Ask the Migraine Experts
We sat down with Brian Grosberg, M.D., and Kiran Rajneesh, M.D., to get answers to your pressing questions about chronic migraine.
During the COVID-19 pandemic, I’ve had an increase in migraine attacks. Is stress likely to blame?
Dr. Grosberg: We know that migraine may worsen or begin after a major stressful event. Other contributing factors during the pandemic could include changes in sleep patterns, dietary intake, the work environment at home, daily screen usage, mood and energy level, and the level of personal interactions.
Dr. Rajneesh: Stress is a major precipitator of migraine, and this pandemic has changed how we live our lives. It’s not only emotional or psychosocial stress—people are going to sleep and waking up at different times, which means the body’s natural rhythms are being disrupted. People are also changing their diets—at home, we’re more likely to snack or have more coffee and tea, all of which increase the risk of migraine flares. The pandemic has disrupted our exercise regimens, our hobbies, and our rest and relaxation, which resets the brain just like sleep does. Each of these factors adds on, increasing the risk of migraine.
After the pain from a migraine subsides, I often feel tired, dizzy, depressed, and unable to focus. Why does this happen, and what can I do about it?
Dr. Grosberg: Following the pain and light- and sound-sensitivity from migraine, many people experience symptoms that closely resemble a hangover, which is known as postdrome. This phase of a migraine attack is marked by fatigue, body aches and pains, and mental fogginess that can persist from a few hours to days. These symptoms may be lessened by staying well hydrated, performing stretches or light physical activities, avoiding things that intensify headache, and using acute migraine treatments in an optimal fashion.
Dr. Rajneesh: Migraine starts in one part of the brain and spreads across it, depleting the neurotransmitters. This can leave people feeling worn down, dizzy, or irritable, or with decreased concentration. To ease these postdromal symptoms, it can help to take a nonsteroidal anti-inflammatory drug within two hours of the pain, as long as you’re not overusing them. Rest up with a short nap if possible, or do five to 10 minutes of meditation or biofeedback.
Because I take preventive medication for chronic migraine, some of my friends and family members don’t understand when I tell them I’m having a migraine attack. How can I explain this?
Dr. Rajneesh: You need to tell them that migraine is an electrochemical imbalance in the brain, and even though you’re taking preventive medicine, it’s not 100 percent effective. The goal is to have fewer headaches per month—and to reduce their severity and duration. It’s nearly impossible to get to zero. There’s no magical cure for migraine.
Dr. Grosberg: Unfortunately, misunderstandings about migraine are common. Many people who have never experienced one don’t realize the profound physical and psychological toll it has on the person. It’s important to explain that migraine is a neurological disorder and much more than just a headache, with symptoms that can also include light- and sound-sensitivity, nausea, and/or vomiting. And emphasize that with chronic migraine, people experience 15 or more days of headache per month. Reinforce the message that even with treatment, it often takes time for improvements to occur, and having the support and understanding of friends and family members is extremely important.
Is there a diet that will prevent migraine flare-ups?
Dr. Rajneesh: There has been no big study that shows one diet is better for migraine. It’s an entirely personal thing. In general, a diet with lots of vitamins, micronutrients, and antioxidants—from fresh vegetables and fruits—helps reset balance in the brain. Our brains are constantly turning over cell membranes, and that process is helped by these micro nutrients and antioxidants.
Dr. Grosberg: Diet recommendations should be tailored to each individual with migraine. If the person isn’t aware of specific food triggers—alcohol, chocolate, and cheese are common ones—headache diaries can be helpful for revealing them. Avoiding identified food triggers can prevent migraine attacks. But there is no one-size-fits-all migraine prevention diet.
I recently felt dizzy, as I sometimes do with a migraine, but I didn’t have head pain. Could this be vestibular migraine?
Dr. Grosberg: Many people with migraine experience dizziness or a lack of balance in the midst of their headaches—this is termed vestibular migraine (also referred to as migraine-associated vertigo). These symptoms can occur before or during the headache, or even without any head pain. Vertigo can occur without any outside trigger, or it can be set off by a change in head position. The diagnosis can be confusing, as it may resemble or actually be another disorder happening coincidentally.
Dr. Rajneesh: The electrochemical dysregulation of migraine can start at different locations in the brain, so you can have different manifestations. Vestibular migraine starts in the brain stem and affects mostly balance, which can make people feel dizzy or woozy. You need to get this variation checked out, because these symptoms can be signs of other conditions.
When I have a migraine attack, the slightest touch, even brushing my hair, feels painful. Why is that, and what can I do about it?
Dr. Grosberg: This is an example of allodynia, the experience of pain from a stimulus that is normally not painful—combing or pulling your hair back, shaving, wearing eyeglasses, taking a shower, resting your head on a pillow, or exposing your skin to a hot or cold stimulus. The presence of allodynia has implications for both treatment and migraine prognosis. Triptans are often less effective when taken during a migraine attack after allodynia has developed; that’s why it’s important to treat acute attacks before allodynia appears. In addition, allodynia is a risk factor for progression to worse headaches. If allodynia occurs often, talk to your doctor about migraine prevention medication.
Dr. Rajneesh: With allodynia, the brain’s signals start registering touch as pain, especially around the head. Allodynia can keep the cycle of migraine alive through kindling—keeping the abnormal activity alive and preventing the migraine from subsiding. What can help is changing the stimulation or pressure—by undoing a ponytail, taking off a headband, or repositioning a mask or hijab.
Brian Grosberg, M.D., is director of the Hartford HealthCare Headache Center and a professor of neurology at the University of Connecticut School of Medicine. Kiran Rajneesh, M.D., is director of the neurological pain division at the Ohio State University Wexner Medical Center in Columbus.