The Migraine Spectrum

What is a Migraine?

Migraines are the third most prevalent illness in the world, with over 36 million people in the United States suffering from them. A migraine is a headache disorder, characterized by recurring attacks of moderate-to-severe headaches. Typically, patients complain of headaches on one side but it can occur on both sides.

What are Migraine Symptoms?

Migraines affect more women than men and are more common between the ages of 30 and 39 year old, but are still high between the ages of 40-50.  The average frequency of migraine headaches is one and a half per month. A patient with more than 15 headache days per month, over a three month period, has chronic migraines.

Migraines can be pulsating in nature, associated with sensitivity to light, sound and smell and can cause nausea and or vomiting. Between 20–to-40 percent of patients have auras, or visual symptoms, consisting of flashing light, figures, patterns and shapes. Blurry vision, darkness or itchiness in one or both eyes, and tingling or weakness in arms can also be symptoms.

Can hormones affect migraines?

Hormones are a very common reason for migraines. Typically, I see migraines in women before and during their menstrual period, which could be related to a drop in estrogen.  Occasionally, hormonal contraceptive methods are prescribed for migraines related to menstrual periods; however, some patients report an increase in headache frequency with these medications. Migraines can also become common during pregnancy in the first trimester, which can improve in the second trimester when the hormones are more stable.

How long do migraine headaches last?

Migraines can last from four to 72 hours. When it lasts longer than 72 hours, it becomes known as a status migrainosus. With status migrainosus, the patient typically needs IV medications to abort the headache.

Does diet affect the onset of migraines?

It has been known that certain foods can trigger migraines in susceptible people. The most common triggers are caffeine, alcohol, like red wine, foods with MSG, and chocolate.

I have my patients keep a diary of the frequency of their migraines nd exactly what they ate one-to-two hours before. The diary helps me have an idea of what could trigger each individual migraine. Prevention of migraine is the most important.

Are migraines hereditary?

Yes, migraines can run in the family. There is approximately 50 percent chance of developing migraines if one parent has history of migraine.

Diagnosis and time frame of migraine headaches.

A brain MRI and blood work are frequently ordered to rule out secondary causes for headaches; however, migraines are easily diagnosed by taking a history and a complete physical exam. Migraine headaches need to be differentiated from other types of headaches, like tension headaches or sinus headaches.

 Diagnostic Criteria for Migraine without Aura.

  • At least five attacks fulfilling criteria below
  • Headache attacks lasting four to 72 hours (untreated or unsuccessfully treated)
  • Headache has at least two of the following four characteristics:
    • Unilateral location
    • Pulsating quality
    • Moderate or severe intensity
    • Aggravation by or causing avoidance of routine physical activity
  • At least one of the following during the headache:
    • Nausea or vomiting
    • Photophobia and phonophobia

Diagnostic Criteria for Migraine with Aura (Classic Migraine)

  • At least two attacks fulfilling criteria below.
  • One or more of the following fully reversible aura symptoms:
    • Visual
    • Sensory
    • Speech and/or language
    • Motor
    • Brainstem
    • Retinal
  • At least 2 of the following 4 characteristics:
    • At least one aura symptom spreads gradually over at least five minutes, and/or two or more symptoms occur in succession
    • Each individual aura symptom lasts 5 to 60 minutes
    • At least one aura symptom is unilateral
    • The aura is accompanied, or followed within 60 minutes, by headache

Source: Headache Classification Subcommittee of the International Headache Society 2013.

Why should a person see a neurologist for migraines?

Primary care physicians may treat migraines. When a patient does not respond to regular pain medications, new onset headaches on a patient older than 50 years old or the patient presents with nausea, confusion, dizziness or focal symptoms, I strongly recommend seeing a neurologist.

The goal is to rule out secondary reasons for headaches, such as a tumor, stroke or brain hemorrhage. A neurologist can provide the best approach to treat headaches with pharmacological and non-pharmacological therapies.


When a patient is diagnosed with migraines, the goal is to treat the headaches with minimal side effects.  I typically order nonsteroidal anti-inflammatory drugs (NSAIDs) and frequently I combine NSAIDs with triptans and antiemetics. If the patient has more than three migraines per month, I frequently order preventive medications like antiepileptic drugs, blood pressure medications and anti-depressants.

If the patient failed two or more preventive medications and continues with more than 15 headache days per month, lasting more than 4 hours, I typically recommend Botox injections. Botox therapy for chronic migraine consists of 31 injections in seven key areas of the head and neck every three months. The patients get maximum benefits after the second and occasionally, third set, of Botox injections.