, A., H., Ford, S., Millen, C., et al., (2010). "The prevalence of neck pain in migraine." Headache. Sep;50(8):1273-7.

Lampl, C., Rudolph, M., Deligianni, C., et al., (2015). "Neck pain in episodic migraine: premonitory symptom or part of the attack?" The Journal of Headache and Pain. Sep;16:80.

Maniyar, F.H., Sprenger, T., Monteith, T., et al., (2015). "The premonitory phase of migraine-what can we learn from it?" Headache. May;55(5):609-20.

Robbins, L., D., (1989). "Cryotherapy for Headache." Headache: The Journal of Head and Face Pain. Oct;29(9).

Sprouse-Blum, A., S., Gabriel, A., K., Brown, J. P., et al., (2013). "Randomized controlled trial: targeted neck cooling in the treatment of the migraine patient." Hawaii JMed Public Health. Jul;72(7):237-41.

Ulcer, S., Coskun, O., Inan, L., E., et al., (2006). "Cold Therapy in Migraine Patients: Open-label, Non-controlled, Pilot Study." Evid Based Compliment Alternat Med.  Dec;3(4):489-493.  

Sharron Murray, M.S., R.N. is the author of Migraine: Identify Your Triggers, Break Your Dependence On Medication,Take Back Your Life. San Francisco: Conari Press, 2013.

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

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

Copyright October 29th, 2016, Sharron E. Murray 




Do you know the difference between migraine as a headache and migraine as a disease? - Learn about the "Migraine Brain" 




Almost everybody gets a headache sometime in their lives. Because so many people suffer from headaches and headaches have numerous causes, many of which can be life-threatening, the International Headache Society developed a classification system to help doctors provide accurate diagnoses and offer effective treatments for their patients. As well, the specific diagnostic criteria must be fulfilled for patients to be entered into research projects.

The most recent edition of The International Classification of Headache Disorders (ICHD) is the -3 beta version (ICHD-3 beta). The document is extensive. To address its entirety is beyond the scope of this article. Therefore, to give us an idea of the numerous types of headaches a person might experience, we take a brief glimpse at the ICHD-3 beta list of Classifications and Diagnosis (for a more complete list, see Cephalalgia, pages 636-685). In this version, headaches are classified as:

1. Primary: (are caused by independent pathomechanisms)

  • Migraine: including migraine without aura, migraine with aura (aura with headache and aura without headache; migraine with brainstem aura; hemiplegic migraine and types of familial hemiplegic migraine; sporadic hemiplegic migraine; and, retinal migraine), chronic migraine, complications of migraine (Status migrainous, Persistant aura without infarction, Migrainous infarction, Migraine aura-triggered seizure), probable migraine, and episodic syndromes that may be associated with migraine like cyclical vomiting syndrome and abdominal migraine 
  • Tension-type headache: including infrequent episodic, frequent episodic, chronic, and probable
  • Trigeminal autonomic cephalalgias (TACs): including cluster headache, paroxysmal hemicrania, hemicrania continua
  • Other primary headache disorders: including primary cough headache, primary exercise headache, primary thunderclap headache, primary stabbing headache, and new daily persistent headache (NDPH)

 2. Secondary: (a secondary symptom to another disorder known to cause headache)

  • Headache attributed to trauma or injury to the head and/or neck: including head trauma, whiplash, and craniotomy
  • Headache attributed to cranial or cervical vascular  disorder: including ischemic stroke or transient ischemic attack (TIA), intracranial hemorrhage, giant cell arteritis GCA) 
  • Headache attributed to non-vascular intracranial disorder: including increased cerebral spinal fluid pressure, idiopathic intracranial hypertension (IIH), low cerebral spinal fluid pressure, intracranial neoplasm, epileptic seizure
  • Headache attributed to substance or its withdrawal: including carbon monoxide-induced headache, alcohol-induced headache, headache by food or additive (monosodium glutamate-induced headache), cocaine-induced headache, histamine-induced headache, calcitonin gene-related peptide-induced headache, medication-overuse headache (MOH)
  • Headache attributed to infection
  • Headache attributed to disorder of homeostasis: including hypoxia and/or hypercapnia, high altitude headache, airplane travel, driving, sleep apnea, dialysis, pre-eclampsia or eclampsia, hypothyroidism, fasting
  • Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure: including cervicogenic, glaucoma, acute and chronic rhinosinusitis, temporomandibular disorder (TMD)
  • Headache attributed to psychiatric disorder

3. Painful cranial neuropathies, other facial pains and other headaches: including trigeminal neuralgia, occipital neuralgia, optic neuritis. 

Keeping these things in mind, it is important for us to know that a person may receive more than one primary headache diagnosis. For example, in my case I have migraine with aura, migraine without aura, and tension-type headache.  As well, we may have a primary headache and receive a diagnosis for a secondary headache such as medication overuse headache or cervicogenic headache. 

Another point to be aware of is that headache is a phase of a migraine attack. A migraine attack is considered to have four phases: premonitory (prodrome), aura, headache, and postdrome (resolution). Not all of us go through each phase. For instance, you may never have an aura. Another person may have an aura without a headache (see ICHD-3 beta, pages 645-650 for specific diagnostic criteria).

In addition, we need to know migraine attacks may be  episodic or chronic. Episodic migraine (EM) includes a range of attack frequency with headache days 0-14 days per month. If our headache days occur on 15 or more days per month (tension-type or migraine-like) for more than 3 months, with the features of migraine headache on at least 8 days per month, we are given the diagnosis chronic migraine (CM). We should know that the most common cause of symptoms of chronic migraine is medication overuse (ICHD-3 beta).

This brings us to a discussion about migraine as a disease.




Migraine is believed to be a genetic neurological disease. As persons with migraine, we are thought to have an inherited sensitivity of the nervous system that makes our brains (neurons) hyperexcitable. This hyperexcitability gives us a predisposition to migraine attacks. Although research continues to explore the exact cause of migraine, a number of areas in our brains are thought to be directly or indirectly involved in the complex pathogenesis, including the hypothalamus, brainstem, cortex, limbic system, and the trigeminovascular pathway (Charles, 2012; Burstein et al., 2015;  Maniyar et al., 2015).

That said, in the Burstein article, during a discussion of disease mechanisms, the authors report, "migraine attacks are likely to begin centrally, in brain areas capable of generating the classical neurological symptoms of prodromes and aura, whereas the headache phase begins with consequential activation of meningeal receptors at the origin of the trigeminovascular system" (p. 6620). Here, it is important for us to know that as a migraine attack progresses through these  phases, a number of electrical and chemical events take place, including the involvement of neurotransmitters, neuropeptides, and proinflammatory mediators such as dopamine, serotonin, norepinephrine, glutamate, nitric oxide, calcitonin gene-related peptide, histamine, bradykinin and protaglandins. The entire range of these mechanisms is thought to be associated with the wide variety of symptoms we experience (Charles, 2012; Burstein, et al., 2015; Maniyar et al., 2015). 

Let's take a brief look at some examples (for more detailed discussions, see references cited):

Premonitory (prodrome) phase: 

Premonitory symptoms may precede the headache phase of a migraine attack, with or without aura. A number of symptoms have been reported, including fatigue, euphoria, depression, irritability, food cravings, constipation, neck stiffness (pain), yawning, difficulties with concentration, nausea, blurred vision, bloating, pallor, change in facial expression or body perception, piloerection, and sensitivity to light, sound, and smell (Charles, 2012; ICHD-3 beta, 2013; Burstein, et al., 2015; Maniyar, et al., 2015). In the Burstein article, the authors report premonitory symptoms most commonly described by patients point to the potential involvement of:

  • the hypothalamus, including symptoms fatigue, depression, irritability food cravings, and yawning;
  • the brainstem, including symptoms muscle tenderness and neck stiffness;
  • the cortex, including symptoms abnormal sensitivity to light, sound, and smell; and
  • the limbic system, including depression and anhedonia (p. 6620). 

In addition, both the Charles and Maniyar articles suggest premonitory symptoms may be associated with the hypothalamus and note the neurotransmitter dopamine may play an important role. In the Maniyar article, the authors also report emotional changes and a feeling of tiredness may result from involvement of limbic/frontal areas mediated by the hypothalamus; posterior hypothalamic dysfunction could explain neck discomfort and stiffness; and, involvement of the frontal cortex could explain difficulties in reading, writing, and concentration (p. 611). It is interesting to note that in the Charles article, the author mentions some premonitory symptoms may come and go before the headache phase, others may build up in intensity leading up to the headache, occur during the headache, and persist well beyond the resolution phase (p.413). 

Aura phase 

Aura may begin before pain, after headache has started, or continue into the headache phase. (ICHD-3 beta, 2013; Maniyar, et al., 2015). In the Burnstein article, the authors report aura symptoms point to the potential involvement of: 

  • the visual cortex, including scintillating lights* and scotomas*;
  • the somatosensory cortex, including paresthesia, and numbness of the face and hands;
  • the motor cortex or basal ganglia, including tremor and unilateral muscle weakness; and
  • the speech area, including difficulty saying words or aphasia (p. 6619). 

*Scintillating lights are visual hallucinations that are bright and fluctuate in intensity. Scotoma is defined as loss of part(s) of the visual field of one or both eyes (ICHD-3 beta, 2013, p. 808).


Headache is usually unilateral, pulsating, moderate to severe intensity, and may be aggravated by movement but may be felt all over the head, (on one or both sides and in the middle of the head), including the eyes, frontal, occipital and neck areas (Kelman, 2005; ICHD-3 beta, 2013; Burstein, et al., 2015). In the Burstein article, the authors report, as headache progresses, we may experience a variety of: 

  • autonomic symptoms, including nausea, vomiting, nasal/sinus congestion, rhinorrhea (runny nose), lacrimation (tearing one or both eyes), ptosis, drooping of upper eyelid) yawning, frequent urination and diarrhea:
  • affective symptoms, including depression and irritability;
  • cognitive symptoms, including attention deficit, difficulty finding words, transient amnesia, reduced ability to navigate in familiar environments; and, 
  • sensory symptoms, including photophobia (sensitivity to light), phonophobia (sensitivity to sound), osmophobia (sensitivity to smell), cutaneous allodynia (sensitivity to touch) and muscle tenderness (pages 6619-6620).


Some symptoms may persist beyond the headache phase. Postdromal symptoms are thought to be similar to those in the premonitory phase and may include: 

  • hyperactivity or hypoactivity (tiredness, weakness, fatigue);
  • cognitive difficulties;
  • mood change (depression);
  • residual head pain, lightheadedness;
  • neck pain and/or stiffness; 
  • yawning;
  • food cravings; and,
  • gastrointestinal symptoms (Charles, 2013; ICHD-3 beta, 2013). 


Numerous sources commonly refer to migraine as a severe headache. However, as the authors of the Burstein article report, the extent of our symptoms suggests that "migraine is more than a headache. It is now viewed as a complex neurological disorder... and as such, it is evident that the migraine brain differs from the nonmigraine brain" (p. 6620).

The authors also mention that "because the migraine brain is extremely sensitive to deviations from homeostasis (wake-sleep cycles, body temperature, food intake, etc.), it seems reasonable that hypothalamic neurons that regulate homeostasis and circadian cycles are at the origin of some of the migraine prodomes" (p. 6629). In line with this, the Maniyar article indicates hypothalamic involvement can explain many of the premonitory symptoms. Here, the authors suggest further research is needed to investigate whether treatment during the premonitory phase can reliably prevent headache in patients who are able to predict the headache phase of a migraine attack (p. 618).

And, lastly, we should know the Charles article reports "a comprehensive approach of migraine demands appreciation of all the phases of an attack and the development of future therapies may hinge not only on an understanding of what goes on in the brain during a headache but also what happens in the hours before it begins and after it ends" (p. 417).


Burstein, R., Noseda, R., & Borsook, (2015). "Migraine: Multiple Processes, Complex Pathophysiology". The Journal of Neuroscience. April;35(17): 6619-6629. 

Charles, A. (2013). "The evolution of a migraine attack - a review of the evidence." Headache. Feb;53(2):413-9. 

Headache Classification Subcommittee of the International Headache Society. The International Headache Society. "The International Classification of Headache Disorders: 3rd edition (beta version). Cephalalgia. 2013;33:629-608. 

Kelman, L. (2005). "Migraine pain location: a tertiary care study of 1283 migraineurs." Headache. Sep;45(8):1038-47.

Maniyar, F. H., Sprenger, T., Monteith, T., et al., (2015). "The premonitory phase of migraine-what can we learn from it?" Headache. May;55(5) 609-20. 

Sharron Murray M.S., R.N. is the author of Migraine: Identify Your Triggers, Break Your dependence On Medication, Take Back Your Life. San Francisco:Conari Press, 2013.

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

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

Updated October 9th, 2016

Copyright June 1st, Sharron E Murray, 2016





Migraine: The power of a breath

"Remember to breathe. It is after all, the secret of life." - Gregory Maguire, A Lion Among Men

At birth, we take our first breath. In death, we take our last breath. During the years between birth and death, we may take countless breaths and never think about the 'act of breathing'. That is, until the 'power of a breath' is drawn to our attention.

In my case, the impact of a single breath caught me by surprise my senior year of nursing school. Given all the delivery rooms were full, a classmate and myself had been left to monitor a young, single mother, who was not as far along in her labor as the other mothers. The doctor had been called and, once contractions increased in frequency, we had been instructed to push the emergency bell and alert a registered nurse for assistance. We had also been told, since the baby was going to be given up for adoption, the young mother was not to see her newborn. 

Contractions increased. The bell was pushed. No one came to our rescue. Panic! I was at the foot of the bed and could see the baby's head. Breathless and heart pounding, I grabbed the gloves laid out for the doctor and tried to remember, shoulders down or shoulders up? Guide the baby out. "Oh, God," I still remember my terrified prayer, "Please do not let me drop the baby in the kick bucket."

Meanwhile, my classmate, much calmer than myself, had plopped herself on a stool at the head of the bed, turned on the bit of gas we were allowed to administer, and holding a mask over the young mother's mouth and nose was gently saying, "Breathe in, Breathe out, everything's fine". Amazingly, the rhythm of those words subdued the turmoil inside me. I took a breath, guided the baby out, and, as the doctor and registered nurse entered the room, put the wailing little body on the mother's tummy. The umbilical cord was cut and the newborn was safely transported to the nursery. Sighs of relief.  My classmate had created "calm in the midst of chaos."

Throughout my career in critical care nursing, I used those words to create "calm in the midst of chaos" with patients, families, registered nurses, and student nurses. Depending on the situation, "Breathe in, Breathe out" was followed by "you've got this, everything is under control, I'm here for you", or whatever seemed to be appropriate at the time. Oddly enough, I never applied them to myself and my journey with migraine until my first visit to the migraine clinic. So, now that I have your attention, let's take a closer look at the 'act of breathing" and how, for those of us with migraine, it can help create "calm in the midst of chaos " and, with practice, contribute to a decrease in duration and severity of our migraine attacks.

At this point, we need to be aware that one of the areas in the brain implicated in the pathogenesis of migraine disease is the hypothalamus. The main function of the hypothalamus is to regulate homeostasis, or balance between our internal and external environments.  An example of how the hypothalamus maintains homeostasis, and one that is critical to our survival, is the stress response. The stress response is an adaptive physiological response to a real or perceived threat. When a perceived threat (stressor) is recognized, the hypothalamus tells the adrenal gland to release a flood of hormones, including but not limited to, epinephrine, norepinephrine, and cortisol. For those of us with migraine disease, fluctuations in these hormones may trigger a migraine attack (i.e. "let-down" stress), make us susceptible to other triggers like poor sleep, dehydration, and skipped meals, and given the headache phase of an attack itself may be perceived as a stressor, amplify attack duration and severity. 

Thus, we arrive at the 'power of a breath' and how to create "calm in the midst of chaos". During an attack, along with increased heart rate and blood pressure, our breaths may become rapid and shallow. Only the upper portion of our chest (thorax) may expand, limiting the amount of oxygen that gets to the lower portion of our lungs. Low oxygen levels may make us feel dizzy and lightheaded. Pain and anxiety may make us panic and breathe faster, creating a vicious cycle (chaos). As well, other symptoms we have may be magnified, including cold nose, hands and feet (vasoconstriction); chills; nausea and vomiting; confusion; and, insomnia. In addition, gastric emptying may be delayed (gastric stasis) and the oral medications we take may be prevented from entering the small intestine and being absorbed.

At the migraine clinic, I was told breathing effectively during an attack could help slow my respirations down, increase my oxygen intake, promote relaxation, increase absorption of my medications, and hopefully, decrease the severity and duration of my attack. Made sense to me. In other words, taking my own advice, "Breathe in, Breathe out", I could create "calm in the midst of chaos".

Rhythmic Breathing 

So, let's take a look at a technique, rhythmic breathing, I find particularly helpful (Murray, 2013, p. 153). Most of us are unaware of our breathing pattern, therefore, to begin with, you need to identify your normal pattern of breathing. Place one hand on your chest and the other on your abdomen. Take a breath in and notice which hand moves outward with the breath. If the hand on your chest moved, you are a thoracic (chest) breather. If the hand on your abdomen moved, you are an abdominal breather. You should know thoracic breathing is the usual finding in healthy adult females, and abdominal breathing is predominate in infants, children, adult males (more common with rapid rates) and in the elderly because the chest stiffens with age. (Murray & White, 1999, p.p. 25, 76, 78). The reason females (and perhaps some males) tend to be chest breathers rather than abdominal breathers is not well defined but, in graduate school, I was told it was thought to be related to "vanity" (push the chest out and suck the tummy in).

Rhythmic breathing involves inhaling and exhaling at a fixed pace while you pay attention to the flow of air going in and out of your body. The breath is not forced , and the chest and abdomen move as one unit. On inhalation, this allows the diaphragm to drop down into the tummy and more air to reach the bottom of the lungs. On exhalation, the diaphragm moves back into position, the lungs and respiratory tissue recoil, and air escapes into the atmosphere.  Some sources have you count to 3, 4, or 5 as you inhale and exhale. I have stuck with the words I learned long ago in nursing school, "Breathe in",  and "Breathe out".

So, get comfortable. You can sit or lie down:

  • Place one hand on your lower chest and the other on your abdomen.
  • As you inhale slowly through your nose, say the words, "breathe in".
  • As you exhale slowly through your nose or mouth, say the words, "breathe out".
  • Concentrate on relaxing your muscles.

Slow and and out... a hand on the lower chest and a hand on the belly, everything moving together, expand on inhalation, contract on exhalation. After you repeat the pattern a few times, you should start to feel calm. If you practice this technique throughout the day (standing, sitting, or lying down) between attacks, you will find it easier to draw upon when you have an attack. As well, you may find during any stressful situation or event, you automatically revert to the technique.

"You've got this!" Warm wishes for great success.



Murray, S., MS., RN. Migraine: Identify Your Triggers, Break Your Dependence On Medication, Take Back Your Life.  San Francisco:Conari Press, 2013.

Murray, S. E., MS, RN, &  White, B. S., DrPH, RN-Cs, ANP. GNP. Critical Care Assessment Handbook. Philadelphia: W.B. Saunders Company, 1999.

Copyright May, 2016, Sharron E. Murray.

Follow Sharron on twitter @murraysharron, her FB 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 consult a qualified health care professional.




Can an electronic diary driven by personalized analytics overcome the challenge of identifying and managing individual migraine triggers?  


Although determining migraine triggers is believed to be an important step in migraine management, establishing connections between individual triggers and subsequent attacks is difficult. If you have episodic or chronic migraine and have tried to figure out your triggers, you are probably aware that the process can be a frustrating and stressful event.

Perhaps, the challenge we face is best expressed by Dr. Richard Lipton, a professor of Neurology at Albert Einstein College of Medicine and Director, Montefiore Headache Center, in an article, "Migraine: More than Just a Headache", (Reynolds, 2016). Here is an excerpt:

"Trigger management is very important, but the challenge is that there are huge individual differences in which triggers matter, " says Dr. Lipton. He has seen patients come into his clinic with drastic weight loss because they've tried to avoid every food listed as a potential migraine trigger without knowing if any really affect them personally, "and there's nothing left to eat". True trigger identification, he says, requires that people keep a migraine diary and look at multiple attacks over time.

Dr. Lipton is excited about the new generation of online diary tools, such as Curelator Headache, which he recommends to his patients. These tools let migraineurs use a smartphone or tablet to track exposures and symptoms in real time and generate reports of potential triggers they can discuss with their doctor.

"It's one of those areas of medicine where rationalization and individualization is particularly important," says Dr. Lipton, "and the better we get at identifying individual triggers, the better we'll be able to give people individualized advice on trigger avoidance." (p.4/8).

It is important for us to know that in a recent study, "Towards improved migraine management: Determining potential trigger factors in individual patients", (Peris, et al, 2016),  published in Cephalalgia and presented with aditional data at the 58th Annual Scientific Meeting of the American Headache Society, the Headache Group, Department of Neurology at Medical University of Vienna, Austria and Curelator Inc. collaborated in an analytical approach to identify potential trigger-factor associations (potential triggers or premonitory symptoms) with migraine attacks in individuals with migraine. The study authors report individual 'potential trigger' profiles were successfully generated for almost all 326 migraine patients (87%) who kept detailed diaries for 90 days. An average of four trigger factors per patient were associated with an increased risk of attack and in 85% of patients, trigger profiles were highly individual and unique. In an adapted press release, "Triggers for migraine attacks determined for individual patients", (MNT, June 8, 2016), Dr. Christian Wober, one of the study authors and head of the section specializing in headaches at MedUni Vienna's Department of Neurology, is quoted as saying, "For the very first time, this new analysis therefore provides information about the correlation between migraine attacks and a broad spectrum of possible trigger factors for each individual patient and is therefore a step towards personalized migraine management."

This brings us to a discussion about Curelator Headache and this new analytical approach to the identification and management of migraine triggers. Curelator Headache is a digital tool that guides individuals with migraine to track and discover factors associated with increasing and decreasing the risk of having a migraine attack and dismiss factors that have no effect on attacks. Along with Dr. Richard B. Lipton and Dr. Christian Wober, members of the clinical advisory board are other leading international headache and migraine experts, including  Dr. Peter Goadsby, Dr. Anne MacGregor, Dr. Paul R. Martin, Dr. Noah L. Rosen, and Dr. Stephen D. Silberstein.

People can get Curelator at no cost through a coupon referral program that Curelator runs through any participating neurologist (alternatively, a premium version can be purchased on their website). Either way, when a person downloads an app from the Curelator website (premium version*), after approximately 90 days of accumulating daily data a subsequent statistical analysis provides the individual three visual maps:

  • Trigger Map (factors showing increased risk of an attack, including high association and low association).
  • Protector Map ( factors associated with a decreased risk of an attack). For example, if poor quality sleep is a trigger for you, good quality sleep may be protective for you; and, if stress is a trigger for you, relaxation may be protective for you.
  • No association Map (factors that do not appear to be associated with an attack). For example, if foods with tryramine show no association with your attacks, there may be no need for you to avoid some of the foods you enjoy.

In addition, you receive a Personal Analytical Report, including the amount of acute medication you have taken (can help identify medication overuse), missed daily medication (preventives), and missed other medications. This report can be shared by you with your physician, or, with your permission, sent to your physician by Curelator Headache, with the goal of increasing your knowledge of your individual triggers and improving your clinical outcomes. 


I was introduced to Curelator Headache in the fall of 2014 and began to use the tool January, 2015. Before starting to use the tool, I, like other users, was asked to list my suspected triggers. It is interesting to note, in a study conducted by Curelator Headache of hundreds of individuals analyzed who firmly believed they knew their triggers, the accuracy was surprisingly low. On average, accuracy was less than 20%. Factors accurately identified more frequently than others included stress and sleep quality. Dietary factors did poorly. Two individuals, myself and a person from Northern Europe, had above a 70% accuracy. Both of us had meticulously kept diaries for more than 5 years.

After receiving my first set of trigger maps, I had an interview with Alec Mian, PhD, CEO, Curelator Headache. We talked about the method I used to track and successfully manage my triggers, how I use Curelator Headache, and my early results. Since that time (almost a year ago), in addition to the information I shared during the interview, I continue to use Curelator Headache because:

  • Comorbidities may increase the frequency of migraine attacks and/or headache days. For example, in my situation, I have had comorbid hypothyroidism for decades. About 6 months ago, I noticed an increase in headaches, along with a sluggish digestive system and a general feeling of malaise. My daily diary helped me distinguish between these headache days and migraine (headache phase). After a discussion with my doctor, the dose of my thyroid supplement was increased and the related headaches have diminished. 
  • Following a neck injury in my forties, cervicogenic headache has been, for me, increasingly troublesome. Again, through the data I input, my daily diary helps me distinguish between neck pain associated with cervicogenic headache and neck pain as a premonitory symptom related to migraine. 
  • As I proceed on this journey with trigger management, I find I am able to experiment a bit more with my known triggers. For example, small doses of sun and heat are now tolerable, in particular, if I am relaxed. 
  • Perhaps, most importantly, the few minutes I spend each day punching in my data have become a "mindfulness moment".  A brief time for me to reflect on the challenges of my day, acknowledge emotions like sadness, anger and happiness and let go of what doesn't serve me well. If I feel particularly stressed, I realize I need a session of meditation at bedtime to promote relaxation and help induce sleep. As well, I think about exercise; and, what and how much, I had to eat and drink, not in a stressful way, but one that facilitates learning and reinforces healthy lifestyle habits.

*NOTE: You can choose your plan, free or premium, when you download the tool and customize your app at this time. 


Mian, A. (2015). "Q&A with Sharron Muray and Alec Mian." Curelator Headache. December 3, 2015.

Mian, A. & Martin, P.R. (2016). "Confabulation, card tricks and confirming your migraine triggers (part 1)." Curelator Headache. April 7, 2016.

MNT. (2016). "Triggers for migraine determined for individual patients." Adapted Media Release . Tuesday 7 June, 2016.

Peris, F., Donoghue, S., et al. (2016).  "Towards improved migraine management: Determining potential trigger factors in individual patients". Cephalalgia.  May 14. pii: 0333102416649761 

Reynolds, S. (2016).  "Migraine: More than Just a Headache". A Woman's Health- Women Magazine. April 25, 2016. pp 3-8. 

Sharron is a health and wellness author. A person with migraine herself, her most recent book, "Migraine: Identify Your Triggers, Break Your Dependence on Medication, Take Back Your Life-an Integrative Self-Care Plan for Wellness", (2013), is a Conari Press publication.

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

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

Copyright, August 4, 2016: Sharron E. Murray