One billion people suffer from migraines around the world annually, affecting people of all ages. Migraines are ranked the second leading cause of disability worldwide and are consistently the fourth or fifth most common reason for emergency visits annually (28).
If you or a loved one suffers from migraines, you can attest to how disabling migraines are. However, there is hope for migraine sufferers beyond pharmaceutical options, as migraines respond very well to a root-cause approach to treatment. By getting to the core of the problem, it is possible to achieve sustained relief and resolution of migraine headaches.
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What Are Migraines?
According to the National Institute of Neurological Disorders and Stroke (NINDS), a migraine is "a type of headache characterized by recurrent attacks of moderate to severe throbbing and pulsating pain on one side of the head." Migraine pain is caused by the activation of nerve fibers within the wall of blood vessels traveling inside the brain's meninges (the three layers of membranes that line and enclose the brain and spinal cord).
There are many types of migraines, the two most common being migraine with or without aura. Migraine with aura, previously called classic migraine, is characterized by visual, sensory, or language disturbances, known as auras, that precede or accompany the onset of a migraine headache. Migraine without aura, or common migraine, is the most common type of migraine that occurs without preceding neurological symptoms.
Other types of migraine include (22, 35):
- Abdominal Migraine: intense central abdominal pain associated with little-to-no headache and additional symptoms of nausea, vomiting, pallor, light sensitivity, and loss of appetite
- Basilar-Type Migraine: throbbing headache that is felt on both sides at the back of the head, most commonly in teenage girls. Additional symptoms include partial or total loss of vision or double vision, dizziness and loss of balance, poor muscle coordination, slurred speech, ringing in the ears, and fainting.
- Hemiplegic Migraine: a rare and severe type of migraine that causes temporary paralysis on one side of the body before or during a headache. Vertigo, pricking or stabbing sensations, and difficulties seeing, speaking, or swallowing may begin before the headache.
- Menstrual Migraine: a headache that affects women around the time of their period
- Migraine without Headache: aura symptoms, nausea, and constipation without head pain
- Ophthalmoplegic Migraine: an uncommon type of migraine associated with head pain, a droopy eyelid, large pupils, and double vision
- Retinal Migraine: attacks of vision loss or disturbances in one eye associated with the onset of migraine
- Status Migrainosus: a rare and severe migraine characterized by debilitating pain and nausea lasting at least 72 hours
Migraine Signs & Symptoms
Migraines are severe headaches that typically include a severe throbbing or pulsating headache, often on one side of the head, accompanied by sensitivity to light and sound, nausea, vomiting, and sometimes visual disturbances or auras. Untreated migraines usually last 4-72 hours, and patients are generally asymptomatic between attacks. (22)
Four phases of a migraine attack have been identified. Not all migraine sufferers experience all four phases, and the duration and severity of each stage can vary from person to person.
- Prodrome: can occur hours or even days before the actual headache and is characterized by subtle changes in mood, energy levels, or appetite. This phase may involve irritability, fatigue, food cravings, or heightened sensitivity to light or sound.
- Aura: occurs in 25% of migraine sufferers and is characterized by transient neurological symptoms such as visual disturbances (flashing lights, blind spots), sensory changes (tingling, numbness), or even difficulty speaking. The aura lasts no longer than an hour and is a warning sign of an impending headache.
- Headache: may last anywhere from a few hours to a few days and is often accompanied by nausea, vomiting, and increased sensitivity to light and sound.
- Postdrome: the headache gradually subsides, but individuals may feel exhausted, mentally foggy, or experience lingering symptoms such as mild headache, sensitivity, or mood changes.
Root Causes of Migraines
The exact cause of migraines is still not fully understood, but they are believed to result from a complex interplay of genetic, environmental, and neurological factors. One widely accepted theory is that migraines are initiated by abnormal brain activity that affects the blood vessels and chemicals in the brain. Changes in blood flow and the release of certain neurotransmitters, such as serotonin, play a role in migraine development. (23)
Furthermore, the central nervous system is believed to be involved in migraines. Certain brain regions are thought to become overly sensitive or reactive, leading to a cascade of events resulting in the symptoms of migraines. The trigeminal nerve, a major pain pathway, is also believed to play a role in transmitting pain signals during a migraine. (28)
Migraine has a strong genetic component. Migraines tend to run in families; people with a family history of migraines are three times more likely to experience them. Specific genes related to regulating blood vessels and neurotransmitters have also been associated with migraines. (28)
Many triggers can contribute to migraine episodes. These triggers vary among individuals but can include hormonal changes, such as fluctuations in estrogen levels, certain foods and beverages (e.g., aged cheese, chocolate, alcohol), stress, lack of sleep, bright lights, strong odors, and changes in weather or barometric pressure. (11, 35)
How to Diagnose Migraines
Migraines are diagnosed clinically. Blood tests and imaging are not necessary for most patients but may be considered to rule out other conditions or help doctors better understand the underlying causes of migraine headaches.
Step 1: Clinical Diagnosis
Doctors should suspect migraine headaches in patients with moderate-to-severe headache attacks lasting 4-72 hours that may be accompanied by nausea, vomiting, and sensitivity to light/sounds.
Migraines can be diagnosed clinically using the ICHD-3 Diagnostic Criteria for Migraine. To diagnose migraine, the headache should not be better explained by another condition.
Migraine Without Aura
Migraine without aura is characterized by at least five attacks that meet the following criteria:
- Headache lasting 4-72 hours when untreated (or unsuccessfully treated)
- Headache has at least two of the following: some text
- Unilateral location
- Pulsating quality
- Moderate-to-severe pain
- Aggravation by or causing avoidance of routine physical activity
- Headache is accompanied by at least one of the following:some text
- Nausea, vomiting, or both
- Photophobia (sensitivity to light)
- Phonophobia (sensitivity to sound)
Migraine With Aura
Migraine with aura is characterized by at least two attacks that meet the following criteria:
- The patient experiences at least one of the following fully reversible aura symptoms:some text
- Visual
- Sensory
- Speech, language, or both
- Motor
- Brain stem
- Retinal
- The headache meets at least three of the following:some text
- At least one aura symptom spreads gradually over at least five minutes
- At least two aura symptoms occur in succession
- Each aura symptom lasts 5-60 minutes
- At least one unilateral aura symptom
- At least one positive aura symptom
- Headache accompanies or follows aura within 60 minutes
Chronic Migraine
Chronic migraines are diagnosed when a patient experiences a migraine at least 15 days per month for more than three months. The following criteria must also be met:
- At least five attacks meeting the criteria for migraine without aura or at least two attacks meeting the criteria for migraine with aura
- On at least eight days per month for more than three months, the patient experiences an attack with features of migraine with or without aura, or the patient believes the migraine is relieved by a triptan or ergot derivative.
Step 2: Labs to Identify Root Causes of Migraines and Customize Treatment Plans
After making a clinical diagnosis, doctors can order specialty tests to identify a patient's migraine root causes and triggers to create holistic, customized prophylactic treatment plans.
Female Hormone Panel
About three out of four people with migraines are women, and more than half of migraines in women are related to their periods. Sudden drops in estrogen and progesterone right that occur right before menstruation are believed to influence menstrual migraines. (21)
Comprehensively evaluating female hormones with one of the following panels can be highly beneficial for assessing the role of sex hormones as a cause of migraine:
- DUTCH Cycle Mapping + Complete (Dried Urine) by Precision Analytical (DUTCH)
- Female Hormone Panel by Precision Point
- Saliva Hormone Female Evaluator (11 Days) by Access Medical Labs
Sleep and Stress Hormones
Other hormones that control our circadian rhythm and stress response can influence how we sleep and perceive stress. Melatonin and cortisol are the primary hormones involved in the sleep-wake cycle. Cortisol is also one of the primary hormones produced by the body as part of the natural stress response. A salivary test can measure cortisol and melatonin throughout the day to qualify and quantify the body's secretion curve for each hormone.
- Sleep and Stress Panel by Ayumetrix
- Advanced Adrenal Stress Test by Precision Point
- Comprehensive Melatonin Profile by Genova Diagnostics
Food Sensitivities
Several dietary triggers are well documented to prompt the onset of migraine, including alcohol and nitrate- and tyramine-rich foods. Substantial evidence also suggests that IgG immune reactivity to various foods is linked to migraines. For example, this study confirmed that individuals who regularly experience migraines are more likely to test positive for more IgG food sensitivities than those who don't experience migraines regularly. That study, in addition to this one, has also concluded that therapeutic elimination of IgG-reactive foods resulted in the successful control and reduction of migraine headaches without needing medications.
A food sensitivity panel can help identify food sensitivities to make dietary interventions and modifications more effective for patients.
- 184 IgG Food Sensitivity Panel by Alletess Medical Laboratory
- 144 Food Panel: IgG by US BioTek
- FIT 176 by KBMO Diagnostics
Micronutrient Analysis
Deficiencies in magnesium, niacin, riboflavin, cobalamin, CoQ10, carnitine, alpha-lipoic acid, and vitamin D have been associated with migraine (11). Nutrient testing allows for identifying nutrient insufficiencies and deficiencies to create a personalized supplementation plan to restore optimal nutrient status.
- Micronutrient Test by SpectraCell
- Cellular Micronutrient Assay by Cell Science Systems
- NutrEva FMV by Genova Diagnostics
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Treatment Plan for Migraines
Treating migraines involves two primary approaches: acute management and prophylactic strategies. Acute management aims to alleviate symptoms once a migraine has started, providing immediate relief from head pain and other associated symptoms. Prophylactic strategies, on the other hand, focus on preventing migraines from occurring in the first place.
Acute Management
Here's Why This Is Important:
Acute management aims to provide immediate symptom relief, prevent the escalation of migraine episodes, and allow individuals to resume their normal activities.
How Do You Do This?
Abortive medications are taken as soon as symptoms occur to relieve pain. Recommended first-line therapies include:
- Over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)
- Triptan drugs, which increase levels of serotonin in the brain to cause blood vessels to constrict and lower pain levels
Other medications that have proven efficacy in treating migraine but are reserved for second-line therapy (due to potential for adverse effects or abuse potential, route of administration, or cost) include:
- Ergot derivative drugs, which bind to serotonin receptors on nerve cells and decrease the transmission of pain signals
- Opioids
- Antiemetic drugs
- Intramuscular ketorolac and promethazine
Ginger, known for its anti-inflammatory, analgesic, and antiemetic properties, has been explored as a natural migraine abortive with promising results. Research has shown that ginger can be as effective as sumatriptan in reducing the symptoms of migraines with fewer side effects. Studies evaluating the use of ginger in acute migraine management have noted increased proportions of patients with reduced pain scores or who are pain-free two hours after ginger administration. General dosing recommendations include taking half a teaspoon of ginger powder mixed in warm water or 400 mg of dry ginger extract. (38)
Prevention
Why Is This Important?
The goal of migraine prophylaxis is to reduce the frequency, severity, and duration of migraine attacks, thereby improving the overall quality of life for sufferers. Preventive treatment helps avoid medication overuse, reduces the risk of migraines becoming chronic, and allows individuals to maintain daily functioning with fewer interruptions.
How Do You Do This?
Preventive medications are generally prescribed to patients who experience at least four headaches a month, at least eight headache days monthly, or experience debilitating attacks despite appropriate acute management. First-line preventive medications include divalproex, topiramate, and beta-blockers (metoprolol, propranolol, and timolol). (10)
Dietary intervention is a powerful tool in the treatment of migraines, and numerous studies have found elimination diets of various sorts to reduce migraine severity and frequency. Elimination diets can be created based on the common migraine food triggers, customized based on food sensitivity test results, or a combination of the two. For the highest chance of success, patients should follow an elimination diet for 4-12 weeks before reintroducing foods back into the diet to help identify dietary triggers. (12)
Some of the most commonly reported triggers for migraine include chocolate, cheese, nuts, citrus fruits, processed meats, monosodium glutamate (MSG), aspartame, fatty foods, coffee, and alcohol (12). This handout offers a user-friendly table that lists recommendations for a generalized migraine prevention diet. It can be an excellent starting point for patients who have yet to experiment with making any dietary changes for migraine treatment.
Fasting, missing meals, and overeating are common triggers for migraine (12). Given this, patients should be instructed to eat at regular time intervals.
Stress-relieving mind-body therapies, including acupuncture and biofeedback, have been shown to reduce the frequency and severity of migraine headaches. Possible mechanisms behind these effects include these modalities' abilities to modulate neurotransmitters and hormones, reduce inflammation, and improve blood circulation (14, 39).
A number of natural herbs and supplements have been reported effective in treating and preventing migraine headaches:
Magnesium helps to maintain vascular tone and prevent neuronal excitability. Low brain and tissue concentrations of magnesium have been found in patients with migraine. Citrate and oxide magnesium forms, dosed 600 mg daily, are most commonly used in clinical studies; magnesium supplementation is linked to reduced intensity or frequency of migraine attacks and improved cerebral blood flow (40). (37)
Feverfew (Tanacetum parthenium) is an herb native to southeastern Europe. Researchers believe feverfew's parthenolide constituent has anti-inflammatory effects and relieves smooth muscle spasms, making it effective against migraines. A 1983 survey found that 70% of 270 migraine sufferers who had eaten 2-3 fresh feverfew leaves daily had decreased frequency and intensity of their migraines. Other studies that have used feverfew in combination with other natural ingredients also show a reduction in the frequency and severity of migraines. A typical dose is 25-100 mg of dried leaves twice daily or 0.25-0.5 mg of parthenolide twice daily for at least three months. (9, 19, 34)
Butterbur (Petasites hybridus) root can be used to prevent migraines. Studies report 50-68% reductions in migraine frequency with butterbur root extract supplementation. The plant contains liver-toxic pyrrolizidine alkaloids, so use alkaloid-free extract preparations for safety. Butterbur is usually administered at 50-100 mg twice daily with meals for 4-6 months, then gradually reduced to the lowest effective dose to maintain migraine remission. (40)
Low vitamin B2 (riboflavin) status can cause migraines by inducing mitochondrial dysfunction. A systematic review concluded that riboflavin supplementation is safe and effective for preventing migraine symptoms in adults. Additionally, this study found that riboflavin dosed at 400 mg daily could reduce the usage of abortive migraine medications after 3-6 months of treatment.
Similarly to riboflavin, coenzyme Q10 (CoQ10) supports mitochondrial function and energy metabolism. Studies support using CoQ10 in 100-300 mg daily doses as a safe and effective intervention for reducing migraine headaches' frequency, duration, and severity (31, 33).
Migraine Case Study
You can read about a real case study here:
Case Study: How Ashley Became Migraine-Free in Six Weeks With A Root Cause Approach
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Key Takeaways:
- There are many types of migraines, all of which are extremely painful and disabling. While various medications can effectively treat and prevent acute migraine attacks, they can come with unwanted side effects and high costs.
- Alternative treatment approaches that focus on correcting imbalances related to hormones, food sensitivities, and nutrient deficiencies can reduce the frequency and severity of migraine headaches.
- Doctors can use the sample protocol outlined in this article to help patients achieve better long-term control and remission of their migraines.
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