Adam Sewell MD


A migraine is characterized by intense, throbbing pain, that is often experienced at the temples, the front or back of one or both sides of the head, and there is sometimes eye involvement. Women are far more likely to experience migraines, but they are found in any gender and all age groups. One culture or ethnicity is not more likely to experience them than any other.

The severe pain, and associated neurological symptoms, are often described as debilitating with migraines. The head pain may be either unilateral (one-sided) or bilateral (both sides), and the entire experience usually lasts from one-to-four hours. Sometimes, however, a migraine can linger for several days, or return several times a week as a “chronic migraine”. With some migraines, there is nausea and vomiting.

Migraines are categorized as “Classical” and “Common.”
The Classical Migraine produces one-sided pain, and many people see an aura about 30 minutes to an hour before a migraine. Auras can include flickering lights or other visual disturbances. In a common migraine the pain is felt on both sides of the head, and there are, typically, no visual disturbances. Some other sensory manifestations include: smells, blurry vision, numbness or tingling in the face, unsteadiness and weakness.

Although the exact cause of migraines is unknown, it’s thought to be a combination of environment and genetics. Some common environmental triggers are: bright lights, loud noises, certain foods (chocolate, peanut butter, avocado, banana, citrus, dairy products, and fermented/ pickled foods, MSG), alcohol drinks (red wine), certain medications (birth control pills), menstrual cycle fluctuations, exertion activities; as well as mental health disorders, such as depression.


In the past, it was believed that blood vessel changes caused migraines. However, recent research reveals that migraines aren’t just caused by blood vessel changes in the brain, but also, the various brain nerve pathways and neurotransmitters. Migraines are thought to have a genetic link or predisposition, as they often run in families. The theory is those with a family history of Migraines, may have a gene that predisposes them to migraine HA’s (2007 Goadsby).


Severe headaches are one of the most common reasons people visit an emergency room or see a physician. However, because most headaches are chronic in nature, it is important to seek your general practitioner’s advice in managing headache symptoms. Additionally, most headaches, even severe migraines, are not dangerous or life threatening. There are some instances where headaches are associated with other diseases or conditions, so it is important to always seek treatment for a headache that does not go away or that is sudden and severe or described as “the worst headache of your life”.

There are many medical conditions that cause secondary headaches. A physician evaluation is critical to determine an accurate diagnosis of any chronic headache conditions.

Some of the more serious conditions that require immediate medical attention are: intracranial hemorrhages/ hematomas, meningeal infections (viral, bacterial, and fungal), strokes, and malignant hypertension. Again, if there seems to be anything unusual about the headache(s) that you are experiencing, seeking medical attention is of utmost importance. In order to accurately find the source of a headache, a physician may order a series of tests and studies including: radiological scans (MRI, CT), neurological exam, blood work, or an eye/vision assessment.


There are two pharmacological treatment categories for primary headaches, and are classified as “abortive” or “preventive.”

Abortive therapy

Abortive therapy’s goal is to stop head pain immediately. These medicines may provide pain relief; but they don’t promise a decrease frequency or intensity, and they will not prevent reoccurrences of pain. In addition, the effectiveness varies from person to person, and depending on the cause and type of headache, these medications may not work for some people at all. Over-the-counter medications don’t usually work for cluster headaches, and they only work for some people with certain kinds of migraines. Also, they rarely effects cases of intense head pain.

Common abortive therapies for Primary HA’s:

  • Oxygen – most commonly used for a Cluster HA.
  • Ergots
  • Triptans
  • NSAID’s
  • Anti-emetics
  • Opiates
  • Butalbital with aspirin or acetaminophen

Many patients have pain relief with abortive treatments, but there is serious concern about overuse and medication dependency, especially when the medications cause secondary concerns. In May 2007, the National Neurological Institute in Milan Italy published an article stating “Most patients with frequent headaches eventually overuse their medications, and when this happens, the diagnosis of medication-overuse headache is clinically important, because patients rarely respond to preventive medications whilst overusing acute medications” (2007 Grazzi).

Additionally, overuse of abortive headache medications, may eventually cause a resistance to such medications in the future. This can cause the attacks to become more frequent and severe.

Preventive therapy

Preventive therapies are directed at reducing frequency and severity of headaches. Most of these medications don’t work to alleviate acute pain symptoms. As a result, they are often used in conjunction with abortive therapy medications.

Some common preventive medications for headaches:

  • Cardiovascular drugs (Beta blockers, Calcium channel blockers)
  • Antiseizure medications
  • Antihistamines
  • Antidepressants

Antidepressant medications may help where there is a relationship between a Depression/Anxiety Disorder or sleep disturbance and migraines.

Addressing both the physical and mental health of a patient who experiences chronic headaches, will improve their quality of life and headache symptoms (2007 Frediani F). Mental health disorder treatments can be both medication and/or behavioral therapy.

Another aspect of successful headache treatments, are behavioral interventions and modifications. Behavioral modifications, include: biofeedback training, mind and body relaxation (yoga, acupuncture, massage), and cognitive behavior therapy. All of these treatments have proven quite successful for migraine prevention (2006 Holroyd).

Behavioral and supplemental treatment options:

  • Acupuncture
  • Cognitive Behavioral Therapy
  • Group Therapy
  • Massage
  • Exercise and Nutrition Counseling, Vitamin Supplements
  • Prayer
  • Biofeedback
  • Chiropractic Manipulations
  • Hormone Supplements

Recent studies have proven the effectiveness of Botulinum A toxin (Botox) injections as a migraine treatment option. Some of those who have received Botox injections for facial wrinkles, also, noted headache relief. The Botox injection is offered in the same area for headaches, as it is for wrinkles in cosmetic procedures.

In 2007, The Chicago Medical School at Rosalind Franklin University of Medicine and Science, compared the efficacy of Botox for migraines and tension headaches and reported positive findings using Botox as a headache treatment (2007 Freitag).

A 2006 publication stated that 75% of patients who received Botox injections for the preventative migraine treatments, reported eventual compete pain relief from headaches. No adverse effects have been reported, as “Botox (BTX-A) showed good efficacy and tolerability as a prophylactic agent” (2006 Anand). Trained pain physicians can safely offer Botox injections as a migraine treatment option.

Proven treatment options for reducing migraine frequency:

  • Botox Injections
  • Occipital Nerve Stimulation
  • Cervical Facet Injections
  • Cervical Epidural Steroid Injections
  • Sphenopalatine Nerve Blocks
  • Occipital Nerve Blocks
  • Supratrochlear Nerve Blocks
  • Supra/ Infraorbital Nerve Blocks

There has been a tremendous amount of research on the effectiveness of treatments for headache relief, and research has, generally, shown that conventional and conservative therapies are often not effective in treating the associated facial pain and peripheral/ central desensitization. Both are common in migraines.

One migraine study, conducted by the Department of Anesthesiology, Intensive Care and Pain Management in Italy reported, 85% of patients responded favorably to supraorbital and greater occipital nerves blocks (1997 Caputi).

Transnasal sphenopalatine ganglion (SPG) block injections can be helpful for migraines as well.  .

The combinations of therapies above have been proven to reduce painful symptoms for all types of headaches.

Headache Journal

Lastly, a headache journal can be a helpful way to monitor headache triggers and symptoms and can be an excellent personal resource that you can share with your physician. Often, just realizing the environmental or physical triggers of your headaches, can have tremendously positive results and give you a sense of control over the pain you are experiencing. It can be a written record of detailed symptoms and notes on food, sleep routines and other important information, revealing possible headache triggers. Additionally, pain management can be noted. What treatments work? Which ones don’t? These things can all be recorded in your headache journal.

For more information or questions about headaches, treatments, and other items mentioned, please see your pain physician.

Resources/Journal Articles

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