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"Let food be thy medicine and medicine be thy food." Hippocrates 

November 12, 2013, the American College of Cardiology/American Task Force on Practice Guidelines published the AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk. These guidelines include lifestyle recommendations for diet.

Because recent studies have shown a correlation between migraine, cardiovascular disease, and hypertension, along with an increased risk of stroke, these guidelines are important for us to know. But, before we get to them, let's refresh our knowledge and take a brief look at the definitions of cardiovascular disease and hypertension.


The American Heart Association (AHA) defines cardiovascular disease as heart and blood vessel disease. Also called heart disease, many of the disorders involved are related to atherosclerosis. Atherosclerosis develops when plaque builds up in our arterial walls. Plaque consists of fat, cholesterol, calcium and other substances found in our blood. Accumulation of plaque is believed to narrow our arteries and make it difficult for blood to flow through. Eventually, an area of plaque can rupture and cause a blood clot to form. If the clot is large enough, it blocks the flow of blood.

Heart Attack

When a clot forms and blocks a blood vessel in the heart, it is called a heart attack. If the clot completely blocks off a vessel, the portion of heart muscle supplied by that artery starts to die. A large amount of damage to the heart muscle can affect the pumping action of the heart. This can lead to heart failure. Without treatment, the bodys' need for oxygen and nutrients may be compromised.   


If blood flow to the brain is blocked, an ischemic stroke can occur. In this case, the portion of the brain supplied by the vessel involved will begin to die. A hemorrhagic stroke happens when a blood vessel in the brain breaks (ruptures). According to the National Stoke Association, hypertension is the most important risk factor for stroke.

It is important to know that although brain cells that die from lack of oxygen cannot be replaced, injured brain cells can be repaired with rehabilitation. In this way, functions like speech, memory and motor power can improve.


To understand hypertension, we need to take a brief look at the physiology of blood pressure. Blood pressure is the force of blood pushing against our arterial walls. For a person over 18, an optimal blood pressure is considered to be 120/80 or lower. The top, or systolic, number is a measurement of the force our blood exerts on our arterial walls when our heart pumps. The bottom, or diastolic, number is the force our blood exerts on our arterial walls when it rests between beats.

Hypertension, or high blood pressure (stage one hypertension) is a measurement of 140/90 or higher. High blood pressure makes our hearts work harder to pump blood through our bodies. This can cause our blood vessel walls to thicken and deteriorate. Besides stroke, it can lead to a number of other problems like heart attack, heart failure, and kidney failure.

Relationship between cardiovascular disease, hypertension and migraine

Although more research is necessary, endothelial dysfunction and hypercoagualability, as well as pathological reactivity, have been reported as important findings in people with migraine. We should know that endothelial cells form the inner lining of our blood vessels and provide an anticoagulant barrier between our vessel walls and our blood. In addition, these cells react with physical and chemical stimuli in our circulation and help regulate homeostasis, vasomotor tone, and immune and inflammatory responses. Injury of these cells results in many pathologic states including atherosclerosis, loss of membrane function and clot formation.

Dietary Recommendations to Reduce Cardiovascular Risk

Keeping all of these things in mind, let's take a look at the dietary recommendations to reduce cardiovascular risk. Overall, dietary patterns, rather than individual dietary components, are emphasized as foods are typically consumed in combinations rather than individually. Two dietary patterns, along with their relationship to health outcomes, that have been identified based on expert evidence are the DASH (Dietary approaches to stop hypertension) and Mediterranean (Med)  patterns

That said, let's examine the diet recommendations for lowering low-density lipoprotein (LDL) cholesterol, and the diet recommendations to lower blood pressure.

Diet recommendations for lowering (LDL) cholesterol are:

  • Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats.
  • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other conditions including diabetes mellitus (type 2 diabetes). *For those of us with migraine, we would add migraine disease here.
  • Achieve this pattern by following plans such as the DASH* dietary pattern, the USDA* (US Department of Agriculture)) Food Pattern, or the AHA* (American Heart Association) Diet.

 *The DASH diet is high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, and nuts; and low in sweets, sugar-sweetened beverages, and red meats. It is also low in saturated fat, total fat, and cholesterol and rich in potassium, magnesium, calcium, protein, and fiber.

*The USDA diet suggests choosing a variety of foods from the five major groups: grains, vegetables, fruits, protein foods, and dairy products and limiting oils, solid fats, and added sugars.

*The AHA diet suggests an overall healthy dietary pattern that includes a variety of fruits and vegetables, whole-grain products, low-fat dairy products, skinless poultry and fish, nuts and legumes, and nontropical vegetable oils. As well, saturated fat, trans fat, sodium, red meat (the leanest cuts possible), sweets and sugar-sweetened beverages should be limited.

Diet recommendations for lowering BP are the same as those for lowering LDL cholesterol with the addition of lower sodium intake:

  • Choose foods with less sodium and prepare foods with little or no salt.
  • Consume no more than 2,400 mg/day of sodium.
  • Further reduction of sodium intake to 1,500 mg/day is desirable since it is associated with an even greater reduction in BP.
  • If you can't meet these goals at the moment, reducing sodium intake by at least 100 mg/day can lower BP.

*Most of the sodium we consume is in processed foods. Therefore, it seems best to avoid them.

Maintaining a healthy diet is one of the most difficult, but important, things we can do to help decrease the frequency of our migraine attacks and reduce our risk for the development of cardiovascular disease, hypertension, and stroke (if we have a family history of these disorders, our risk is even greater). If you find the task of selecting foods suitable for your needs overwhelming, have a number of comorbid diseases, or have poor renal or liver function, you might want to ask your doctor for a referral to a nutritionist to help plan your diet and recommend appropriate supplements to avoid nutritional deficiencies and further organ damage. 


American Heart Association. (2011)."What is Cardiovascular Disease?" 

Eckel, H.,E., et al. (2013, November 12). "2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation.

National Stroke Association. (2013). "High Blood Pressure (Hypertension)".

Mancia, G., et al (2011). "Hypertension and migraine comorbidity: prevalence and risk of cerebrovascular events: evidence from a large, multicenter, cross-sectional survey in Italy (MIRACLES study)." Journal of Hypertension, Vol 29, No 2. Lippincott Williams & Wilkins. DOI:10.1097/HJH.0b013e3283410404  

Schurks, M., S., et al. (2009). "Migraine and cardiovascular disease: systematic review and meta-analysis."  BMJ. 2009;339:b3914.

Sumpio, B., E., Riley, J.,T., and Dardik A. (2002). " Cells in focus:endothelial cell." Int. J. Biochem Cell Biol. Dec;34(12): 1508-12. 

Sharron is a health and wellness author. A person with migraines herself, 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: 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 February 4th, 2016

Copyright 2013, Sharron E. Murray









In Eastern medicine, what we eat is thought to affect our health more than anything else. For example, along with natural healing properties and nourishment, foods are believed to influence the balance of energy in our bodies:

  • warming foods like meat, poultry and dairy are thought to have a stimulating effect, 
  • cooling foods such as fruits, vegetables, and liquids are thought to have a calming effect, and  
  • neutral foods like fish, whole grains, nuts, legumes, beans and seeds can be eaten anytime.

The selection of foods is based on the individual's needs to bring about an optimal state of wellness. For example, if you're tired, sluggish or depressed and tend to get chilled easily, the consumption of warm foods may increase your energy. On the other hand, if you tend to be hyperactive and get overheated, cooling foods may be more appropriate for you. 

Other guidelines to foster wellness include:

  • favor whole, organic and seasonal foods, with the larger portion to include a variety of fruits, vegetables, fish and whole grains.  
  • minimize the intake of dairy, meat, foods high in saturated or trans fats, and those full of sugar, salt and cholesterol, along with caffeine and alcohol.
  • avoid processed foods and those with additives, chemicals, preservatives, pesticides, and artificial colors and sweeteners.


In Western medicine, what we eat tends to focus on the amount of calories, carbohydrates, protein, fats, vitamins, and minerals in a given food. Even though the current food guidelines include fruits, vegetables, grains and proteins, with the larger portions being vegetables and grains, our diet often revolves around our lifestyle and can include:

  • fast foods,
  • junk food,
  • sugar and sweets,
  • salty foods,
  • fatty, greasy and fried foods, and
  • processed and packaged foods that contain additives, chemicals, preservatives and artificial sweeteners.


The foods we consume are often associated with diseases and disorders like diabetes, hypertension, stroke, heart attack, gastric reflux, gastritis, irritable bowel syndrome, pancreatitis, cirrhosis, gallstones, celiac disease, hemorrhoids, allergies, inflammatory responses, cancers, and obesity. Some of these diseases and disorders may be comorbid for many of us with migraine.

In particular, we are believed to be at risk for development of disorders like hypertension, heart disease, stroke, and obesity. If we have fat around our belly (large waistline or "apple shape"), our risk for cardiovascular disease increases. As well, although migraine may not be directly linked to diabetes, we need to be aware that increased fat around our belly can lead to insulin resistance, an elevation in our blood glucose levels, and diabetes. In addition, if we have a family history of these diseases, our risk is intensified.

Food and beverage triggers

Along with the dietary issues that may be associated with our individual comorbidities, our diet and nutrition may be complicated by food and beverage triggers, which may precipitate our migraine attacks. Although numerous, subjective (often without scientific evidence), and unique to the individual, some of the more common ones are believed to include:

  • chemicals in the foods and beverages we ingest and/or the chemicals, additives, preservatives, pesticides, and artificial colors and sweeteners that are added to the product. Examples include: tyramine (cheeses, bananas, avocados, nuts, peanut butter, canned soups, soy sauce), alcohol, caffeine, phenylethylamine (chocolate), sulfites (fermented beverages and wines), nitrites (bacon, ham), and aspartame.  
  • gluten, a type of protein found in wheat, barley, rye and to a lesser degree oats. It may be added to a number of processed foods as a stabilizer, emulsifier, thickener, starch or hydrolyzed protein. Examples include: salad dressings, sauces, seasoned rice mixes and snack foods, beer, self-basting poultry, vegetables in sauce, soups, and pasta.
  • MSG, a sodium salt derived from glutamic acid. It may be added to a number of foods like sauces, gravies, processed meats, packaged foods, and canned soups and vegetables to enhance flavor. 

Food cravings

Even if we do not have food and beverage triggers, food cravings, especially for simple carbohydrates that may contain fat and salt, as well as sugar, may add to the complexity of dietary management and increase our risk for hypertension, stroke, heart attack, obesity and diabetes. These may be related to:

  • low serotonin levels that occur with alterations of this neurotransmitter during our migraine attacks.
  • fluctuations in our hormone levels with our menstrual cycle and other hormonal changes (serotonin levels increase with estrogen levels and drop with estrogen levels).
  • fluctuations in blood glucose levels that may occur late in the day or early evening, or with fasting or skipped meals.
  • low magnesium levels that may be associated with triggers like alcohol and caffeine (deplete magnesium from the body); a drop in magnesium levels right before the onset of menstruation; and some studies have shown that, along with low brain magnesium during attacks, we may have low systemic magnesium levels.

Examples of foods and beverages that we may crave include: starches and sugars like pasta, potato chips, chocolate, candies, ice cream, cakes, cookies, and sodas. When we reach for these foods and beverages to satisfy our cravings, we can exacerbate the fluctuations in serotonin and magnesium levels, and the dips and peaks in our blood glucose levels.


Keeping in mind the dietary issues I have shared with you and how they impact those of us with migraine, here are some guidelines that have helped me achieve optimal health with migraine and that you might want to take into consideration:*  

1. Avoid your known personal triggers. I have found that by following the remaining guidelines, some of the unknowns were taken care of for me.

2. Avoid processed and packaged foods and those with additives, chemicals, preservatives, pesticides, and artificial colors and sweeteners.

  • In Eastern medicine, it is thought that what isn't excreted from the body as waste can accumulate as toxins and lead to disease. 
  • In Western medicine, many of these packaged and processed foods contain possible triggers like sulfites, nitrites, MSG, gluten, and aspartame. As well, although debatable in the literature, some of these ingredients are thought to be neurotoxins and carcinogens. In addition, although more studies are necessary, with frequent consumption artificial sweeteners are thought to be associated with weight gain, metabolic syndrome (3 or more of: blood pressure >135/80 mmHg; fasting blood glucose >100 mg/dl; large waist circumference -men>102cm, women >89cm; low high density lipoprotein or HDL cholesterol -men <40mg/dl, women <50 mg/dl; triglycerides >150mg/dl), type 2 diabetes, and cardiovascular disease.

3. Avoid fast food; junk food; refined foods and sweets with white four and sugar; rich and creamy sauces; greasy and fatty foods; high fructose corn syrup; hydrogenated oils; fermented foods and beverages; sodas; and, hot and spicy foods. Minimize intake of dairy products and red meat.

  • In Eastern medicine, many of these are thought to lead to a sluggish digestive system and the accumulation of damp phlegm (mucus); and/or, cause an excess of liver fire to accumulate and rise to our heads. 
  • In Western medicine, apart from being migraine triggers for many of us, a number of these foods contain fat, salt, and sugar that can contribute to fluctuations in our serotonin levels, weight gain, hypertension, and increased total cholesterol, triglyceride and blood glucose levels. 

4. Avoid or minimize consumption of caffeine and products that contain caffeine such as coffee, tea, sodas, diet sodas, and chocolate.

  • In Eastern medicine, stimulants are thought to create imbalance and disharmony in our body, mind, and spirit. 
  • In Western medicine, apart from being triggers and stimulants for many of us and interfering with our sleep, some of these products can contain fat and sugar. This can contribute to fluctuations in our serotonin levels; weight gain; and, increased total cholesterol, triglyceride, and blood glucose levels. In addition, it is thought that caffeine can deplete magnesium from our bodes.
  • Caffeine (including caffeine in medications) withdrawal can contribute to morning migraines. If you are sensitive it is best to avoid after 2 pm.  

5. Avoid or minimize alcohol intake.

  • In Eastern medicine, alcohol consumption is thought to contribute to imbalance and disharmony in our body, mind, and spirit.
  • In Western medicine, although alcohol is a CNS depressant, some studies show that it has both stimulating and depressant effects in humans. Increased heart rate and aggression are associated with stimulation and, for some people, stimulating effects appear to be more rewarding than sedative effects. As well, alcohol is thought to contribute to fluctuations in serotonin levels, can deplete magnesium from our bodies, and may interfere with sleep.

6. Eat wholesome organic foods with no antibiotics, growth hormones, pesticides, additives, preservatives, artificial colors, or flavors.

  • If organic fruits and vegetables are too expensive or difficult for you to obtain, whenever possible substitute natural foods and beverages that are minimally processed and have no artificial ingredients, added colors, chemicals, or preservatives. 
  • Thoroughly wash non-organic fruits and vegetables in salt water or a fruit and vegetable wash to remove chemicals and pesticides.

7. Eat a variety of fresh fruits, vegetables, whole grains (breads and cereals), beans, legumes, fish, and poultry to help prevent fluctuations in your serotonin levels and curb food cravings (caution as beans and some fruits and vegetables like strawberries, tomatoes, and spinach may be a trigger for you).

8. Eat whole, unprocessed foods such as green leafy vegetables, avocados, bananas, dried fruit, nuts, fish (halibut), low-fat dairy (yogurt), wheat germ, peanut butter, rice, sunflower seeds and unrefined grains to maintain magnesium intake (caution as avocados, bananas, yogurt, dried fruits, nuts, peanut butter, and sunflower seeds may be triggers for you).

  • Chocolate (which may explain why we crave it) is also high in magnesium but it is also high in fat. If chocolate isn't a trigger for you (we may experience chocolate craving as a premonitory factor and may not be a trigger), try to have a small piece of high quality, anti-oxidant rich dark chocolate rather than milk chocolate, which may have more calories and fat.

9. Favor fiber-rich foods such as leafy green vegetables, parsley, onions, brown rice, bran, carrots, celery, asparagus, papaya, pineapple, cherries, grapes, prunes, and fresh herbs and spices such as ginger, oregano, rosemary, cilantro, dill, sage, mint, and turmeric to help with digestion and elimination (caution as onions, papaya, pineapple, and prunes may be triggers for you).

10. If necessary, eat small, regular meals (5-6 times a day) to prevent food cravings, and dips and peaks in blood glucose levels, from getting out of control (hypoglycemia can trigger a migraine attack).

  • Include protein at every meal or snack to help slow digestion and moderate fluctuations.

11. Eat your breakfast before 9 a.m., lunch before 1 p.m., and dinner before 7 p.m.

12. Avoid fasting and skipped meals to avoid fluctuations in blood glucose levels and hypoglycemia.

13. Stay hydrated with water as dehydration can trigger a migraine attack (8-10, 8 ounce glasses a day is suggested but you may need more with heat and exercise).

Maintaining a healthy diet is one of the most difficult, but important, things we can do to help decrease the frequency of our migraine attacks and reduce our risk for development of diseases and disorders like hypertension, stoke, heart disease, obesity, and diabetes. If you find the task of selecting foods suitable for your needs overwhelming, have a number of comorbid diseases, or have poor renal or liver function, you might want to ask your doctor for a referral to a nutritionist or dietitian to help you plan your diet and recommend appropriate supplements avoid nutritional deficiencies and further organ damage. 

 *from "Migraine: Identify Your Triggers, Break Your Dependence On Medication, Take Back Your Life -An Integrative Self-Care Plan For Wellness"

Sharron :).

Updated, December 3, 2015


Reubin, A. et al. (2013). "Stimulant and Sedative Effects of Alcohol." Current Topics in Behavioral Neurosciences, Volume 13, pp 489-509.

Swithers, S., E., (2013). "Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements." Trends in Endocrinology and Metabolism xx, from

Sharron is a health 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 specific concerns about your health or nutrition, please consult a qualified health care professional.

Copyright 2013, Sharron E. Murray











Eastern medicine is a naturalistic philosophy of health and medicine that looks at the interrelationship of our body, mind, and spirit. Every human being is considered unique. The patient and the doctor work together to maintain and sustain good health. The focus of the relationship is on the prevention of disease and the concept of wellness. This requires an individual to take responsibility for his/her own health and to maintain a healthy lifestyle that includes diet, exercise, and practices such as meditation to reduce the effects of stress and balance the energy centers in his/her body.

In his book "Secrets of Self-Healing" (Avery, 2008), Dr. Ni lists five principles for self-healing and wellness that provide powerful tools for maintaining and restoring optimal health. These five principles are:

  • diet and nutrition
  • herbs and supplements
  • exercise and acupressure
  • lifestyle and environment
  • mind and spirit. 

Today, in Western medicine, along with the diagnosis, treatment, and prevention of symptoms and diseases, most physicians and health care personnel acknowledge the relationship between an individual's diet, lifestyle, exercise and level of stress to his/her health. Besides medications, medical procedures, and surgeries, a variety of relaxation and behavioral treatments and therapies are part of treatment plans for a number of illnesses to promote, maintain and restore good health.

In her article "Migraine Research", Dr. Dawn C. Buse reports that people with migraine can live healthy, productive lives with an effective treatment plan that includes a proper diagnosis, medical care, and

  • acute and preventive pharmacological therapies 
  • non-pharmacological therapies such as biofeedback, relaxation training, cognitive behavioral therapy, meditation, guided visual imagery, and yoga 
  • a healthy diet
  • healthy lifestyle habits like regular sleep/wake schedules and exercise, adequate hydration, no smoking, moderate caffeine intake, and
  • trigger management.

Given this information, let's take a closer look at these principles and concepts and, from a perspective of Eastern and Western medicine, apply them to migraine disease. Keep in mind that we are individuals, who are unique in our triggers, symptoms, comorbities, and risk factors for the progression of episodic to chronic migraine, as well as risk factors for the development of numerous other diseases and disorders.

That said, there are five principles that have helped me revert from chronic migraine and medication overuse headaches (MOH) to infrequent episodic migraine. In addition, these five principles have been instrumental in maintaining and restoring my optimal overall health. They are:

  1. Diet and nutrition
  2. Herbs, supplements and medications
  3. Exercise
  4. Lifestyle habits
  5. Mind and spirit

In subsequent articles, I share each of these principles with you in more detail, along with research studies that support scientific efficacy. 

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.

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

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

Updated, February 1, 2016

Copyright 2013, Sharron E. Murray









Migraine: Three Ways to Avoid Medication Overuse Headaches

Migraine, a largely inherited (genetic) neurological disease with clinical manifestations know as migraine attacks, affects the lives of millions of people worldwide (37-38 million in the United States). For many of us, the majority women, the relentless headache, a phase of the attack, can be excruciating and accompanied by debilitating bouts of nausea and vomiting.

Because our attacks often increase in frequency and severity during the very busiest years of our lives (twenties to fifties) when we are balancing our jobs, family responsibilities, and social obligations, we may inadvertently (often due to gaps in knowledge, poor response, and lack of effectiveness) overuse acute medications (over the counter or prescription) to abort attacks and manage pain, while we attempt to maintain the roles we juggle and keep up with the demands we face. This, as I found out, can lead to medication overuse headaches (MOHs), previously known as rebound headaches.

We should also be aware that we may develop MOHs because of a delay in diagnosis, or a misdiagnosis. For example, in the case of misdiagnosis, because of common symptoms like nasal and sinus congestion, clear nasal discharge and watery eyes, migraine may be misdiagnosed as "sinus" headache and the wrong treatment may be selected.

According to the new International Classification of Headache Disorders, Third Edition  (ICHD-3 beta version, p733.), "Medication-overuse headache is an interaction between a therapeutic agent used excessively and a susceptible patient". It goes on to say that about half of the people with headache on 15 or more days per month for more than 3 months, fit the diagnosis for medication-overuse headache. Drugs implicated include:  

  • opioids = to or >10 days per month,
  • combination analgesics that contain opioids, barbiturates, and/or caffeine = to or >10 days per month,
  • simple analgesics including acetaminophen, acetylsalicylic acid, and non-steroidal anti-inflammatory drugs (NSAIDs) = to or >15 days per month, 
  • abortive drugs like ergots, and triptans. = to or >10 days per month, and 
  • multiple drugs for acute or symptomatic treatment of headache (we may not be able to give an adequate account of names or quantities) on 10 or > days per month for > 3 months.

We need to know that medication overuse (regular use on 10 or 15 days per month, for more than 3 months, depending on the medication) is considered to be a risk factor for the progression of episodic to chronic migraine. Episodic migraine (EM) refers to migraine attacks that occur with less than 15 headache days/month. Chronic migraine (CM) refers to attacks that occur with headache (tension-type-like and/or migraine-like) days more than 15 days/month for a period greater than three months, with features of migraine equal to or >8 days per month.  

In my case, unaware of the chance of MOHs, as I took more and more Imitrex to treat my attacks, I progressed to CM, with headaches every day of the month for a number of years. If you think you may be experiencing MOHs, here are some suggestions I have to help you break the cycle of overuse, prevent the progression of episodic to chronic migraine, and improve the quality of your life:

  • First, to avoid medication overuse do not exceed your recommended dose, or take the medication more often than your doctor, or the label on the container, has recommended. If a medication is not working for you, ask your doctor to switch you to one that might be more effective. If you are not on a preventive medication, ask your doctor about one. 
  • Second, if the route of administration is not working for you, ask your doctor to switch you to another one. For example, if you cannot keep the pills you swallow down, a sublingual form, nasal spray, injection, or rectal suppository may be more beneficial.
  • Third, if the frequency and severity of your migraine attacks persist no matter what, or how much, medication you ingest, you might want to do what I did when I found I couldn't keep taking Imitrex to manage my attacks and maintain the hectic lifestyle I loved: consider incorporating acupuncture or one of the other integrative therapies like biofeedback, behavioral modification (cognitive behavioral therapy), meditation, mind-body exercises such as tai chi and yoga, and/or energy healing techniques like Reike and healing touch into your treatment plan. 

These therapies can help balance our nervous systems, stabilize our serotonin levels, increase our endorphins, and thus decrease the frequency and severity of our migraine attacks. As well, because these therapies permit our bodies to relax, facilitate digestion, and allow our energy and blood to circulate freely, they can enhance the effect of the medication we take, and reduce the amount we require.    

Keep in mind, we need to have an accurate diagnosis for our headaches; our doctors should be aware of any integrative therapies or treatments we incorporate into our treatment plans, including herbs and supplements; and, we should never discontinue, or wean ourselves off, any medication without our doctors' consent. 

Lastly, we should know around 50% of patients apparently with chronic migraine revert to an episodic migraine subtype after drug withdrawal and, equally, many patients overusing medication do not improve after drug withdrawal. For these reasons, patients meeting the criteria for chronic migraine and the criteria for medication-overuse headache should be given both diagnoses (ICHD -3 beta version, p. 650). Keeping a daily diary is a good way to help our doctors diagnose and manage both chronic migraine and medication overuse headaches.

Reference: International Headache Society (2013). "The International Classification of Headache Disorders" (3rd Edition). Retrieved August, 4th from 

Sharron :).

Updated Aug, 2016.

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 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 Sharron E. Murray



MIGRAINE AND STRESS: What is the relationship? And, why should stress management be part of our treatment programs?

Migraine is a neurological disease. Although the pathophysiology is not completely understood, research has shown it to be a complex brain disorder that involves genetics, hyperexcitable brain cells, several neuronal pathways, neurotransmitters (chemical messengers in the brain), inflammatory mediators, vascular irregularities, and environmental influences. In this article, we will take a look at the role of serotonin, define stress, discuss the stress response, examine the relationship between migraine and stress, and introduce techniques and therapies effective for stress management. 


Serotonin is a neurotransmitter found in the brain and in the gut. It helps regulate pain, vessel tone, peristalsis (movement of food through our gut), sleep, mood, and appetite. Along with neurotransmitters like Dopamine and Norepinephrine, Serotonin levels are believed to fluctuate during a migraine attack. Some sources indicate that people with migraine may have a low serotonergic disposition. Low levels can contribute to our headache pain, gastric stasis, nausea, vomiting, food cravings, and mood swings.


Stress is defined as the normal physical response of our bodies to any demands or changes. It is our body's way of adapting to internal or external, perceived or real challenges, termed "stressors".

The term "stress" is associated with the exertion of pressure. This pressure can be related to environmental, chemical, physical, or emotional stressors. We need to know that our body does not distinguish between these. For example, it reacts the same way whether we are overcome by toxic fumes, break a leg, having problems with our boss, are worried about mounting bills, or are anxious about a loved one.

Stress response

Acute stress

When we perceive a threat or feel "stressed" (pressured), our body activates the sympathetic branch of the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis. This causes a flood of hormones to be released including, but not limited to, epinephrine (adrenaline), norepinephrine (noradrenaline), and cortisol to fight the challenger. We know this as the "fight or flight" response, or acute phase of stress. In this phase, stress is good. It keeps us on our toes and allows us to stay focused, energetic, and alert. Levels of epinephrine, norepinephrine, and cortisol are high, giving us the energy to fight the stressor at hand. Once the emergency has passed, the levels of these hormones return to normal.

Symptoms related to acute stress include:

  • increased heart rate, blood pressure and respirations, 
  • dry mouth, 
  • sweating, 
  • cold hands and feet, 
  • facial pallor, 
  • chills, 
  • nausea and vomiting, 
  • "choked-up-feeling",
  • gastric stasis,
  • diarrhea, 
  • headache, 
  • lightheadedness,
  • rapid speech,
  • stuttering,
  • restlessness, 
  • nervousness, 
  • insomnia, 
  • anxiety, and 
  • panic attacks. 

Chronic stress

Chronic stress is not good for us. In this phase, the HPA axis may wear out and levels of epinephrine, norepinephrine, and cortisol can become depleted. When that happens, levels of dehydroepiandrosterone (DHEA), a steroid produced by the adrenal glands and used to make estrogen and testosterone start to fall and neurotransmitters like serotonin are affected. Our body's metabolism slows down and we may feel tired, fatigued, and gain weight, especially around the middle. A decrease in our sex hormones can cause hormonal imbalances and loss of our sex drive, while low levels of serotonin can contribute to emotional disturbances like anxiety and depression.

Symptoms related to chronic stress include:

  • extreme fatigue,
  • lethargy,
  • weight gain (difficulty losing weight), 
  • cold hands and feet, 
  • menstrual irregularities, 
  • loss of sex drive (libido), 
  • indigestion, 
  • heart burn, 
  • recurrent infections, 
  • rash,
  • headache, 
  • backache,
  • hypertension, 
  • hemorrhoids, 
  • varicose veins, 
  • poor concentration,
  • intense mood swings, 
  • anxiety, and 
  • depression. 

Migraine and stress

Numerous studies have shown that stress plays an important role before the onset of migraine, in the maintenance of the disorder, the frequency of our attacks, and the progression of episodic to chronic migraine. At this point, you should know that several studies have shown stress to be a trigger for migraine attacks. As well, stress is a factor that makes us more susceptible to our triggers (additive effect)

Other factors to consider in the relationship between stress and migraine include

  • the perception of stress is unique to the individual (what stresses me may not stress you),
  • some people are more sensitive to stressors than others, and
  • comorbid illnesses can affect our susceptibility. For example, I have Mitral Valve Prolapse, a condition which makes me extremely sensitive to stressors.

Keeping these things in mind, ways that stress can impact our migraine attacks include:

  • If stress is severe, prolonged, and/or frequent, it can affect our sleeping and eating patterns and make us more susceptible to triggers like fatigue and hunger.
  • Because stress can affect our estrogen levels and serotonin levels tend to fluctuate with our hormonal levels, it can exacerbate the pain of our hormonal migraines.
  • It may also contribute to new onset migraine attacks during menopause or other hormonal changes like initiation of birth control pills or pregnancy.
  • Because chronic stress can deplete our serotonin levels, it can increase the frequency, duration, and severity of our migraine attacks, and play a role in the development of chronic migraines.
  • The pain of the headache we experience during our migraine attack can itself stimulate the ANS and HPA and initiate the stress response we just discussed. This can not only exacerbate our pain, but other symptoms like nausea, vomiting, gastric stasis  (slowed peristalsis or movement of food through the gut), and mood swings including irritability, anxiety and depression. The slowed peristalsis may delay gastric emptying and affect how our oral medications are absorbed, thus delaying our pain relief.
  • The relaxation phase following an episode of stress is thought to be responsible for the migraine attack known as a "let-down" or "weekend" migraine.

Stress Management

Effective stress management is essential for those of us with migraine to help quiet our minds and calm our bodies. Behavioral, relaxation and stress management techniques, including biofeedback, meditation, guided imagery, breathing techniques, yoga, physical therapy, massage therapy, and acupuncture, have been shown to help minimize our physiological responses to stress, decrease sympathetic arousal, and stabilize our serotonin levels. Other therapies like energy-healing techniques such as Healing Touch and Reiki are thought to be helpful. These therapies have even better effects when combined with a healthy diet that is free of chemicals and preservatives, avoidance of excessive caffeine and alcohol, no smoking, and a regular sleep schedule and exercise program.

Adoption of stress management techniques has other benefits. Because these techniques and lifestyle modifications involve participation and commitment, our treatment becomes a collaborative process where we partner with our doctor or other health care professional in our care. Besides a feeling of empowerment, when we adopt a healthy lifestyle we can decrease our risk for the progression of episodic to chronic migraine, increase our chances of reverting from chronic to episodic migraine, and decrease our risk for a number of other disorders and diseases like hypertension, stroke, and diabetes.

Lastly, migraine can steal moments and events from our lives that we cannot recreate. Many of us have to give up our careers and our dreams. Feelings of loss of control and helplessness are prevalent. Stress management cannot cure our migraines but it can help us lead more full and happy lives. If you do not have a stress management program in place, you might want to consult with your doctor or other health professional about integrating one into your treatment plan.


Amoils, S., M.D. & Amoils, S., M.D. (2011).  Get Well & Stay Well. Ohio:Integrative Medicine Foundation.

Buse, D. C. PhD. & Andrasik, F., PhD. (2009). Behavioral Medicine for Migraine. Neurol Clin 27, 445-465. doi:10.1016/j.ncl.2009.01.003

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.   

Hamel, E. (2007). Serotonin and migraine: biology and clinical implications. Cephalalgia. Nov. 1293-300.

Sauro et al. (2009). The Stress and Migraine Interaction. Headache.: The Journal of Head and Face pain, 49 (9), 1378-1386. 

Updated February, 2018

Sharron Murray, MS, RN is a Health and Wellness author. 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. 

Copyright 2013, Sharron E. Murray