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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
Alliance for Headache Disorders Advocacy (2015). “Fact sheet Headache Disorders”. Headache On The Hill, Washington, DC…/2015-headache-on-the-hill/
Batcheller, P. (2014). “A Survey of Cluster Headache (CH) Sufferers Using Vitamin D3 as a CH Preventive (P1.256). Neurology. April 8, vol. 82 no. 10 Supplement P1.25
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.
Buse, D.C., Lipton, R., et al. (2014). “Barriers to Chronic Migraine Care: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes ) study”. Neurology. April 8, 2014 vol. 82 no. 10 supplement 19-1.004.
Burch, C., Loder, S., et al. (2015). “The Prevalence and Burden of Migraine and Sever Headache in the United States: Updated Statistics From Government Health Surveillance Studies.” Headache. Jan;55(1):1-34. Doi: 10.1111/head.12482.
Cowan, R.P. (2014). “CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don’t.” Headache Currents. April 25, DOI: 101111/head.12364 .
Headache Classification Subcommittee of the International Headache Society. (2013). “The International Classification of Headache Disorders: 3rd edition (beta version). Cephalalgia. 33:629-808.
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




Migraine, "Sinus" headaches and "Sinusitis" - Facts we need to know


                     "A correct diagnosis is three-fourths the remedy." - M.K. Gandhi 

Several studies and reports indicate that migraine is often misdiagnosed by ourselves or our physicians as sinus headache or sinusitis. In a recent study designed to estimate the frequency of misdiagnosis of sinusitis among migraine patients (Al-Hashel et al., 2013) results showed: 

  • of 130 migraine patients who met the ICHD-III-beta criteria (International Classification of Headache Disorders, 3rd edition), 106 patients were misdiagnosed as sinusitis.
  • the delay in diagnosis ranged from 1-38 years.
  • chronic migraine was significantly higher in misdiagnosed patients compared to patients with the correct diagnosis.
  • medication overuse headache (MOH) was reported only in patients misdiagnosed as sinusitis.
  • a delay in the diagnosis of migraine led to chronification of the headache and transformation, in some cases, into MOH. 

The authors propose that the delay in diagnosis could be attributed to the presence of sinus pain, sinus congestion, and nasal discharge during headache attacks. They go on to say that these autonomic symptoms have been reported in previous studies which concluded the "presence of autonomic symptoms during migraine attacks often leads to confusion and incorrect diagnosis of sinusitis." They add, "appropriate recognition of migraine in patients who complain about sinus headaches may help to minimize the suffering and unnecessary interventions, start migraine directed therapy, and improve quality of life".

Therefore, to increase our knowledge about "sinus" headache, "sinusitis" and migraine, and help us receive appropriate diagnosis and treatment, this article addresses:

  • what is "sinus" headache?
  • what is "sinusitis"?
  • how to differentiate "sinusitis" from migraine.
  • can "sinusitis " trigger a migraine? 

What is "sinus" headache? 

Sinus headache is commonly thought of as pain and pressure in the forehead, behind the eyes, or in the face, but may be referred posteriorly. The areas are tender to touch and the headache is often accompanied by: 

  • nasal and sinus congestion,
  • clear nasal discharge, and 
  • watery eyes.

We should know that the ICHD-III-beta criteria states that "the term 'sinus headache' is outmoded because it has been applied both to primary headaches (migraine and tension-type) and headaches supposedly attributed to various conditions involving nasal or sinus structures."  The previously used term "sinus headache' has been replaced with "Headache attributed to disorder of the nose or paranasal sinuses" and is associated with other symptoms and/or clinical signs of the disorder. 

What is "sinusitis"? 

True sinus headache is more properly called "sinusitis" or rhinosinusitis (Cady, 2008, and Hutchinson, 2011). It is often associated with viral or bacterial infection and may be characterized by:

  • purulent (thick yellow or green) nasal discharge,
  • decreased smell and taste,
  • bad breath,
  • fever,
  • cough, (may be productive of mucous and worse at night),
  • general feeling of illness (malaise), 
  • pain and pressure in our upper teeth, forehead, behind our eyes and in our face, and
  • pain may worsen when we lean forward or bend our heads.

The pain should improve with remission of a viral infection (within 7days) or, if our infection is bacterial, successful treatment with antibiotics. With persistent or recurrent infection, we may have to undergo a CT scan or nasal endoscopy to rule out signs of obstruction, polyps or other signs of sinus disease.

We should know the ICHD-III-beta criteria says, "simply finding pathological changes on imaging of acute rhinosinusitis, correlating with the patient's pain description, is not enough to secure the diagnosis of acute rhinosinusitis. Evidence of causation should be demonstrated by at least two of the following: 

  1. headache has developed in temporal relation to the onset of the rhinosiusitis
  2. either or both of the following: headache has significantly worsened in parallel with worsening of the rhinosinusitis; headache has significantly improved or resolved in parallel with improvement in or resolution of the rhinosinusitis
  3. headache is exacerbated by pressure applied over the paranasal sinuses
  4. in the case of unilateral rhinosinusitis, headache is localized ipsilateral to it."

How to differentiate sinusitis from migraine:

According to the ICHD-III-beta criteria, the presence or absence of purulent discharge and other features of acute rhinosinusitis help differentiate these conditions. Or, in the words of Dr. Susan Hutchinson (2011),  "in the absence of fever, pus from your nose, alteration in smell or foul smelling breath, you likely have a migraine headache".

Dr. Hutchinson suggests an additional way to determine whether our headaches are migraine is to ask ourselves the following questions taken from Dr. Richard Lipton of Einstein College of Medicine ID Migraine Questionnaire:

  •  In the last 3 months, how disabling are your headaches; do they interfere with your ability to function? (Are you missing work; school; family activities?)
  • Are your headaches ever associated with nausea? 
  • Are your headaches ever associated with sensitivity to light?

If we meet two of the three above criteria, migraine is likely present 93% of the time. When all three are present, migraine is likely 98% of the time.

Dr. Hutchinson adds, "your diagnosis needs health practitioner confirmation for accuracy and best treatment. She goes on to say "getting the right diagnosis and treatment can free you from the recurring burden of failed headache treatment and disability".

Can sinusitis trigger a migraine? 

According to ICHD-III-beta criteria, an episode of migraine may be triggered or exacerbated by nasal or sinus pathology. Dr. R. Cady, (2008), explains this as, "People with migraine inherit a nervous system that is more sensitive to change than those without migraine. If the nervous system perceives a threat from either the external or internal environment, the nervous system response can be an attack of migraine."

Every addition to true knowledge is an addition to human power."- Horace Mann   

In my situation, I was misdiagnosed with sinus headache for a number of years. Like many patients, I went through a number of failed treatments, including over the counter and prescription decongestants, antihistamines, nasal sprays, analgesics, and anti-inflammatory medications, before I went to a migraine clinic and was told my symptoms were part of my migraine.

However, along with migraine disease, I can still have an episode of acute rhinosinusitis. To help prevent the rhinosinusitis from triggering or exacerbating a migraine attack, I monitor other internal and external trigger factors that might increase the probability of an attack and, where possible, initiate protective factors (Lipton et al., 2014 and Pavlovic et al., 2014). These include:

  • Stay hydrated as mouth breathing and fever can lead to dehydration. Drinking plenty of fluids also helps keep mucous thin.
  • Eat regular meals or, if my appetite is poor, 6 small meals a day to avoid hunger.
  • Avoid dairy products as increase mucous.
  • Maintain a regular sleep routine to avoid altered sleep patterns. This is sometimes difficult because night time cough, snoring, and sinus pressure, along with a dry mouth may inhibit sleep. A humidifier is helpful to increase moisture in my room. A glass of water by my bedside helps with dry mouth.  
  • Consult with my doctor if I need medication to relieve my symptoms.
  • Monitor my stress levels and use techniques like meditation and biofeedback to help me relax (quiet my mind and calm my body).

In summary: 

  • migraine is commonly misdiagnosed as sinus headache.
  • sinus headaches are more properly called rhinosinusitis .
  • rhinosinusitis is associated with purulent nasal discharge.
  • migraine may be associated with watery eyes and runny nose, but the fluid is clear.
  • patients with rhinosinusitis may also have migraine.
  • rhinosinusitis may trigger or exacerbate a migraine attack.
  • see your doctor for a full diagnosis for your headaches as treatment of rhinosinusitis differs significantly from treatment for migraine (Cady, R., 2008, and Hutchinson, S., 2011).



Al-Hashel, J., Y., Ahmed, S., F., Alroughani, R., & Goadsby, P., J. (2013). "Migraine misdiagnosis as a sinusitis, a delay that can last for many years." The Journal of Headache and Pain. 14:97. doi: 10.1186/1129-2377-14-97.

Cady, R., K., MD. (2008). "Sinus Headaches, Allergies, Asthma and Migraine: More Than a Causal Relationship?" Headache, The Newsletter of ACHE. Summer 2001, Volume 12, Issue 2. Updated November, 2008. 

Eross, E., Dodick, D., & Eross, M. (2007). "The Sinus, Allergy and Migraine Study (SAMS)." Headache. Feb;47(2):213-24.  

Hutchinson, S., MD. (2011). "'Sinus Headache'"or Migraine". Headache, The Newsletter of ACHE.   

International Classification Committee of the International Headache Society (IHS). "The International Classification of Headache Disorders, 3rd edition (beta version)". Cephalalgia.  33(9) 764-765 (629-808).

Lipton, R., B., Pavlovic, J., M., Haut, S., R., Grosberg, B., M., & Buse, D., C. (2014). "Methodological Issues In Studying Trigger Factors and Premonitory Features of Migraine." Headache. Nov;54(10):1661-9. doi:10.1111/head.12464. Epub 2014 Oct 23.

Pavlovic, J., M., Buse, D., C., Sollars, M.,Haut, S., & Lipton, R., B. (2014). "Trigger Factors and Premonitory Features of Migraine Attacks: Summary of Studies." Headache. Nov;54(10):1670-9. doi:10.1111/head.12468.

Schreiber, C., P., Hutchinson, S., Webster, C., J., Ames, M., Richardson, M.,S., Powers, C. (2004). "Prevalence of migraine in patients with a history of self-reported or physicain-diagnosed "sinus" headache." Arch Inter Med. Sep 13;164(16):1769-72.

Sharron is a health and wellness author. A migraineur 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 professional. 




Can we use associations between migraine triggers, premonitory symptoms, and migraine attacks to predict our attacks and decrease their frequency? 


"The world is full of suffering. It is also full of overcoming it." -Helen Keller 

For many of us with migraine, our world revolves around painful and debilitating attacks. Addressing this issue, the authors of two recent journal articles have drawn attention to how, if knowledge and understanding of relationships between trigger factors, protective factors, and premonitory features can be established, we may be able to improve our ability to predict, preempt, and reduce the frequency of these acute episodes (Lipton et al., 2014, and Pavlovic et al., 2014).

In this article, we use these journal articles, and the definitions provided within them, to guide us in a discussion of: 

  • trigger factors,
  • protective factors,
  • premonitory features, 
  • self-prediction, and 
  • preemptive therapy. 

Trigger Factors

Before we get to trigger factors, let's review a bit about migraine. Migraine is a neurological disease. As migraineurs, we are thought to have an inherited sensitivity of the nervous system that makes our brains hyper-excitable. This hyper-excitability gives us a predisposition to migraine attacks. 

Attacks, including headaches and other symptoms, are referred to as the ictal state. The goal of treatment in the ictal state is to relieve pain and restore function. The time between attacks, where we may be relatively free of symptoms but have a predisposition to attacks, is referred to as the inter-ictal state. The goal of treatment in the inter-ictal state is to reduce the probability of transitioning to the ictal state. 

Now, let's examine trigger factors. Triggers are internal or external stimuli that provoke or "set off" migraine attacks in those of us who have the disease. 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 of our brain and surrounding nerves to cause migraine symptoms" (Dr. Andrew Charles, AHS14AZ).

As well, we need to be aware that triggers are different from risk factors. Risk factors like genetics, sex, and obesity, increase the onset of the disease in a person previously free of migraine. 

That said, Lipton et al., (2014), define trigger factors as measurable endogenous (internal) or exogenous (external) events (exposures) associated with an increased probability of an attack over a brief period of time.

Endogenous trigger factors include:

  • altered sleep patterns.
  • hormonal changes like estrogen withdrawal.
  • hunger.
  • dehydration.
  • psychological factors such as stress or relaxation following stress.

Exogenous trigger factors include: 

  • environmental factors like weather changes, bright or flickering lights, loud noises, and strong odors.
  • dietary factors.
  • alcohol.
  • exposure to, or withdrawal from, certain medications.

To help us understand how these triggers can increase the probability of an attack over a brief period of time, let's take a look at observations from a 28-day study of 33 patients with chronic migraine and 22 patients with chronic tension-type headache. The objective was to evaluate the time-series relationships between stress, sleep duration, and headache pain (Houle et al., 2012, cited in Spierings et al., 2014).

Observations for the stress-headache relationship are:

  • High stress yesterday and today predicts very high headache activity today.
  • Low stress yesterday and today predicts low headache activity today.
  • Low stress yesterday and high stress today also predicts low headache activity today.
  • High stress yesterday and low stress today predicts high headache activity today.

The conclusion is that headache precipitation needs at least 2 consecutive days of stress and that it is more likely to occur during let-down stress. Let-down stress was confirmed in a study by Lipton et al., (2014).

Observations for sleep duration and headache are: 

  • Low sleep duration (<4 hours) yesterday and today predicts very high headache activity today.
  • Low sleep duration yesterday and high sleep duration today also predicts high headache activity today.
  • Approximately 8 hours of sleep on consecutive days predicts low headache activity today. 

The conclusion is that headache precipitation needs at least 2 consecutive days of sleep deprivation and that headache is likely to occur with oversleeping.

Observations for stress and sleep duration are: 

  • Low stress and low sleep duration are associated with the lowest headache activity today.
  • High stress and high sleep duration are associated with the most headache activity today.  

Protective factors: 

While trigger factors increase the probability of a migraine attack, protective factors are events that decrease the probability of attacks over a defined period of time (Lipton et al., 2014). Keeping the above observations in mind, the protective factors would be low stress and high quality sleep (8 hours). Other examples include: eating regular meals, practicing relaxation techniques, and preventive medications. Also, we should be aware that things which make us feel better can decrease the length and severity of our symptoms. Examples include: cold packs, sleep, and for some, Essential Oils and aromatherapy .  

Premonitory features (Prodrome)

Premonitory features are defined as subjective cognitive, behavioral, or physical features that precede the onset of aura in migraine with aura, and before the onset of pain in migraine without aura (Lipton et al., 2014, and  Pavlovic et al., 2014). These symptoms may begin within 2-48 hours (some suggest 72 hours as symptoms may develop slowly) of aura or headache onset. Premonitory symptoms may include:

  • fatigue (feeling tired, weary),
  • yawning,
  • difficulty concentrating, thinking, reading, and writing,
  • dizziness,
  • irritability (mood changes),
  • stiff neck,
  • neck pain,
  • light sensitivity,
  • blurred vision,
  • noise sensitivity,
  • sensitive skin,
  • pallor,
  • nausea, 
  • constipation,
  • food cravings,
  • frequent urination,  
  • thirst, and
  • lots of energy.

About one third of patients with migraine seen in headache centers have premonitory symptoms (Lipton et al., 2014). For those of us who have premonitory symptoms (prodrome), it is interesting to note that in a study of 893 patients (Kelman, 2004), where one third of the participants had prodrome symptoms, the most common symptoms were tiredness, mood changes, and gastrointestinal symptoms.  As well, results showed patients with prodrome differed from patients without prodrome in having more triggers, longer duration of aura and  longer time between aura and headache; more aura with no headache; longer time to peak headache and to respond to triptan; longer duration of headache; more headache associated nausea, running of nose and tearing of eyes; and, more and longer duration of postdrome (resolution phase).   


Self-prediction refers to our assessment of the probability that we will have a migraine attack over a defined period of time (Lipton et al., 2014). To predict our attacks we need to be familiar with our trigger factors and premonitory symptoms and be able to associate them with headache onset. Finding these associations can be challenging.

Let's take a look at some of the challenges we may face:


To begin with, because most of the literature regarding migraine triggers consists of studies performed using patient interviews and surveys, the results may be subject to recall bias and selection bias. With a lack of sound scientific evidence to support our beliefs that a certain trigger initiates an attack, a number of our triggers come under scrutiny.  

For example, many people claim they are 'better than the weatherman" in predicting the weather. However, several studies suggest that our perception of weather as a trigger may be overestimated (Friedman and De Ver Dye, 2009).  This appears to be true for a number of other environmental influences, such as indoor and outdoor lighting, poor air quality, noise, and exposure to strong odors and chemicals (including those in foods and beverages), even though we are believed to be more sensitive to various environmental stimuli than individuals without migraine. 

Unique to the individual 

While specific triggers may be controversial, a vast number of studies show we have a wide range of these precipitating factors. In one of the largest studies to date, when asked, about triggers, 76% of 1750 individuals with ICHD-2 diagnosis of migraine reported triggers. When presented with a list of triggers to choose from, this figure rose to 95% (Kelman, 2007, cited in Pavlovic et al., 2014)). The most common triggers, occurring at least occasionally, were: 

  • stress (80%), 
  • hormones (65% of women),
  • missed meals (57%), 
  • weather (53%0,
  • sleep disturbances (50%),
  • odors (44%).
  • alcohol (38%),
  • heat (30%), and 
  • foods (27%).  

In the Kelman study, we need to know that those of us with triggers were shown to have more severe attacks and symptoms, higher recurrence rates, more associated sleep and mood disturbances, longer lifetime duration of migraine, and more family members with migraine. In addition, migraine with aura and chronic migraine were more frequently associated with triggers than migraine without aura and episodic migraine.


In this instance we need to know if a specific trigger is always followed by an attack. In a study of 120 patients with migraine or tension-type headache (Wober et al., 2006, cited in Spierings et al., 2014), participants were asked if triggers brought on their headaches always (consistently), or sometimes (occasionally). Of the fifteen most common triggers acknowledged (menstruation, weather, stress, red wine, smoking, hunger, alcohol, skipping meals, noise, change in sleep habits, glare, relaxation after stress, exhaustion, odors, and physical activity), only menstruation was statistically significant as a constant rather than occasional trigger.


This brings us to the inference that single triggers (apart from menses) might not be consistently potent enough to initiate an attack and therefore it may take a combination of triggers (additive effect). For example, we discussed the relationship between sleep and stress. Other examples include stress and hunger, (Turner et al., 2013), and combinations of chemicals in foods and beverages, such as tannin, tyramine, and MSG.     

Mistaken identity 

Here, those of us with premonitory symptoms need to know that, in this phase, we may mistakenly identify triggers or confuse them with premonitory symptoms. For example, many of us believe chocolate is a trigger for our attacks. However, consider hormonal migraines. Declining estrogen levels that occur at the time of menstruation as well as low levels that are encountered during the menopausal transition are migraine triggers for some women. Low estrogen levels are associated with low serotonin levels. Low serotonin levels promote food cravings for starches and sugars, including chocolate. If we regularly eat chocolate during these times, we may be experiencing a chocolate craving as a premonitory feature, not a trigger factor.

Fatigue (exhaustion) is another confusing factor. Feeling tired or weary is recognized as  a trigger, a premonitory symptom, and a feeling of exhaustion that persists through an attack and hangs on for days. Extreme fatigue may be a symptom of chronic stress.   

The way to find a needle in a haystack is to sit down -Beryl Markham    

To help us make associations between triggers, premonitory symptoms, and attacks, which can be like trying to find "needles in a haystack", we are encouraged to keep diaries. In other words we need to "sit down" and record a large amount of data. 

If we are using paper diaries, our recall ability, combined with the chore of flipping through pages to try and figure things out, may make us frustrated, especially if our attacks are high frequency or chronic. Hence, we may give up.

In my case, I opted out of paper diaries and journals and initially used a bank calendar, then my Day-Timer (a monthly calendar I could see at a glance). Appointments, work commitments, social obligations, family responsibilities, etc. were already scheduled in. All I had to do was make a note of perceived triggers, including, stress, what I ate or drank, environmental influences like weather, noise and light, hormonal influences, sleep patterns, and premonitory symptoms, along with medications, protective factors and comfort measures that helped me find relief.

Since then, options for diaries have expanded with technological advances. Data can be captured within the same day and time stamped to eliminate the frustration and inaccuracy of recall. In a large electronic diary study, where patients were asked how likely they were to have a migraine, a close relationship between the estimated probability and observed probability showed 72% accuracy (Giffin et al., 2003, cited in Lipton et al, 2014).)

"You can't stop the waves but you can learn to surf." -Jon-Kabat-Zinn (Amaal Starling MD AHS14AZ)

Once trigger factors are identified, we can avoid or learn to mange them.  For example, we can avoid triggers that are not consistent with a healthy lifestyle such as toxic smells, hunger, dehydration, and lack of sleep. We can learn to manage, "learn to cope" (train ourselves not to over-react to stimuli), with other triggers like  stress (Martin et al., (2014).

Recognizing our premonitory symptoms as signs of an impending attack gives us a window of opportunity to intervene with protective factors.  For example, in my case, fatigue, blurred vision and irritability are definite indications that a headache phase is on its' way. Since I have become accomplished at protective measures such as biofeedback, diaphragmatic breathing, and meditation, I can often take action to avoid, or lessen, the pain and associated symptoms (ictal state).

Preemptive therapy 

Preemptive therapy (or short term prophylactic treatment) is an emerging strategy with features of both acute and preventive treatment (Pavlovic et al., 2014). The advantage for people who spend most of their time in the inter-ictal state and are able to reliably predict attacks is that medication may be taken only when it is needed, that is in advance of an anticipated attack to avoid a headache, not on a daily basis (Lipton et al, 2014). An example of this approach is the short-term prevention of menstrual migraine. An additional advantage is that, because medication is taken only when necessary, it reduces exposure to medication and the harmful effects of medication overuse.

"Life is 10% what happens to you and 90% how you can handle what happens to you." -Anonymous 

There is no cure for migraine disease. However, as research continues to progress, we can increase our knowledge and understanding of associations between trigger factors, protective factors, premonitory features and attacks, and improve our ability to predict attacks , as well as decrease their frequency.



Friedman, D., I., MD., MPH., & De Ver Dye, T., PhD. (2009). "Migraine and the Environment." Headache. Feb;25:941-950.

Kelman, L. (2004). "The premonitory symptoms (prodrome): a tertiary care study of 893 migraineurs." Headache. Oct;44(9):865-72. 

Lipton, R., B., Pavlovic, J.,M., Haut, S. R., Grosberg, B. M., and Buse, D., C. (2014). " Methodological Issues In Studying Trigger Factors and Premonitory Features of Migraine". Headache. Nov;54(10):1661-9. doi:10.1111/head.12464. Epub 2014 Oct 23. 

Martin, P., R., & Reece, J., et al. (2014). "Behavioral management of the triggers of recurrent headache: A randomized controlled trial." Behavioral Research and Therapy. 61: 1-11.    

Pavlovic, J., M., Buse, D., C., Sollars, M., Haut, S., & Lipton, R., B. (2014). "Trigger Factors and Premonitory Features of Migraine Attacks: Summary of  Studies." Headache.  Nov;54(10):1670-9. doi:10.1111/head.12468.   

Spierings, E., L., H., Donoghue., S., Mian, A., & Wober, C. (2014). " Sufficiency and Necessity in Migraine: How do we Figure Out if Triggers are Absolute or Partial and, if Partial, Additive or Potentiating?" Curr Pain Headache Rep. 18:455. DOI. 1007/s11916-014-0455-y.  

Turner, D., P., et al. (2014). "Nightime snacking, stress, and migraine activity." J Clin Neurosci.  

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 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.

Copyright December, 2014, Sharron E. Murray