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The influence of regular lifestyle behaviors in migraine



  "Good habits are worth being fanatical about." John Irving

Much is written about lifestyle habits and migraine. Altered sleep patterns, (poor sleep), hunger (skipped meals, fasting, hypoglycemia), dehydration, high- intensity exercise (strenuous), and stress are thought to trigger migraine attacks. Good quality sleep, regular meals, adequate hydration, low-intensity exercise, and low stress (stress management therapies) are believed to be protective for migraine.

Acknowledging the importance of the role lifestyle factors play in promoting wellness and managing disease, in a recent study, "The impact of regular lifestyle behavior in migraine: a prevalence case-referent study," (Woldeamanuel and Cowan, 2016), the study authors aimed to evaluate the differences in migraine occurrence among participants who do and do not maintain the regular lifestyle behaviors (RLBs) of sleep; exercise; and, daily mealtime pattern and hydration status. Since a review of the literature revealed previous studies have investigated each of these factors alone, the purpose of this present study was to examine the connection between these three factors and migraine occurrence.  In this article we take a look at the authors findings and what the results mean to those of us with migraine. 

To begin with, we should know a bit more about the study. Participants were 175 episodic and 175 chronic migraine patients age 15 years and older, with charts regularly documenting RLB.  Electronic medical records were continuously followed and studied for one year (January 1, 2014 to January 1, 2015) at the "Stanford Headache and Facial Pain Clinic".  Patients younger than 15 years, those with primary insomnia, shift workers, and charts not documenting notes on RLB were excluded. Diagnosis was made using the ICHD-3 beta  (International Classification of Headache Disorders) criteria and each diagnosis was confirmed by a Headache Specialist. The potential for effect modification by medication use (abortive and/or preventive), depression, and anxiety was tallied and analyzed in both episodic and chronic migraineurs. 

The study focused on the following three self-report domains: 

  • Maintaining regular sleep hours with consistent-sleep wake time both in weekdays and weekends.
  • Maintaining regular daily mealtime and adequate hydration status (consisted of keeping consistent meal hours with the number of meals personalized to the preference of each patient as the study focused on regularity of mealtimes rather than frequency); adequate hydration consisted of keeping regular amounts of water intake personalized to patient preference.
  • Maintaining daily aerobic exercise of any form for 20 minutes duration that raised heart rate. 


175 patients with episodic migraine and a combined total of 1016 mean monthly headache days and 175 patients with chronic migraine and a combined total of 3786 mean monthly headache days were continuously enrolled: 

  • In both groups, 22% of the patients were males.
  • The mean age was 41 years in the episodic group and 40 years in the chronic migraine group. 
  • The mean monthly migraine frequency for episodic patients was 5 and 25 among chronic patients.
  • All 3 lifestyle behaviors were seen in lower frequency among the chronic migraine group, with a decreasing pattern from regular mealtime, regular sleep, to daily exercise in both groups. When comparing the impact from each lifestyle behavior to the impact of the combined RLB, regular sleep had identical impact. 
  • The group of chronic migraine patients who followed RLB were progressively converting, month after month, into episodic migraineurs, while episodic migraineurs not following RLB , month after month, were converting into chronic migraine.


It is important for those of us with migraine to know: 

  • The mean age and mean frequency of episodic and chronic migraine were representative of migraine patients in the general population 15 years and older
  • The risk of having chronic migraine was significantly reduced for patients with RLB and higher RLB prevalence was protective from developing chronic migraine.
  • Adjusting these results to the possible effect modifier of medication use and depression and/or anxiety showed no significant implications. 

In addition, along with providing evidence for the importance of sleep regulation in headache medicine, the authors of the study suggest evidence is provided for the relevance of: 

  • Employing non-pharmacological evidence-based migraine therapeutic protocols for individual lifestyle behavior modification that are applicable in daily clinical practice and beyond. 
  • Empowering and reinforcing self-management skills and desirable lifestyle behavior modifications for long-term management and prevention.
  • Behavior modification treatment to help revert and unlearn strategies that led to the formation of undesirable and inappropriate behaviors and teach new and appropriate behaviors. 

Limitations and Conclusions 

The authors conclude engaging in RLB is a moderating factor in migraine. Migraine patients who follow all three domains of RLB are more likely to have episodic than chronic migraine. They add, learning self-regulated behavior can enable the person with migraine form favorable lifestyle habits, which can ultimately help control migraine. The authors suggest the positive results from this study indicate the need for a full prospective randomized controlled clinical trial to further investigate and validate the role and impact of RLB in migraine management. These studies will facilitate investigation into:

  • The degree of flexibility in maintaining RLB.
  • Further validation of causality between lack of RLB and chronic migraine, or whether there is an undetermined factor causing both, e.g. high stress level.
  • The need for psychometrically sound measures or wearable tracking devices to track lifestyle behaviors as they relate to migraine to avoid the limitations of self-report and improve accuracy of real-time data and behavior.

"Strength doesn't come from what you can do. It comes from overcoming the things you once thought you couldn't" - Rikki Rogers 

For many of us with migraine, our attacks may increase in frequency during the busiest years of our lives when we are balancing our jobs, family responsibilities, and social obligations. Maintaining lifestyle habits like regular sleep schedules, mealtimes and hydration, along with daily exercise routines, can be a challenge.

However, we need to be aware that as our attacks increase in frequency, so do a host of other problems that can complicate our treatment and contribute to migraine- related disability. That said, when my migraine attacks escalated from episodic to chronic, making substantial changes in what I ate and drank, my eating and drinking habits, my sleep routine, and learning to manage my physiological  stress response, were the most difficult things I did to reduce the frequency of my attacks and remit from chronic to episodic migraine. But, it is important to note, that as my attacks decreased in frequency, I gained a feeling of empowerment (internal locus of control), which motivated me to continue to create an environment conducive to wellness.

Today, although I have learned to manage my disease and and have infrequent attacks, I continue to  use an electronic tool to track my daily trigger management and to remind myself of the importance of regular lifestyle habits. For me, "Good habits are worth being fanatical about". 

Sharron :)  


Woldeamanuel, Y. W., & Cowan, R.P. (2016).  "The impact of regular lifestyle behavior in migraine: a prevalence case-referent study." Journal of Neurology. pp 1-8. First online: 25 January.

Sharron Murray, MS, RN, is a health and wellness author. Her most recent book is , "Migraine: Identify Your Triggers, Break Your Dependence On Medication, Take Back Your Life- An Integrative Self-Care Plane for Wellness."  San Francisco: Conari Press, 2013

Follow Sharron on twitter @murraysharron and on facebook, Sharron Murray, MS, RN

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

Updated September 27, 2016

Copyright March 3rd, 2016, Sharron E. Murray 
















Puzzled by migraine triggers? 7 things to know to help manage attacks 

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, which makes our brains hyperexcitable. This hyperexcitiability gives us a predisposition to migraine attacks.

Once we have been diagnosed with migraine, we need to know about triggers. Although much is written about triggers and scientific evidence is often insufficient, inconclusive, and debatable, seven important things we should be aware of are:


Triggers are internal and external stimuli that "set off" (provoke, initiate) migraine attacks in those of us who have the disease. In other words, migraine disease makes us vulnerable to triggers. 


It is important for us to know that triggers do not cause our symptoms. "During a migraine attack, a storm of electrical and chemical activity 'switches on' different areas in the brain and surrounding nerves to cause migraine symptoms" (Dr. Andrew Charles, AHS14AZ).


 Triggers thought to be associated with an increased probability of an attack over a brief period of time include: 

  • Altered  sleep patterns (poor sleep, interrupted sleep, oversleeping).
  • Hormonal changes like estrogen withdrawal.
  • Hunger (missed and skipped meals, fasting, hypoglycemia).
  • Dehydration.
  • Stress, including perceived emotional stress and "let-down" stress.  As well, stress can make us more susceptible to other triggers. For example, perceived emotional stress may interrupt our sleep or make it difficult for us to fall aseep.
  • Environmental factors like weather changes, bright or flickering lights, loud noises, and strong odors.
  • *Dietary factors including magnesium deficiency and chemicals and additives in foods, such as tyramine (e.g., aged cheeses, bananas, avocados, fava beans, garbanzo beans, lima beans, organ meats like liver, pickled foods, canned soup, nuts, peanut butter, tomatoes, and soy sauce), tannin (e.g., chocolate, cheeses, ice cream, nuts, bananas, smoked foods, and cigarette smoke), aspartame (e.g., diet sodas), phenylethylamine (e.g., chocolate), sulfites (e.g., fermented foods and beverages), nitrites (bacon, ham, pepperoni, and other processed meats), gluten (e.g., wheat, barley, rye, and may be added to number processed foods as thickener,stabilizer, emulsifier, starch, or hydrolyzed plant protein), MSG (e.g., sauces, gravies, processed meas, packaged foods, and canned soups and vegetables).
  • Alcohol.
  • Exposure to, or withdrawal from, certain medications, caffeine.    

*Food cravings (hunger) in the premonitory phase may be mistakenly identified as triggers. For example, declining estrogen levels that occur at the time of menstruation as well as low levels that are encountered during the menopausal transition, are triggers for some women. Low estrogen levels are associated with low serotonin levels. Low serotonin levels may promote food cravings for starches and sugars, including chocolate. If we mistakenly identify a food craving as a trigger, we may unnecessarily avoid something we enjoy.  


While specific triggers may be controversial, in a study where respondents were presented with a list to choose from (Kelman, 2007, cited in Pavlovic et al, 2014), the most commonly occurring triggers were:

  • Stress.
  • Hormones.
  • Missed meals.
  • Weather.
  • Sleep disturbances.
  • Odors.
  • Alcohol.
  • Heat.
  • Foods.


While a single trigger may initiate an attack, a single trigger (apart from menstruation) may not be powerful enough to consistently initiate an attack by itself. In other words, we need to know if a specific trigger is always followed by an attack. Since it may take a combination, or loading of triggers (additive effect, stacking, cumulative) to provoke an attack, it is helpful for us to know which triggers occur either singly or in combination with others. For example, high stress plus poor quality sleep or oversleeping, is associated with an increased chance of an attack. (Spierings et al, (2014)


Perhaps, the most important thing to know about triggers is they are unique to the individual.  Keeping a diary can help us identify our personal triggers and make associations between these triggers and our attacks. An advantage of electronic diaries is they can capture data on the same day and eliminate the inaccuracy of recall, along with the frustration of flipping through pages to try and figure everything out. 


Once we identify our unique triggers, we can avoid or learn to manage them. For example, we can avoid triggers that are not consistent with a healthy lifestyle such as toxic smells; chemicals and additives in foods and beverages; hunger; dehydration; and, lack of sleep or oversleeping.  We can learn to manage others like stress. 


Murray, S. "Can we use associations between migraine triggers, premonitory symptoms, and migraine attacks, to predict our attacks and decrease their frequency?" Sharron Murray's Articles, December, 2014.

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

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

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

Updated July 6, 2016

Copyright September, 2015, Sharron E, Murray



Migraine and Disabling Headache Disorders- Hope through research, education and advocacy

"There is no medicine like hope, no incentive so great, and no tonic so powerful as expectation of something tomorrow." - Orison S. Marden
For me, hope for living with migraine has always come through my background in nursing, including the importance of research and knowledge (education) in the diagnosis and treatment of disease. Now, advocacy has chimed in. I was introduced to advocacy in the fall of 2012, when I met Teri Robert online. A short while later, through email and phone conversations, I became more familiar with her dedication for migraine and headache advocacy, as well as the event, "Headache on the Hill (HOH)."
I attended my first HOH in 2013 and was stunned to learn the total disease burden and disability burden of migraine and headache disorders. As well, the lack of attention and funding for research from NIH for these disorders  was a complete surprise.
Given my background in Critical Care Nursing, research and education were priorities in patient care and treatment outcomes. It seemed I was always participating in a study, applying findings of a study, recruiting patients for a study, or writing about a study. The quote "no medicine like hope, no incentive so great, and no tonic so powerful as expectation of something tomorrow" was put into action as I watched the words unfold in clinical practice and patients survived unbelievable circumstances because of research.
To see such a dismal amount of attention and funding provided for a disease I had struggled with all my life, and one that had claimed my nursing career, well I was taken back. Now, I was motivated to do everything I could to contribute to advocacy and draw attention to the plight of my fellow persons with migraine and the friends I had made, who lived with what I witnessed as 'unimaginable' pain of cluster headaches. 
I couldn't make it to HOH2014 because of a family crisis and HOH2015 due to surgery on my calf and my surgeon forbidding me to walk for a month. But, coincidentally, I received a "Dear Colleague" request from the Director of the National Center for Complementary and Integrative Health, National Institutes of Health (NIH-NCCIH), for input to identify research topics to be included in their new strategic plan.
Since many of us use these therapies to help prevent attacks, treat headache and other symptoms, and to contribute to good health, even though there is a lack of scientific-based efficacy for a number of them,  I jumped at the opportunity and focused my comments on 'headache medicine'.
But, why stop there? Given, a predominant reason for the use of these strategies is the lack of effective acute and preventive medications, I attached a copy of my response, with a short note, to the information I sent to my Senator's office from HOH2015.
You should know that in the "How to Submit a Response" section of the form I received, it stated, "respondents are advised the Government is under no obligation to acknowledge receipt of the information or provide feedback with respect to any information provided." Much to my surprise, I received a response from the Director, Office of Policy, Planning, and Evaluation NIH-NCCIH the very next day after my submission.  She advised me that my thoughtful comments would be taken into careful consideration in their new strategic plan to guide the Center's research efforts and priority setting.
So,  as I wait for more feedback,  "There is no medicine like hope, no incentive so great, and no tonic so powerful as expectation of something tomorrow". I will keep you posted. In the meantime, I have attached my response for your information. 

As mentioned in Strategic Objective 1, “Advance Research on Mind and Body Interventions, Practices and Disciplines,” there is an increasing interest by the public, as well as across many health care disciplines, regarding the potential application of mind and body approaches to a variety of challenging health problems.” Given the multiple challenges of ‘headache medicine’, in my response to your request for information to help identify and consider research areas and topics to be included in your next strategic plan, my comments and suggestions on mind and body approaches, as well as the use of herbs and supplements, focus on the Primary Headache Disorders: Migraine, Tension-Type Headache, and Cluster Headache.
Patients with headache disorders use complementary therapies to help prevent attacks, treat headache and other symptoms, and to contribute to good health, even though there is a lack of scientific-based efficacy. A predominant reason for the use of these strategies is the lack of effective acute and preventive medications, in particular migraine-specific.
Some facts about headache disorders prepared by the “Alliance for Headache Disorders Advocacy” (AHDA) and shared at “Headache On The Hill (HOH) 2015” include:
  • Headache disorders are the most prevalent neurological disorders, affecting more than 90% of Americans.
  • Approximately 36 million Americans (estimates are as high as 40 million) suffer from migraine headaches, including 25% of middle-aged women and 19% of veterans of the Iraq war. 
  • A quarter of American families contain someone with migraine. 
  • 4% of Americans experience head pain more than 4 hours per day for more than 15 days per month.
  • Cluster headache is as prevalent as multiple sclerosis and these attacks are among the most severe pain conditions known.
Migraine, a genetic neurobiological disorder, is characterized by hyperexcitability and episodic events known as migraine attacks. Episodic and chronic migraine are differentiated in the number of headache days per month. In episodic migraine (EM), headache occurs on less than 15 days per month. In chronic migraine (CM), headaches occur on 15 or more days per month (tension-type and/or migraine-like), with the features of migraine headache on at least 8 days per month.
Many persons with migraine have a poor response to acute medications, including simple analgesics, combination analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, barbiturates, and triptans. Lack of effectiveness of acute therapy can contribute to medication overuse, which can perpetuate or exacerbate headaches. Overuse of acute medications, in particular opioids and barbiturates, has been shown to increase progression of EM to CM and is a common cause of chronic migraine symptoms.
Some people revert to EM after medication overuse is stopped, but many do not. Along with treating migraine attacks early and decreasing attack frequency, to prevent medication overuse headaches, acute medication use needs to be monitored by physicians and nonpharmacological options substituted when possible (Lipton & Bernstein, 2015).
Tension-type headache is characterized by a typically bilateral, mild or moderate pain, with a pressing or tightening quality. The headache may coexist with migraine and needs to be distinguished to select the right treatment, while avoiding medication overuse.
Cluster headache, a trigeminal autonomic cephalalgia (TAC), is characterized by severe attacks of ipsilateral pain, which can last 15-180 minutes and occur from once a day to every other day up to 8 times a day. Attacks may be associated with a number of unpleasant autonomic symptoms (ICHD-3 beta, 2013).
Results of a study, “Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine” (Lipton et al, 2015), showed among persons with episodic migraine (EM), ineffective acute treatment was associated with an increased risk of new-onset chronic migraine (CM) over the course of 1 year. Another study using data from the American Migraine Prevalence and Prevention (AMPP) study showed about 2.5% of persons with episodic migraine (EM) progress to chronic migraine (CM) per year (Manack, Buse et al, 2011).
As attacks increase in frequency, so do a host of other problems that can complicate treatment and contribute to headache related disability. For example:
  • Comorbidities, including obesity (2 to 5 times more likely to develop CM than persons normal weight), heart disease, angina, high cholesterol, high blood pressure, stroke, circulation problems, immune disorders, other chronic pain disorders, pulmonary disorders, anxiety, and depression, along with individual, family and societal burdens, increase.
  •  Some psychiatric comorbidities, including depression, are associated with worsening disease progression and disease outcomes, including suicide attempts (Buse, Silberstein et al, 2013).
  • Persons with CM are significantly more disabled than those who have EM, have higher levels of unemployment and lower personal and household incomes, increased comorbidities (nearly 1 in 3 persons meets the criteria for depression) a greater impaired quality of life inside and outside the home, and may have associated brain abnormalities that are persistent and perhaps progressive (Lipton, Serrano et al, 2014, and Lipton & Silberstein, 2015).
In a recent study designed to assess the comorbidity burden of patients with cluster headache (Joshi & Loder, 2015), of 170 subjects, results showed:
  • 51% had used antidepressants.
  • 20% had been diagnosed with anxiety disorders.
  • 25% had been diagnosed with depression.
  • 23% had been diagnosed with hypertension.
  • 21% had been diagnosed with hyperlipidemia.
  • 7.6% had been diagnosed with diabetes mellitus.
  • 7% had been diagnosed with ischemic heart disease.
  • 6% had been diagnosed with obesity.
  • 4% had been diagnosed with organic sleep disorders.
  • 13% had been diagnosed with cardiovascular disease.
  • 10.5% had been diagnosed with trigeminal neuralgia.
  • 4.7% had been diagnosed with epilepsy.
The authors suggest further research about common comorbidities might reveal shared biological mechanisms that could be explored for treatment purposes.
Mind and body approaches
Along with pharmacological treatment and educational interventions, lifestyle modifications, and trigger management, mind and body approaches have been shown to reduce migraine attack-related impairment and decrease the frequency and severity of attacks. Approaches that have demonstrated efficacy include cognitive behavioral therapy (CBT), biofeedback, and relaxation techniques like diaphragmatic breathing, meditation, and guided imagery. These strategies, along with acupuncture, can be used alone or in conjunction with medication (Lipton & Silberstein, 2015). While evidence for the efficacy of acupuncture is growing, more research is required for approaches like yoga, exercise, physical therapy, massage therapy, craniosacral therapy, reflexology, chiropractic therapy and energy healing techniques such as, healing touch.
Cognitive behavioral therapy helps persons with migraine and headaches understand that their thoughts and feelings influence their moods, behaviors and ultimately their health. In general, the remainder of the mind and body approaches listed in the preceding paragraph can:
  • Relax tense muscles in the neck and shoulders.
  • Relieve muscle spasm and inflammation and relieve pressure on adjacent nerves.
  • Stabilize serotonin levels (thought to fluctuate during attacks).
  • Increase endorphin levels.
  • Ease the effects of stress (balance the nervous system) and promote calmness and relaxation (quiet the mind and calm the body).
  • Improve sleep.
  • Balance emotions.
  • Increase self-awareness.
  • Promote a feeling of empowerment.
  • Facilitate a better quality of life for the individual.
  • Reduce the burden of the disorder on the individual, family and society.
Herbs and Supplements
Patients with headache disorders may use herbs and supplements to prevent attacks, and relieve pain and other symptoms, regardless of lack of efficacy or consideration for safety. Because many patients use these in combination with medications, further scientific investigation is needed to prevent dangerous drug interactions and side effects.
Herbs used include: butterbur, feverfew, ginkgo biloba, white willow bark, turmeric, ginger, cayenne, peppermint, lemon balm, valerian, and skull cap. Of these only butterbur (with restrictions) is recommended as a Level A complementary therapy for migraine prevention and feverfew is mentioned as Level B and thought to be probably effective. Supplements used include: magnesium, riboflavin (Vitamin B2), Coenzyme Q 10, and fish oil. Of these, magnesium and riboflavin are listed as Level B complementary therapies that are probably effective for migraine prophylaxis, coenzyme Q 10 is considered to be possibly effective and is listed as Level C, and data are reported to be conflicting or inadequate to support the use of fish oil (omega-3) for migraine prevention (Holland et al, 2012).
In a survey of 110 cluster headaches using a daily anti-inflammatory regimen of vitamin and mineral supplements , including Vitamin D3 and omega-3 fish oil, as a preventative, data suggested a possible causal relationship between a vitamin D3 deficiency and cluster headache. The authors conclude that at less than 30 cents a day, this regimen with 10,000 IU/d vitamin D3 is safe, effective and well tolerated, and it can be combined with most standards of care treatment strategies for cluster headaches (Batcheller, 2014).
An abundance of data supports the substantial impact of headache disorders on public health:
  • “Global Burden of Disease Study 2010,” showed migraine was the 4th most disabling disorder among women and the 7th most disabling medical disorder worldwide (Lipton & Silberstein, 2015).
  • According to a world Health Organization analysis, migraine alone is responsible for at least 1% of the total US medical disability burden (HOH 2015).
  • 1 out of every 6 outpatient visits for migraine takes place in the ED. This is unfortunate because management of migraine in the ED is often sub-optimal. Patients may be prescribed non-migraine-specific medications such as opioids, which have been associated with dependence and MOHs (Burch, Loder et al, 2015).
  • US annual direct and indirect economic costs of headache disorders exceed $31 billion (HOH 2015).
  • Headache disorders are responsible for 9% of all US lost labor productivity (HOH 2015).
  • Migraine or severe headache affects roughly 1 out of every 7 Americans annually (Burch, Loder et al, 2015).
  • Migraine is 2-3 times more common among women than men (Burch, Loder et al, 2015).
  • Greater than 1400 more US women with migraine with aura die annually from cardiovascular diseases compared to women who do not have migraine (HOH 2015).
  • Based on a sample of Americans, suicide attempts are 3 times more likely in individuals with migraine with aura compared to those with no migraine, whether or not major depression is also present (HOH 2015).
  • Results from US Cluster Headache Survey showed 55% of respondents had suicidal ideations, 20% lost jobs secondary to cluster headaches, and another 8% were out of work or on disability secondary to their headaches (Rozen & Fishman (2012).
  • Migraine prevalence is higher than average in certain vulnerable or underserved populations, e.g., low socioeconomic status, uninsured, unemployed, or employed part-time (Burch, Loder et al, 2015).
  • Migraine is less frequently diagnosed among active duty US Armed Forces personnel than the general population, but 1-year prevalence is increasing (Burch, Loder et al, 2015).
  • Migraine and headache are leading causes of outpatient ED visits and remain an important public health problem, particularly among women during their reproductive years (Burch, Loder et al, 2015).
In Strategic Objective 3, it states a concerted effort is needed to address gaps in scientific evidence and public information about CAM therapies.
Gaps in scienetific evidence and public information 
It is interesting to note that in a recent study that examined gaps in diagnosis, treatment, and knowledge of individuals with chronic migraine in the US (Buse, Lipton, et al 2014), knowledge and use of empirically and guide-line supported nonpharmacological treatments for migraine prevention was low among those under the care of a “Headache specialist” and very low among those not under the care of a “headache specialist”. Awareness of all preventive treatments and strategies among all respondents with CM was as follows:
  • Avoiding things or activities that trigger my headaches – 62.7%
  • Taking a daily prescription medication – 53.0%
  • Receiving injections every few months – 17.4%
  • Vitamins or herbs – 33.5%
  • Biofeedback - 16.8%
  • Relaxation techniques (meditation, visual imagery, diaphragmatic breathing,) – 47.5%
  • Cognitive behavioral therapy (CBT)/psychotherapy – 12.9%
  • Acupuncture – 33.5%
  • Yoga – 29.2%
  • Exercise - 48.8%.
  • Weight management/dieting 34.6%.
  • Not aware of any way to prevent headaches or reduce their severity – 17.9%
  • Don’t remember – 1.9%
Addressing the lack of knowledge of physicians and the lack of scientific evidence about Cam practices used among individuals suffering from headache, in an article “CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don’t”, (Cowan, 2014), the author suggests that until such time as the body of scientific literature adequately addresses non-conventional approaches, physicians must understand as best as possible these approaches, which are commonly used by their patients.
Education, availability and cost
Along with a need for increased scientific-based evidence for use of integrative therapies in ‘headache medicine’, it would seem an increase in education about the benefit of these therapies is required among patients and physicians, as well as across health care settings and multi-disciplinary health care teams. Promoting and fostering availability of these therapies for individuals with headache disorders across the country, as well as decreased cost to the individual is essential. Many persons with headache disorders are forced to travel out of state to 'headache and migraine clinics', often at their personal expense, to receive an accurate diagnosis for their headaches and the multidisciplinary care they require. As well, therapies like acupuncture, yoga, etc., may be limited to the individual because of logistic access and financial concerns. Another example involves persons with cluster headache and oxygen therapy. While the effect of oxygen therapy has been studied in a few studies and there is evidence for an acute, but not prophylactic effect, and the treatment is safe, sufferers of cluster headache do not always have access because of logistics and financial concerns (Petersen et al, 2014).
In the initial national priorities for comparative effectiveness research, headache disorders, including migraine are not mentioned. Given the information presented in this article, it would seem a priority for NIH-National Center for Complementary and Integrative Health to recognize the serious and damaging effects of headache disorders on the individual, family, and society. Needs to be addressed and funded in comparative effectiveness research involving integrative (CAM) approaches and headache disorders include:
  • Compare the effectiveness of mindfulness-based interventions (e.g., cognitive behavioral therapy, biofeedback, yoga, meditation, deep-breathing training) and usual care in treating migraine and other headache disorders.
  • Compare the effectiveness of acupuncture for migraine and headaches using a cluster-randomized longitudinal study.
  • Compare the effectiveness of strategies like exercise, physical therapy, chiropractic therapy, massage therapy, and energy healing techniques, such as, healing touch and usual care in treating headache disorders.
  • Compare the effectiveness of dietary supplements and usual care in the treatment of headache disorders.
  • Establish a prospective registry to compare the effectiveness of these treatment strategies for headache disorders, including migraine, tension-type headache and cluster headache.
Sharron Murray, MS, RN
Author, “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
Former nursing faculty member, California State University, Long Beach. Member Sigma Theta Tau International Society of Nursing, American Holistic Nurses Association, Healing Beyond Borders, and American Headache and Migraine Association
Person with migraine and patient advocate. , @murraysharron, and her
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Holland, S., Silberstein, S. D., et al. (2012). “Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults.” Neurology. April 24, vol. 78. No. 17 1346-1353.
Joshi, S., & Loder, E. (2015). “The Comorbidity Burden in Patients with Cluster Headache.” Neurology. 80 (1001): P01.083.
Lipton, R. Serrano, D., et al. (2014). “Sociodemographic, Disability, and Employment Differences Between Persons With Chronic and Episodic Migraine: Results of the CaMEO (Chronic migraine Epidemiology & Outcomes) study”. Neurology. April 8, vol. 82 no. 10 Supplement S41.002.
Lipton, R., Fanning, K. M., et al. (2015). “Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine.” Neurology. Feb 17;84(7):6888-95. Doi: 10.1212/WNL.0000000000001256.
Lipton, R. B., & Silberstein, S. D. (2015). “Episodic and Chronic Migraine Headache: Breaking Down Barriers to Optimal Treatment and Prevention.” Headache: The Journal of Head and Face Pain.” Volume 55, Issue Supplement S2, (/doi/10.1111/head.2015.55.issue-s2/issuetoc) pages 103-122. March.
Manack, A., Buse, D. C., et al. (2011). “Rates, predictors and consequences of remission from chronic migraine to episodic migraine.” Neurology. Feb 22;76(8):711-8. Doi:10.1212/WNL.0b013e31820d8af2.
Petersen, A. S., Barloese, M. C., & Jensen, R. H. (2014). “ Oxygen treatment of cluster headache: a review.” Cephalalgia. Nov;34(13):1079-87. doi: 10.1177/0333102414529672.
Rozen, T. D., & Fishman, R.S. (2012). “Cluster headache in the United States of America: demographics, clinical characteristics, triggers, suicidality, and personal burden.” Headache. Jan;52(1):99-113. Doi: 10.1111/j.1526666666-4610.2011.02028.x.




Recalled maltreatment, migraine, and tension-type headache

"The initial trauma of a young child may go underground but it will return to haunt us." - James Garbarino

Many people carry around emotional pain from early life. Whether a person felt deprived of love and respect while growing up; experienced separation or divorce of parents; was a member of a dysfunctional family, including household members abusing drugs and alcohol; or, subjected to physical or sexual abuse, maltreatment in childhood is associated with a number of medical and psychological disorders.  Medical conditions include: headache, migraine, fibromyalgia, chronic pain conditions, cardiac conditions, and irritable bowel disease. Psychological conditions and behavioral issues include: depression, anxiety, panic disorder, obsessive compulsive disorder, dissociative disorder, and conduct disorder/legal problems (Buse et al., 2012).

To help us put the link between migraine and adverse childhood experiences (ACEs) into perspective, it is beneficial to review a bit about migraine and triggers. Migraine is a neurological disease. It is essential for us to know that, as persons with migraine, we are believed to have an inherited sensitivity of the nervous system that makes our brains hyperexcitable. This hyperexcitability gives us a predisposition to migraine attacks. Triggers are internal and external stimuli that "set-off" attacks in those of us who have the disease.

Migraine attacks may begin over many years in our lifetime. For example, it is thought that an unusual cluster of stressful life events may trigger the onset of migraine in some individuals who are predisposed to have migraine, while the onset of menstruation or menopause may trigger the onset of attacks in others (Sauro et al., 2009).

Keeping these things in mind, let's take a look at a recent study designed to test the hypothesis that ACEs are more strongly associated with migraine than episodic tension-type headache (Tietjen & Buse, 2014). Using the Childhood Trauma questionnaire (CTQ), rates of maltreatment, including emotional abuse, emotional neglect, and sexual abuse were evaluated in The AMPP Study, a large, US population-based sample of persons with migraine and tension-type headache (TTH). Results showed:  

  • The odds of migraine were greater in those with each ACE (emotional neglect, emotional abuse, and sexual abuse) as compared to those with TTH.
  • Although there were similar findings after adjusting for demographics, after adjusting for depression and anxiety the odds of migraine were greater only in those with emotional neglect, as compared to those with TTH.
  • Further, the odds of migraine, as compared to TTH, were greater in those with 2 versus 1 ACEs, even after adjustments for anxiety and depression.

To understand how ACEs may put us at increased risk for migraine expression, it is helpful for us to know some general information about the effects of ACEs. These include: maltreatment early in life may alter the brain's response to stress via the hypothalamus-pituitary adrenal system; inflammatory markers in adults have revealed higher levels in persons who have been exposed to maltreatment in childhood, suggesting a possible link; and, there is growing evidence that genes may be responsible for either increased vulnerability or resilience in response to early life stressful experiences (Buse et al., 2012).

Given ACEs may be perceived as psychological stress and there is a link between migraine and stress, we need to know:

  • Psychological stress can be defined as a state of mental or emotional strain or tension resulting from the perception of adverse, demanding, threatening, or dangerous circumstances (Buse & Lipton, 2015).
  • Factors (circumstances) perceived as demanding or threatening are referred to as stressors.
  • Stressors activate the physiological stress response, which involves the hypothalamic-pituitary-adrenal axis (HPA axis) and the sympathetic nervous system, including the adrenal medulla. When activated a range of hormones and neurotransmitters are released to maintain homeostasis and initiate survival mechanisms if necessary.
  • Along with initial onset of attacks, the potential effects of stress on migraine are thought to include: can act as a trigger for migraine attacks, including let-down stress; increase our susceptibility to other triggers; amplify attack intensity and duration; increase frequency of attacks and the risk for progression to chronic migraine; and, as migraine itself can be a stressor, create a vicious cycle.
  • Some reports indicate that we may process stressful events and situations differently than the general population and we may have more perceived life stressors.

 "You will find that it is necessary to let things go; simply for the reason that they are heavy." -     Humanity Healing with Ako C. Mischelle 

Chronic stress can wear out our HPA axis and increase our susceptibility to a number of conditions and disorders.  These include: heart disease, hypertension, asthma, obesity, diabetes, sexual dysfunction and menstrual irregularities, sleep disturbances, depression, anxiety and panic disorders, allergies, infections, and immune disorders.

While depression and anxiety have long been shown to be comorbid with migraine, we should be aware that in a study designed to evaluate the prevalence and characteristics of anger and emotional distress in migraine and TTH patients, results showed that chronic TTH and migraine associated with TTH present a significant impairment of anger control and suggest a connection between anger and the duration of our headache experience (Perozzo et al, 2005). The authors of another study (Hedborg et al, 2011) share that it is possible repressed feelings of anger may increase the perception of stress, which in turn may affect the course of migraine. 

Many of us may not discuss our emotions and mood disorders with our doctor or other health care professional because they don't ask us about them, or we are reluctant to share. In my situation, even though I was familiar with the body-mind-spiritual connection from my career in critical care nursing, I did not acknowledge this relationship in myself until my migraines became chronic and I ventured into Eastern medicine.

As I was guided through self-awareness, I learned how to understand and express my emotions to promote healing. Still, until I read, "Recalled maltreatment migraine, and tension-type headache," results of the AMPP study, I did not reflect on my initial onset of migraine attacks and the circumstances surrounding the beginning of my journey with this disease.    

As I recall the events of the summer I was 5 years old and my first memories of headaches, I remember my older sisters were 7 and 8 years old and my younger sister, 4. My father was in the hospital most of the time as he had just been diagnosed with acute rheumatoid arthritis. Towards the end of the summer, my mother was hospitalized for 'female surgery' and my father's oldest sister (a stranger to me) was given the task of escorting me to my first day of school. The following few years, as my father continued to fail in health, my younger sister was diagnosed with rheumatic fever and was in bed for most of her first year at school. Needless to say, attention was scarce and I would have to say, emotional neglect was unavoidable.

Probably, the worry, fear, anxiety and repressed feelings of anger ( I do not like confrontation so held the emotion inside) I experienced as a a child and continued throughout my adult years, not only played a role in the onset of my migraine attacks, as I had the genetic predisposition while my sisters did not, but contributed to their frequency, duration and severity until I learned to be honest in acknowledging my true feelings and express them in a healthy way. In other words, adulthood gave me a second chance to parent myself in a way that promotes love, respect, and healing (Maoshing Ni, 2008).

In Western medicine, cognitive behavioral therapy (CBT) can help decrease the frequency and severity of our attacks by making us more aware of triggers, including the association between stress and headache, and if we have been exposed to ACEs, help us identify and manage trauma related associated thoughts and feelings, and disorders like depression, panic disorder, obsessive-compulsive disorder, eating disorders, sleep disorders, and other comorbidities common with migraine.

As well, biofeedback therapy can help us increase awareness of functions related to our sympathetic nervous system, including heart rate and blood pressure, bring them under voluntary control and improve our circulation, and relieve muscle tension. Relaxation techniques, including diaphragmatic breathing, visual imagery, meditation, yoga, prayer, self-hypnosis, and guided imagery, can help us quiet our minds and calm our bodies.

The more we know about the body-mind-spiritual connection, the more we realize they cannot be separated. Physical illness affects our emotions and our emotions affect our physical health. As you read through this article, perhaps like me, you will reflect on the circumstances surrounding the onset of your first migraine attacks. Hopefully, if emotional strain, whether from ACEs or current challenges, impacts the frequency, severity and duration of your attacks, and you are not receiving the help you need, you will explore the appropriate resources.

I leave you with this quote, "Healing doesn't mean the damage never existed. It means the damage no longer controls our lives." - Author unknown. 

* A special "thank you" to Dawn C. Buse, PHD, Clinical Psychologist, Associate Professor of Neurology, Director of Behavioral Medicine, Montefiore Headache Center, New York, for reviewing this article and providing thoughtful comments and suggestions.



 Buse, D. C., Tietjen, G.E., & SCHulman, E.A. (2012). "Abuse, Childhood Maltreatment and Migraine." American Headache Society. 

Buse, D. C., & Lipton R. B. (2015). "Primary headache: What's stress got to do with it?"Cephalalgia. 0(0) 1-6. DOI: 10.1177/03333102414567382

Hedborg, K., Anderberg, U. M.,& Muhr, C. (2011). "Stress in migraine: personality-dependent vulnerability, life events, and gender are of significance." Upsala Journal of Medical Sciences. August; 116(3): 187-199.

Maoshing, Ni. Dr. Secrets of Self-Healing. New York: Avery, 2008.

Perozzo, P., Casttelli, S. L., et al. (2005). "Anger and emotional distress in patients with migraine and tension-type headache." J Headache Pain. Oct;6(5):392-9. 

Sauro, K. M., &Becker, W. J. (2009). "The Stress and Migraine Interaction." Current Review: Clinical Science. 

Tietjen, G. E., Buse, D. C., et al. (2014). "Recalled maltreatment, migraine, and tension-type headache." Neurology. December 24. 10.1212/WNL.0000000000001120.

 Sharron is a helath and wellness author. A person with migraines 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 Facebook 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.



Episodic or chronic migraine? How, using scientific-based evidence, we can help our doctors improve our treatment outcomes


"We cannot direct the wind, but we can adjust the  sails." - Bertha Calloway

Migraine, a genetic neurological disease characterized by hyperexcitability and episodic events known as migraine attacks, is classified as a primary headache disorder (ICHD-3 beta diagnostic criteria). For many of us with migraine, optimal management of our disease is a challenge.

In an important step toward improving our treatment outcomes, a recent study tested the hypothesis that ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine (Lipton, et al., 2015). In line with this approach, authors of a recent article, (Lipton and Silberstein, 2015), discuss how to breakdown barriers to optimal treatment and prevention for those of us with episodic migraine (EM) and chronic migraine (CM).

To help us have a better understanding of the challenges we face and offer suggestions on ways to assist our doctors in improving our treatment outcomes, using information from this study and journal article, this article focuses on our role as patients in:

  • Diagnosis of Migraine. 
  • Diagnostic criteria for Episodic migraine (EM) and chronic migraine (CM).
  • Risk factors for progression to CM.
  • Acute and preventive treatment. 
  • Electronic diaries. 

"The principle of Priority states (a) you must know the difference between what is urgent and what is important, and (b) you must do what's important first." -Steven Pressfield 

Diagnosis of Migraine: 

When we have a severe migraine attack, we want immediate treatment and relief from our headache and associated symptoms. But, to ensure we receive effective treatment, we must have an accurate diagnosis. 

Our diagnosis of migraine is based on a thorough history, including family history and onset of headache; physical examination; and, should they be necessary, diagnostic tests to rule out other headache disorders. To help our doctor make an accurate diagnosis, we need to be familiar with common characteristics of migraine: 

  • for migraine without aura, headache is usually unilateral location, pulsating in quality, of moderate to severe intensity, aggravated by physical activity (need to have at least 2 of the 4 preceding), lasts 4-72 hours without treatment and is associated with at least one of the following: nausea and/or vomiting, sensitivity to light (photophobia), and sensitivity to sound (phonophobia).
  • for migraine with aura, we may have transient focal neurological symptoms that usually precede or may accompany headache, including visual (most common), sensory, speech and/or language, motor, brainstem, or retinal symptoms. Subforms of migraine with aura include: migraine with typical aura (typical aura with headache and typical aura without headache), migraine with brainstem aura, hemiplegic migraine (familial hemiplegic migraine types 1, 2, 3, familial hemiplegic migraine other loci and sporadic hemiplegic migraine), and retinal migraine.
  • premonitory symptoms, which may begin hours or a few days prior to a migraine attack without or with aura , including stiff neck, neck pain, fatigue, blurred vision, yawning, sensitivity to light and sound, pallor, and difficulty concentrating.

It is important for us to know that we may have: 

  • both migraine without aura and migraine with aura, and
  • migraine with aura without a headache, or with a less distinct headache.

In addition, we need to be aware that frequent episodic tension-type headache often coexists with migraine without aura. Because treatment of migraine differs from that of tension-type headache, we need to be able to distinguish between these two types to help ourselves and our doctors select the right treatment, while avoiding medication overuse (ICHD-3 beta, p. 661). Characteristics of frequent episodic tension-type headache include at least 10 episodes of headache occurring on 14 days or less for >3 months, lasting from 30 minutes to 7 days and, at least two of the following four: 

  • headache typically bilateral location,
  • may be pressing or tightening in quality,
  • is of mild to moderate intensity,
  • does not worsen with routine physical activity.

And, both of the following:

  • headache is not associated with nausea and vomiting, and
  • may be associated with photophobia or phonophobia (only one). 

Diagnostic criteria for EM and CM

EM and CM are differentiated in the number of headache days per month. In EM, headache occurs on less than 15 days per month. If our headaches occur on 15 or more days per month (tension-type-like and/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 of chronic migraine (ICHD-3 beta diagnostic criteria for CM). We should know that response to triptans is not diagnostic of migraine headache as secondary headaches attributable to other disorders like subarachnoid hemorrhage or meningitis, may respond to triptans (Lipton and Silberstein, p. 106).

About 2.5% of persons with EM progress to CM per year. We need to be aware that as our attacks increase in frequency, so do a host of other problems that can complicate our treatment and contribute to headache related disability. For example: 

Given this information, along with ensuring an accurate diagnosis for migraine, we need to work with our doctors to set goals and direct our treatment to reducing our attack frequency, as well as determining and treating comorbid disorders. 

Risk factors for progression to CM: 

It is important for us to know that overuse of acute medications, in particular opioids and barbiturates, is a risk factor for progression to chronic migraine and a common cause of chronic migraine symptoms. However, it is difficult to determine whether medication overuse is the cause of or a response to CM (Lipton and Silberstein, 2015). Some of us  revert to EM after medication overuse is stopped, but many of us do not. Patients who overuse opioids are thought to have the highest relapse rate after withdrawal treatment.

Other modifiable risk factors for progression include comorbidities like obesity (2 to 5 times more likely to develop CM than persons normal weight), moderate or severe depression, anxiety, asthma, and allergic rhinitis; snoring; stressful life events; and, caffeine use/misuse (combination medications containing caffeine). Non-modifiable risk factors for progression are thought to include age, female sex, genetics, low education level, low socioeconomic status, and head or neck injury (potentially modifiable).

Once we identify our personal risk factors, our role is  to work with our doctors to improve or eliminate our modifiable ones, decrease the frequency of our attacks, and if we have CM, increase our chances for remission.

"When a lot of remedies are suggested for a disease, that means it cannot be cured." -Anton Chekhov

Acute and Preventive Treatment

Now, let's take a closer look at the study noted at the beginning of this article (Lipton et al., 2015). The authors predicted that poor treatment efficacy among individuals with EM, leading to longer periods of exposure to pain, might increase the risk of new-onset CM. Using the AMPP study survey, respondents identified all medications they used to treat "their most severe type of headaches." For analysis, medications were combined into simple analgesics, combination analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and triptans. Opioids and barbiturates were combined in one category.

Respondents who used NSAIDs and simple analgesics were less likely to be in the high treatment efficacy categories while persons who used triptans were more likely to be in favorable treatment efficacy categories. The authors note opioids and barbiturates were associated with increased risk of CM in prior studies (Bigal, Serrano et al., 2008).

Results indicated that those with ineffective treatment are at risk for CM onset while those with more effective treatment have better outcomes over 1 year follow-up. The study authors report that these findings support their prediction that exposure to longer periods of pain may be in the causal pathway that leads from EM to CM and suggest that improving treatment outcomes might prevent new onset CM.

If we have EM and a poor response to acute treatment, to decrease the frequency and severity of our attacks, and reduce our chances of progressing to CM, we need to talk to our doctor about acute and preventive treatments as soon as possible. Given individual response to acute therapy varies with the specific drug and dose, and side effects of preventive medications can be unpleasant, to increase responsiveness and compliance, effective communication with our doctor about our progress is essential.

Along with pharmacological treatment and educational interventions, lifestyle modifications and trigger management can help reduce attack-related impairment and decrease the frequency and severity of our attacks. Non-pharmacological approaches for the prevention of EM that have demonstrated efficacy include cognitive behavioral therapy (CBT), relaxation techniques, and biofeedback. These therapies, along with acupuncture, can be used alone or in conjunction with medication (Lipton and Silberstein, 2015).

Electronic Diaries  

One of the most effective ways we can help our doctors improve our treatment outcomes is to keep a diary. Whether a notebook, electronic, or a calendar, a diary can help our doctors and ourselves: 

  • identify possible triggers (trigger patterns) and suggest strategies to minimize or avoid them.
  • recognize premonitory and aura symptoms.
  • recognize the frequency, severity and duration of our migraine attacks (with and without aura, and aura without headache) and headaches (migraine-like and tension-type-like).
  • differentiate tension-type headache from migraine-like headache.
  • identify the location and severity of our pain.
  • assess our functional disability (attack-related impairment).
  • assess the effectiveness of our treatment and recognize the need to adjust doses, alter routes of administration, and add or change our medications.
  • recognize a pattern of medication overuse.
  • assess the effect of lifestyle habits including sleep patterns, skipped meals, exercise, sexual activity, and stress, on the frequency and severity of our attacks.
  • assess the impact of protective factors and nonpharmacological therapies on the frequency and severity of our attacks. 

Given the limitations of paper diaries, including multiple daily entries that have to be made by hand, along with recall bias, in the past few years, electronic diaries have become very popular. However, the authors of a recent review of commercially available mobile apps available in Canada expressed concern about the lack of scientific expertise and evidence base associated with headache diary apps. None of the 38 apps included in their review met all 7 criteria established by the study authors for an ideal diary. Three apps met 5 of the criteria: iHeadache (developed by Better QOL), ecoHeadache (developed by eco TouchMedia), and Headache Diary Pro (developed by Froggyware). Only 18% of the apps were created with scientific or clinical headache expertise. 

An example of a scientific approach to the identification of migraine triggers, as well as to advance basic understanding and management of migraine with the practical intention of reducing suffering and costs associated with the condition, is Curelator Headache (developed by Curelator Incorporated). The simple to use app tracks triggers, associations between single or combinations of triggers and the occurrence of migraine headaches (Spierings, Donoghue, et al., 2014). The clinical advisory board includes neurologists and headache specialists active in clinical practice and research. "Although initial clinical trials have ended, Curelator Headache will constantly run a cohort 1000-2000 patients in clinical trial." (Interview with Alec Mian, CEO at Curelator, March 5th, 2015).



Bigal, M.E., Serrano, D., Buse, D., et al. (2008). "Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population based study." Headache.  48:1157-1168.

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

Headache Classification Subcommittee of the International Headache Society. The International Headache Society. "The International Classification of Headache Disorders: 3rd edition (beta version). Cephalalgia.  2013;33:629-808.

Hundrert, A.S., Huguet, A., et al. (2014). "Commercially available mobile phone headache diary apps: a systematic review." JMIR Mhealth Uhealth.  Aug 19;2(3):e36 doi: 10.2196/mhealth.3452.

Lipton, R.B., Fanning, K., et al. (2015). "Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine." Neurology. Jan 21. doi: 10.1212/WNL.0000000000001256.

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

Lipton,  R.B., & Silberstein S.D. (2015). "Episodic and Chronic Migraine Headache: Breaking Down Barriers to Optimal Treatment and Prevention." Headache: The Journal of Head and Face Pain. Volume 55, Issue Supplement S2. DOI: 10.1111/head.12505_2.

Spierings, E.L., Donoghue, S., et al. (2014). "Sufficiency and necessity in migraine: how do we figure out if triggers are absolute or partial and, if partial, additive or potentiating? Oct;18(10):455. doi: 10.1007/s11916-014-0455-y.

Sharron is a health and wellness author. A migraine sufferer 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 Facebookpage: 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.

Copyright, March 24, 2015: Sharron E. Murray