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Ask Stanford Med: Director of Stanford Headache Clinic taking questions on headache disorders

Ask Stanford Med: Director of Stanford Headache Clinic taking questions on headache disorders

Headaches are the most common form of pain. The condition affects an estimated 60 million Americans and accounts for $30 billion in lost worker productivity. Migraines, which cause pulsating or throbbing pain in the head lasting four to 72 hours, affect roughly 12 percent of Americans and more commonly occur in women than men.

While common treatments range from popping over-the-counter pain pills to lying in a dark room with an ice pack strapped to your head, Robert Cowan, MD, director of the Stanford Headache Clinic, will tell you that managing headache disorders goes beyond finding the right remedy and involves determining a proper diagnosis and developing a comprehensive treatment plan. And he should know: Cowan has suffered migraines his whole life. He understands that the condition can “become a footnote, or it can ruin your life.”

At the Stanford clinic, Cowan and colleagues offer a treatment approach that focuses on prevention and integrates medical, physical, psychological and complementary medicine. A nationally renowned leader in headache care, Cowan also serves as chair of the refractory headache section and in-office education section for the American Headache Society, and he is president of the Headache Cooperative of the Pacific.

We’ve asked Cowan to respond to your questions about headache disorders, recent improvements in managing them, and the use of a multifaceted approach to treating symptoms. Questions can be submitted to Cowan by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Friday (March 8) at 5 PM Pacific Time.

When submitting questions, please abide by the following ground rules:

  • Stay on topic
  • Be respectful to the person answering your questions
  • Be respectful to one another in submitting questions
  • Do not monopolize the conversation or post the same question repeatedly
  • Kindly ignore disrespectful or off topic comments
  • Know that Twitter handles and/or names may be used in the responses

Cowan will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: Managing headache disorders during the holidays and New Stanford headache clinic taking an interdisciplinary approach to brain pain
Photo by Diamond Farah

87 Responses to “ Ask Stanford Med: Director of Stanford Headache Clinic taking questions on headache disorders ”

  1. Dina Says:

    I’ve had headaches since I was in second grade and now I am 20. It usually hurts above my eye and its strength varies everytime. It’s very normal for me to have a headache and I always carry with my iboprufen in my bag and I have it at least 4 times a week. sometimes it’s like a pulse, sometimes it’s like weight on my eye. it definitely affects my ability to study or when i can study. do you have any ideas to what it could be. i’ve done some MRIs when I was younger and nothing came out.

  2. Erin Digitale Says:

    My mom found relief from her chronic migraines with acupuncture. I’m wondering if any research has been done to show how acupuncture or acupressure techniques prevent migraines. What do we know about the mechanism? Thanks.

  3. J Says:

    I have been having headaches/migraines since what i can recall 6-7 years ago occurring at least 2x a month. For the past month I have noticed that I have been getting this multiple times a week, to the point where I cannot concentrate with my studies. I have a Doctors appointment later this month and feel like they are simply going to prescribe me medications. I would rather have the doctor fully evaluate me before concluding that medications is the “cure” do I have the right to request further test?

  4. Dean Says:

    How concerned should people be about migraines as a precursor to strokes?

  5. L Says:

    I have been diagnosed w/ migraines that come in clusters (but cluster headaches have been ruled out). Melatonin in high doses seems to quell them and kick them out of the cluster period. Is there a genetic component to this type of migraine?

  6. claro recta Says:

    We r from Hawaii and my daughter referred to Stanford for Gasroparesis, which symptoms are vomiting, nausea, chronic abdominal pain and at the same time unbearable headache..She doesn’t like lighted room, smells of any food or perfume. Until now, for 3 years she has been bothered by her migraine, what’s the best meds for it aside from narcotic pain meds… regular pain meds are not working..Please give some tips

  7. shagun Says:

    I am 19. I m having migrain from last 2-3 yrs .. I heard in migrain only a part of our head pains but my head pains fully, i feel like dying , i dont like to eat anything n the worse thing from 24hrs my head pains for 9-10 hrs everyday :(

  8. Kimberly Flick Says:

    Doctor, during each migraine attack, I have the fear of an aneurysm occurring due to the intensity of the pain. No one in my family has ever had an aneurysm however, we do have a genetic predisposition to migraines. How great is the chance of an aneurysm? Is this something that I really should put out of my mind?

    Thank you!

  9. Jamie Says:

    I have been getting migraines since the 5th grade. I also have many food allergies/in-tolerances that seem to trigger them too. I also have a PFO (Patent Foramen Ovale) in my heart. From my understanding, this is a birth defect? I wonder if that could be causing the migraines also. I heard that having this “hole in the heart” has been known to. What are your thoughts on this? Thanks

  10. Valerie Says:

    I suffer with chronic migraines. Why, on days when I’m relatively headache free, do I always feel so run down, fatigued and have a general sense of not feeling well?

  11. Debbie Leong-Childs Says:

    My daughter gets migraines pretty regularly – about monthly with menses or when she’s out in the sun and heat. Are there foods or diets that could be helpful? I love the concept of “prevention and integrat[ion of] medical, physical, psychological and complementary medicine.” What complementary and physical treatments work best?

  12. denise flanagan Says:

    Ive had migraine for 30 years now also had a stroke 11 years ago at the age of 31 after having a migraine every day for about 6 weeks , i started getting daily chronic migraine 4 years ago and became extremely photophobic at the same time to the point that i only leave the house a couple of times a month and stay in the car because the light stings my eyes and i get pain in them and end uo with a headache or migraine, after having some relief of migraines from nerve blocks ive found my photophobia no better could you recommend glasses i could use for this , ive tried sunglasses transition glasses and a green tint but none have helpedsorry its so long but i wanted to give you a bit of my history thankyou.

  13. Tori Says:

    I have been diagnosed with Vestibular migraines. Every month about ovulation time I would have a migraine and started taking magnesium to help them. I have had dizzy spells a few times but this past summer it was a daily occurance. After going to an ENT, she was able to help 90%. I am in perimenopause and believe hormones, stress and anxiety is causing some breakthrough dizziness. I am on 125 mg of nortriptyline. The ENT wants to wean me off of them in a few months. Should I continue the meds or will I be able to wean off of them?

  14. Liz Says:

    After a two-year course of topiramate at lower dosages, my neurologist leveled my dosage off at 400 mg./day. I have been at that level for about eight months, and the only negative side effect has been short-term memory loss. My doctor has implied that he thinks it is a high dose and that he’d like to lower the dosage, but I am reluctant to do so because I am doing much better (along with Botox shots every three months, as well as triptans for extreme episodes). How long have you ever kept a patient on topiramate, and under what circumstances would you consider taking a patient off that drug?

  15. Enza Maria Says:

    I was diagnosed by a pediatric neurologist at 4 – today I’m 37. I suffer with migraines that are dibilitatating . Besides the excruciating pain on one side of my head (changes), I am also light, sound & smell sensitive along with with nauseous. I’ve been on all the beta blockers, triptans, antidepressants, anti seizure meds, all kinds of mind altering medication. I have also tried Botox, Spheopalatine Ganglion blocks, trigger point injections. I take naproxen, zofran & toradol injections as abortives, which no longer work! I live in Buffalo, NY & have traveled as far as The Michigan Headache Clinic in hopes for relief. My current neurologist told me last week that there is nothing more that they can do for me. My husband & I thought that seeing an allergist might be a good idea since I have never seen one before. I have asked my neurologist about this about 6 months ago and she shot it down saying that not many people that suffer from migraines find relief from an allergist! Any suggestions or help is so greatly appreciated!

  16. Laura Says:

    Is it unusual when having a migraine to feel numbness on the opposite side of the face and arm? What causes this?

  17. Kim Says:

    I have suffered severe migraines my entire adult life,(now age 50) and have multiple identified triggers including some classics like chocolate and wine but quite by accident I found out when removing dairy from my diet I noticed a huge improvement. As a routine, do you recommend that migraine patients get tested for food allergies? No Dr. has ever recommended this to me. Thank you.

  18. Eileen Says:

    I’ve been suffering from chronic headaches since I got spinal meningitis 32 years ago. All the neurologists I’ve seen treat the headaches like they would migraines. None of the treatments I have tried have helped me. Has been any research on chronic headache resulting from meningitis and are there any different treatments I should be trying?

  19. Kim Says:

    I have an old head injury, dent in my skull, from when I was a kid (9 years old). I’m now 46. Recently I have had migraines specifically pin pointed over the dent. Should I be concerned about this?

  20. Larissa Says:

    I have suffered from chronic migraine headaches, without aura, for the last 7 years. My attacks typically last 3-5 days, and are helped at first with triptans but always outlast the triptans (I don’t overuse them). Because my attacks are so long, they technically fit into the classification of status migraine – but it would be a lot to go the ER every time I had one. How worried should I be about the risk of stroke with these attacks?

  21. Karla Says:

    Hello and thank you for your time today. I am a 47-yr-old female diagnosed with Chronic Migraine Variant (basilar), Chronic Daily Headache, Occipital Neuralgia, Cervicalgia, Syncope, and Migraine Associated Vertigo. (I also have Endolymphatic Hydrops with nausea but no hearing loss.) Vertigo continues to be a severe problem, with and without migraine. It seems to flare 5 or 6 times a year. The last flare kept me bedridden for 4 weeks, crawling to the bathroom. I was treated with meclizine, diazepam and trans-derm scopolamine patches. Vestibular rehab (tried twice) severely exacerbates migraines and cervicalgia. Do you have any thoughts or suggestions? Thanks again.

  22. Anne Says:

    When migraines are chronic, do even the less intense ones count as migraine?
    I get several weekly, but some of them I consider “relatively” tolerable although they come with some sensitivity to light and sound. If some of these are not “over the top” how should they be treated?

  23. vemilytran Says:

    I get headaches only when exposed to perfumes and colognes or similar products and when in bright sunlight without sun glasses for some time. I can avoid both the best I can, but I would like to know why those two things give me headaches. I am otherwise fairly headache free, with rare occasions on which I understand why I have a headache, for example, if I have not eaten all day, or due to an illness.

  24. Mother Olga Krum Says:

    I’ve had migraines since 1971 and chronic migraines for about 10-12 years. I been unable to tolerate the preventive meds I’ve tried, or else they just don’t work. Triptans don’t help much and give me severe gastric problems. Muscle relaxants don’t help, either. And now I can’t even take Tramadol (gastric, again). When I go on Medicare this summer, I plan to return to the clinic in Ojai to look into Botox and/or nerve blocks. Do you have any other suggestions? Thank you!!

  25. Heather Says:

    I have chronic headaches and migraines and was told by many people that my headaches would likely improve during pregnancy. Now that I’m pregnant I’ve discovered that the opposite is true, at least for me. They’re much worse; I have at least one migraine, usually more, every week plus almost daily headaches. I take Tylenol and Fioricet as needed, probably too much although I try my best to limit it. I’m managing the pain okay, but I’m wondering if hormones are playing such a big role then should I consider getting a hysterectomy once I’m done having kids? Head pain is awful and I’d be more than willing to have surgery if it means less pain. Plus I’ve tried just about everything else (at least everything I can afford, and that’s legal)!

    Thanks for taking time to answer questions about headache disorders!

  26. Molly Says:

    Since I was about 10 years old, I’ve been getting headaches pretty much everyday (I’m 22 now). In fact, it’s rare for me NOT to get a headache. I’ve gone to my primary physician and she thought that perhaps it had something to do with my eyesight since I have sensitivity to light during my headaches, but the eye doctor didn’t find anything wrong with my vision. I went to acupuncture about 6 months ago to treat it and it went away for a very long time, but now it’s been returning and its WORSE – the worst it’s ever been. The other day I literally couldn’t sleep because my head hurt so much. I try not to take medication so easily since the headaches are so common, but I feel like I am running out of options. I wake up with a headache every other day now and its so debilitating. As soon as it hurts, it hurts the whole day and ruins everything. Its like a throbbing sinus pain that moves above my eyebrows to my temples and sometimes to the top of my head. Showering doesn’t help and sleep usually does, but now not so much. I get a lot of muscle tension from stress so I’m assuming it has something to do with stress (maybe the stress just results in worse headaches). I’m not sure if its a headache or a migraine or what the difference is, but what I would like to know is what I can do to help make this go away. It can’t be normal that it hurts everyday and that it hurts so badly. What do you think is going on and what should I do? Thank you for your time – I truly appreciate it!

  27. Nikki Says:

    I have chronic migraines with aura. Persistent migraine aura and migraine associated vertigo. I get quite a few status migraines which i know are potentially dangerous but I rarely go to the ER for because they simply give me a shot of toradol which does nothing and causes some unpleasant side effects. However, I had one status migraine that on about day four I woke up and half my right hand was numb. Not a usual aura for me although I sometimes get a cool facial numbness or tingling in my face or hands. This was deeper, it was from pinkie to middle finger and down to wrist. Over the next few days it spread across the hand slowly. And by the time it reached the thumb it had started on the other hand also at the pinkie down to wrist. The fact that it was both sides of the body worried me, because that was un-aura like… the fact it then lasted beyond the migraine worried me further. My doctor suggested it was a persistent migraine aura, which was absurd but he said to wait till I saw my neuro. My neuro said it was nerve damage caused by the migraine… which I had never heard of. By then the numbness was like a loss of sensation, a loss of the ability to feel texture, and I felt pickling pain when touching things, and pain instead of cold and heat. So damage was clearly done, but the migraine could have been coincidental given I get them essentially daily. Is it possible to get nerve damage from a migraine? And could this potentially happen during any status migraine? If so should I go to the ER? They don’t seem to offer any way to abort a status migraine so I don’t see the benefit but I worry about this nerve damage spreading on my left hand or other peripheral nerves.

  28. Julie S Says:

    Why Migraines become chronic when you avoid all your triggers? I have had Migraines for over 25 years. I am now 50 years old and in 2010 my migraines w/aura changed from periodic to daily chronic Migraines. I have been very strict on my diet avoiding all my triggers food wise. I have become overly sensitive to smell, light and sound the past couple of years to the point I’ve become almost a recluse to avoid running into people or situations that would have any loud noise or smells associated. If I go out to the stores I avoid the soap and candle isle like the plague but still manage to have people pass by me or come in front of me who reek of scented soaps or cologne. I have finally found a headache specialist these past 2 years who has been working non-stop to try to find the correct preventive and abortive meds. I am currently set up to receive a 2nd round of Botox in Mid-April but I am reluctant since the 1st round I had didn’t seem to do anything. I was just recently diagnosed Dec/Jan w/Fibromyalgia so I am on Cymbalta and Lyrica. I was not aware that Migraines and Fibro were comorbid conditions and that one symptom of Fibro was migraines. So were hoping that after being on these Fibro meds it will decrease the frequency of the Migraines. But I have NEVER abused my abortive meds nor taken them longer than prescribed-no more than 3-4 days a week. But my burning question is why after so many years would my Migraines become daily when I’ve done everything to avoid them. Some days I cannot bear to open the curtains and I can be bed-ridden for up to 3 days during 1 episode. I’m so tired of it all and want to be well and have a life-Migraines have robbed me of a normal decent life I once had and I want my life back. It is so depressing to have pain day after day non-stop. My abortives now are Imitrex Stat inj, or I take Sprix nasal spray or I take Migranal nasal spray. My 1st line abortive is Fioricet. I take as preventive the Cymbalta, Lyrica and Verampamil. I was on Topomax for a long time and was just recently taken off to be able to take Lyrica, but the Topomax didn’t seem to help much. I tried Depakote and had problems w/the side effects-hair loss and rapid weight gain. I’m so exhausted daily I’m dragging my butt. I try to exercise and when I do I’m even more exhausted and the muscle spasms from the Fibro flare up. Any suggestions?

  29. Becky miller Says:

    I have a two part question. First my main symptom that I’m getting a migraine is that my hair hurts. I know it sounds crazy cause how can your hair hurt! I f I touch or brush my hair and if feels like I’m pressing on a bruise, then I know within the hour I will have a full blown migraine. Is this a normal symptom? My neurologist asked me how I knew when I was getting a headache and I told him that and he acted like I was crazy! He kind of acted like it was all in my head., which I know it’s not! 
       Second is there are a lot of food triggers I have when it comes to migraines. My main ones are sucralose, saccharin, msg and maltodextrin. The problem is they are in almost everything made now days!  Even medicine! How do you get around not consuming them? I can’t even take my high blood pressure medicine because they have preservatives in them that cause migraines, same goes for the typical migraine treatments out there. I have to take esgic three times a day. I feel it’s getting to the point where I can’t eat anything! And now they are saying they will be adding sucralose to milk! I’m desperate for any advice on how to avoid triggers to my migraines!

  30. Claudia Says:


    I have had chronic migraines for the past 10 years. I take 35 mg of Nortriptyline daily and Maxsalt when I have a migraine – which is now more than 4 times a month.
    Lately I have been noticing that my sight is getting worse – I see double images and can’t focus on a single image. I am also getting more sensitive to light. My eye doctor said that Nortriptyline can cause this kind of eye problems.
    Have you heard of that before? If that is correct, is it worth to continue taking Nortriptyline since my headaches continuing occurring frequently with the medication?

  31. Jamie Says:

    I used to have at least three bad headaches and one migraine a month, which would disrupt work and social plans. I ended up getting my blood drawn to test food sensitivities and it came back that some of my favorite foods were hard for my body to process. Based on the results I avoided eggs, dairy, wheat, tomato, and other foods for six months and reintroduced one food item back in at a time. If I didn’t get a reaction from that food item, then I would keep eating it. Overall my headaches & migraines now rarely happen.

    Have you heard of others being treated for chronic headaches and migraines w/ diet? Why is this not mentioned more frequently?

  32. Carolyn B Says:

    What are your thoughts on surgery for migraine? I have been diagnosed with chronic migraine. I take daily preventatives and imitrex, as prescribed, and I follow a healthy lifestyle routine, with daily exercise. My migraines are still very disruptive to my life. Dr. Guyuron at UH in Cleveland performs a surgery I’m considering.

  33. Ann Says:

    Do migraines have any correlation with cardiovascular disease or diabetes?


  34. diane minton Says:

    I have had migraines for the last 4 yrs. I began having them when working in Retail, then went to an office job and they got terribly worse. By the time I got the idea of what was happening to me they had progressed into aura and it was torture. Now after taking seroquel for mania with bipolar I am hardly having them at all. My biggest trigger is fluorescent lighting and I wear sunglasses to the MKT or any other place we go that might have lights similar. I just wrote two articles this week, I expounded on the great things seroqyel does to stop migraines and panic attacks, then yesterday I got one, I took my vistaril and now its gone. Why would I get the headache right after writing about not having them? Thank God for Modern Meds and thanks!

  35. Nancy Says:

    Like a few people who previously commented, I also have chronic migraines and have a concern on my susceptibility to stroke. Additionally, I had spinal meningitis as a child and am lucky to be alive, but I still can’t help but think that there might be a correlation to my migraines. I would look forward to a study or article on a study addressing these two items.

    If a person moves from episodic to chronic migraine and treatments eventually get them back to episodic, is it possible a) to get rid of migraines completely and b)are they likely to return to chronic again in the future?

    Also, I am trying to reincorporate exercise into my week after being pretty much a lump for months due to chronic migraine. I still have chronic migraine, but am trying to push on through them and am working with a wonderful neurologist. However, when I find that exercise, esp. if my head is lowered, that I get a migraine. Bright lights and loud music of gyms doesn’t help either. So if exercise is supposed to help prevent migraines, but causes one instead what do you recommend?

    I was once shown a bell curve by a well known neurologist that indicated that women in their 40s are at the top of the bell curve but as they move into menopause, they find that migraines reduce. I had a hysterectomy in my 30s and went on bio-identical hormones. I tried eliminating them completely to see if it helped, but now my ob/gyn recommends estrogen as I have osteopenia in my spine. Are there any studies or recommendations for women migrainers on hormone replacement therapy?

    Thanks for any advice.

  36. Nilofer Says:

    I started getting migraines starting at age 21. Before that, I had headaches, but after age 21, I got full-on migraines, often with nausea. After learing that many people’s migraines were triggered by gluten, I began cutting it out of my diet. I wasn’t very strict, and so still got some migraines, now that I am very strict, I get far, far fewer (I used to get up to 14 headache-days per month. Are neurologists going to start addressing gluten sensitivity/celiac? The gluten-migraine connection was first made in 1966.

  37. Nilofer Says:

    Another topic, can you comment on the ketogenic diet used by John’s Hopkins to treat epilepsy? Apparently, some people with migraines report relief while using the same diet. One of my neurologists described migraines as mini-seizures. Can you elaborate?

  38. Melanie Symonds Says:

    Hello Dr. Cowan,

    Thanks for the opportunity to ask a question that no one has been able to answer for me as yet.

    For the past two years I have been getting a migraine every 7-10 days. I have not been able to attribute it to any trigger that I can identify. My overall sense is that some substance (chemical/hormone/enzyme?) in my body is slowly increasing until it reaches a saturation or tipping point which triggers the migraine. When the migraine is over 1-3 days later, the cycle starts again. Any thoughts on what the substance(s) could be? Or any other ideas on what could be causing this pattern?

    I’m now 50, peri-menopausal, my menstrual cycle is very irregular/skipping months at this point, though I used to have regular menstrual migraines in the past as well as environmentally and food trigger migraines. My migraine management regimen currently includes: Cymbalta, daily Vivelle Dot & Oral Progesterone, Omega-3, CoQ10, Magnesium, Calcium w/ D3, B Complex w/ extra B6 & B12.

    Many thanks for your time!

  39. Leslie Coutsouridis Says:

    Dear Doctor Cowan,
    I’ve had migraines for 32 years. Now, being post-menopausal,I’ve had migraine daily since October 2011. I’ve tried every class of meds available, botox, and three hospitalizations out of my state. I’m currently on mexiletine which is not stopping the constant pain but mostly keeping me from the E.R..Any new drugs or ideas for me?

  40. Jane O Says:

    I have been told by my neuro that I have white patches on my MRI from severe migraines in the past . My migraines have been w me since age 8. I am now 63 & they are chronic. My question is if I do not take my imitrex because I cannot take it more than 2/ wk & my migraine becomes severe x3 days, what damage can occur long term to my brain? I don’t want rebound from overuse of imitrex but if I am damaging my brain by toughing it out, which is worse?

  41. Rose vrabel Says:

    can someone with ocular migraines take birthcontrol with estrogen in? Or should they take the pill with only progesterone?

  42. Julie R Says:

    My migraines are monthly, just preceding my cycle, and also seem to occur according to barometric changes. I treat them with OTC meds and Sumatriptan, when necessary. Should I also consider acupuncture (given that it is seldom covered by health insurance)? My doctor just suggested I try daily supplements of magnesium, CoQ10, and riboflavin. Given the expense, is that an appropriate method for prevention? (I’m also soy intolerant, and noticed that many of those supplements include a form of soy in the ingredients, or are much more expensive without it.) Thank you!

  43. Bubba Says:

    My migraines started in 1997, not sure, but possibly from a roller-blade accident. About 7 years ago I started getting sharp stabbing pains that just about knock me down, last anywhere from 20 seconds to 20 minutes then just as suddenly go away. This is the point I have to wait to be sure that it is not a migraine attack to not waste a Sumatriptan nasal spray. They have lasted longer and yes, I have wasted medication. My question; is it possible to suffer both migraines and cluster headaches. One other problem is with daylight savings time changes and time zone travel triggering migraines. It is hard to prepare for and each change triggers a series of attacks. Does anyone else go through this? Thank you!

  44. Alex M Says:

    I’m a 36-year-old female, with a life-long history of bad headaches, but only last October did the severe and daily migraines start and not let up. My neurologist has had me on 2 rounds of prednisone (no effect) amitriptyline (currently, after an awful reaction to nortriptyline), Migrelief, butterbur, and magnesium (currently), then recently adding topomax. All this in addition to the various abortive medications I’ve had to take for the excruciating breakthrough migraines (vicotin, imitrex, tramodol, the last of which caused dry mouth, insomnia, racing heart)

    My main question is related to the fact that my poor husband is at his wit’s end, not only watching me go through this every day for nearly 5 months and feeling helpless, but he’s feeling like my neurologist must not be “doing his job” because surely any doctor worth his or her salt would have been able to make more progress by now, and is pushing me to switch neurologists, even though mine lists ‘migraine’ as one of his specialties, and I know that these preventative meds can take months to really start working. So, sorry for the long question, but do you have any advice to pass on to the spouses and partners of those in chronic pain, both in terms of general support, and in terms of how those of us in pain don’t get stuck in the middle of our loved ones and defending our doctors, when we might even have the same questions?

    Second quick question: how can patients know or suspect medication overuse (“rebound” headache”) and when should we just suffer through it, since I know that once established it is especially difficult to get rid of? What meds are most susceptible to them? Are there any that are relatively safe from that risk?

    Looking forward to a pain-free day, someday, somehow…

  45. S Vegas Says:

    Hello, my BURNING question: What is the most recent and successful treatment for hemiplegic migraines? Personal current treatment-no triptans of coarse, Depo Provera, Topamax, Fioricet and Effexor. Have tried Verapamil and was migraine free for a week but then broke out in a severe drug rash. Desperate for answers. Thank you for your attention.

  46. Patricia F Says:

    I am 61 years old and had my first migraine 15 1/2 years ago, and have been unsuccessful in finding triggers that I could avoid to prevent them. I take a small dose 2.5 mg. of Bisoprolol and 30 mg. Amitriptyline nightly (larger doses were no more helpful). I normally take 12 Imitrex over 30 days for migraines and rarely had more than a few consecutive day that I wasn’t fighting a migraine, had one, or getting over one.

    About 8 months ago I started having a shot of Sambuca in the evening with my husband.(I usually avoid alcohol because it usually causes a headache). It didn’t seem to have that effect, in fact, I later noticed that I was more likely to wake up with a migraine when I didn’t have the Sambuca, so I continued the practice not thinking anymore about it.

    Then after six or seven months I realized I was taking only about six Imitrex a month, and suffering much less between headaches.

    As Sambuca is made from Elderberry, I started taking Elderberry (Berries and Flower) capsules (575 mg) twice a day along with the Sambuca each evening. I am now down to 3 or 4 Imitrex a month. Now, I feel the migraine coming, I take an Imitrex and I am over it and feel fine.

    Has there been any research to sugguest that Elderberry works to prevent migraines? Whether there is medical basis for the improvement or not, I am enjoying life so much now, I’m afraid to stop. Am I crazy?

  47. Becky Says:

    I would like to know what the effects of long-term use of drugs such as Topapmax and Imitrex are. I take 800mg of Topamax daily and in any given week can have 4-6 migraines. Then they go away for 2 weeks only to return for another round. It has become a way of life. I have been using the Imitrex since 1995 and the Topamax since 1999, however, the dosage was only recently increased to the 800mg in the last year.

  48. Tanya Says:

    I am just wondering if migraines were triggered from birth a child and worsened after a second child (lasting several months at a time, with little to no relief, despite all conventional and non conventional methods) if there is any hope for any reprieve in the future. I keep hearing that things should settle down in the next couple of years. But I am not sure how much longer I can wait.

  49. MsMigraine Says:


  50. Heidi Ray Says:

    I have been getting Botox injections every 3 months since November 2011. I have had constant and significant muscle weakness since May 2012. I have had numerous tests, including complete bloodwork and and EMG. My physicians say there is little likelihood that the Botox could be causing all-over muscle weakness for this period of time. What is your opinion on whether the Botox could be causing my muscle weakness? Thank you.

  51. Anne Says:

    I’m 71 and have been diagnosed with non-diabetic neuropathy, depression, and migraines. Other than that I’m pretty youthful for my age. Are the three linked at all? On migraine days my depression is much worse and I have trouble sleeping due to increased pain from the neuropathy in my feet. One of the worst symptoms of my migraines is an occassional piercing pain into my temple like an ice pick. I rate it a 10 and fortunately it only lasts for about 30 seconds each time it happens. The rest of the time the migraine is a constant throbbing mess. The worst ones are about an 8 and the usual ones I’d rate a 5. Happily I actually have an appointment with you in a few weeks and am very much looking forward to it. Although I’m sorry you suffer from migraines it will be the first time I’ve seen a medical professional who knows them first hand.

  52. Angelique Says:

    Do migraines cause permanent damage to your brain?

  53. Nilofer Says:

    Could you please provide information regarding the latest genetic studies identifying alleles associated with migraines? Both with and without aura. Thanks so much for your input, this is difficult information to get.

  54. Nancy Says:

    My 15 year old son has been suffering from 1-2 week long migraines since the onset of puberty. The migraines usually begin in his sleep so Axert, his abortive triptan, does not work. He took Topamax for a year and is now taking Amitriptyline but neither have prevented the migraines from happening 2-3 times a month. Why do his migraines usually begin in his sleep and would a sleep study teach us something that could help him?

    Thank you for this opportunity to ask you questions.

  55. Joni Boardman Says:

    Dr. Cowan,
    I know you always told me not to take migraine meds if the headache felt different or if I wasn’t sure it was a migraine. My migraines have been changing some with age. This past week I had a severe headache, but unlike my usual migraines that are one sided around my eye and temple area, this one was from my forehead to the top and back of my head bilateral. It was worrisome since the symptoms were quite different, thought my flu symptoms were returning. I suffered through without any meds. The following day it turned into a typical migraine with dizziness. I then took my Relpax. Is it better to take Relpax even if you are unsure if it is a migraine than to suffer the severe pain? Thank you

  56. Gayle Says:

    Is prolotherapy effective for someone with a 18-year history of chronic refractory migraine? Having tried Botox, acupuncture and occipital nerve block more than once (and tons of preventive meds) with no effect, a friend is insisting a male co-worker was “cured” of his migraines of 6 years with prolotherapy. I’m quite skeptical because I have a broad spectrum of triggers and prolotherapy seems to address only muscular-related pain, but would appreciate your input. Thank you.

  57. Barbetta Says:

    With all the medications out there for migraines I was put on sumatriptan shots now the doctors want to take me off of them at age 60 which is 3 years from now. What medications are out there like this medication that I am taking? I know that my migraines cannot be diagnosed because I wake up with them. But I am looking for a medication that provides the relief that I get from the shots. Been on these shots since they came out and I don’t build up at tolerance to them like I did with other drugs that were given to me for my migraines. Before these came out I took about everything and when these came out that took that headache from being 3 to 4 days down to just 4 hrs. Settles the stomach takes away the pain in my neck does everything the imitrex shots. What is out there that isn’t an anti-depressant, seizure meds, high blood pressure meds? Thank you!

  58. Nicole Says:

    I’ve had migraines, progressing to chronic migraines, for several years. Recently, after upping my Gabapentin dosage to 1800 m a day (from 1500 mg), I began experiencing daily, mild headaches as well as a sudden onset of intense pressure at random times during the day. I seem to have woken up with a low-grade headache everyday for more than 2 weeks now–which is new for me. The pressure I’m experiencing is intense–to the point I need to “pop”/reduce the pressure in my ears sometimes. It is often accompanied with intense pain, comes in waves and can be located not only behind my ears, but sometimes across my eyes and sometimes in my neck. I’ve noticed that these episodes are often accompanied with nausea, a couple of times with vomiting, and my eyes will sometimes become bloodshot and my nose will sometimes run (though I do not have a cold or sinus infection). In the past, my migraines were not generally accompanied with nausea or vomiting. In addition, I’m also still having severe migraines 2-3 times a week. Could this be a medication side effect? Progression of migraines? Something more serious?

  59. Patricia Says:

    I have been suffering from intractable Chronic migraine for six years. I am 39, and the migranes became constant once I had a hysterectomy to remove massive endometriosis on both ovaries, putting me into surgical menopause at age 36. I also suffer from angioedema, facial pain, and severe allergies, have hypothyroidism, and am disabled after a brainstem decompression that has left my C-spine fused to my skull base.

    My question is as follows: should I see an endocrinologist? Taking large quantities of antihistamines, along with thyroid, and estrogen all seem to play SOME role in my migraine escalation. I realize I am a very complex case. I am also severely allergic to opiods, so am experiencing no relief from the relentless headaches that only occur on the left side of my head. The complexity of my case scares most doctors away, or makes them only want to address a small portion of my issues. I can’t but help feel there are *some* connecting threads that might help me unravel the mystery. Could you recommend how I might find a specialist who might be able to make such connections? (say, endocrinologist, immunologist, or a neurologist with a connection to these fields). Any help at all, or suggestions, are greatly appreciated.

  60. Kristina Says:

    I am wanting to know about different migraine treatments. First, do Botox injections really help? I have read conflicting articles on the injections. Second I would like to know if acupuncture helps and how it works.

  61. layla Says:

    My neurologist prescribed a herbal supplement called “petadolex” to treat my intense migraines. I’m 22 years old, I’m extremely active, and I have a pretty clean diet. These migraines were the worst ever. I wore sunglasses everywhere, I preferred staying in dark rooms, and i would get these migraines up to 7 times a day! I took 3 capsules a day and by two weeks my migraines were gone! The supplement is expensive (50 capsules cost $45), but its worth it.

  62. Jandy Says:

    Dr. Cowan, thank you so much for giving your time to answer our questions. I’ve struggled with daily headaches since age 10. I’m now 32. I was diagnosed with Fibromyalgia at age 19. It has only been the last 2 years that I have struggled with chronic migraines. Prior to that, my headaches have seemed to be more tension-type. I cannot remember a day without a headache. Over the last 2 years, I have been getting migraines at an increasing volume. I am on topamax for prevention. I have tried Imitrex, Maxalt, and Treximet: none of which have seemed to help. So far I have been treated by my family physician and rheumatologist.Would you recommend seeing a migraine specialist? I live in PA and could travel to a specialist. Any advice would be appreciated. I also have 4 family members who struggle with migraines.

  63. Michelle Throneburg Says:

    My son is 16 and has been diagnosed with migraines since he was 2 1/2 yrs old. The frequency and duration have gotten worse as he has gotten older. He has intractable migraines and has failed at least 15 preventive medicines throughout the years. Currently he is on 1000 mg divalproex 50 mg amitriptyline hcl and zofran for nausea. he only takes 3 naperson a week and has been taken off of his imitrex. Right now he is in the middle of a 2 month migraine and is in the hospital having DHE treatment. He had his 1st Botox treatment on feb 20th but so far has seen no benefit from it. He has a 504 and is on intermittent homebound education. He has only been to school 5 times since mid Jan. Do you have any suggestions on how we should proceed?

  64. Mrs Migraine Says:

    I have suffered from migraines all my life. It runs in the family – father, maternal grandmother, aunts, uncles, cousins, etc. Also father and uncles had cluster headaches in addition to migraines. Since 75% of migraines are to females and 90% of cluster sufferers are male, I always thought there was a hormonal connection and when my cousin had a complete hysterectomy several years ago, her migraines disappeared and have never returned. That gave me hope that when I go through menopause mine would disappear, but reading these other comments, many of the sufferers have gotten worse after. At age 51, this is distressing to me. My migraines have gotten worse now, but I figured that was because I’m beginning menopause. If they get worse after menopause….well, that’s not an option. Taking topamax 150 mg per day and nadolol 40 mg twice per day to prevent also CoQ10, B-2, magnesium 400 mcg to prevent and Imitrex 50 mg to stop headache or Frova if they won’t stop for days. I was honestly looking forward to menopause to get rid of the migraines. If it makes them worse…any suggestions???

  65. kara Says:

    Like others I have a pain over an eye, extending up over forehead and back across head. I was tested for arteritis (negative result) but suspect it has something to do with tree pollens at this time of year. Had occurrences same time last year. Antihistamine helps to reduce pain. This year, when the pain got stronger, I tried a triptan, and it went away. If this is pollen related, is there an explanation as to what is going on, or another way to prevent during this time of year? I otherwise use triptans for migraines associated with gluten and other food intolerances.

  66. Kathy Says:

    Hi and thank you for fielding all these questions. I have asked my neurologist/headache specialist and not gotten a defined answer, so this may seem like a silly question. Basically when you are having a migraine and you have taken all the meds you are supposed to – when do you know to go get more help at the ER/Urgent care and when do you wait it out? I am on a migraine program and take 150mg Topamax, atenolol 75 mg, 50 xanex 3-4 times a day as needed & wellbutrin 450mg daily preventatives. (I have depression as well) For my actual migraines – Treximet for my 1st line/Frova if needed in 2 hours but was just changed to the Imitrex shot. I have lortab if needed, and ambien to sleep if it is really bad, and phenigen for nausea. My question is when do I know I should go to the ER/Urgent Care? You can only take some meds so many times a week, and I don’t want to be popping the pain and sleep meds until I can take another shot. I was told, “Well you will know when you should go.” Um, no I don’t trust myself to make that decision, that is why I asked. I don’t want to abuse the meds, or create a rebound situation, or be in a migraine longer than I have to that needs more help to get rid of. But some people have them 12 hours, some 3 days, and both are “normal” for migraines because each one is different. I have had both short and longer ones, those are the ones I am asking about, so far, I wait it out, take more pain meds and then another round of migraine meds when I can. I have gone to the Urgent care a couple times though, but only because the 2nd round didn’t work. Any suggestions on how to help determine when to make that call? Thanks for your time.

  67. Debra Says:

    I have 2 questions actually:

    1.Do you feel that self-acupressure is an effective tool in dealing with headaches or, perhaps, certain ones in particular?

    2.As we see everyone growing up with technology, you go into a coffee shop and see everyone from toddlers to seniors hunched over laptops, iPads, eReaders, and various players. Are we going to see an alarming trend of individuals with ergonomically-related headaches starting very early on and continuing thoroughout their lives?

  68. Jennifer Brodeur Says:

    I began suffering episodic common migraines about 12 years ago. About 4 years ago, in a stressful job, they became more and more frequent. In an unrelated event, I was sent by my opthamologist for an MRI due to nystagmus, wherein they found lesions that looked like those caused by Multiple Sclerosis. On the day I had the MRI I was also experiencing a migraine, and the twin flares near the front ventricles were obvious. M.S. was ruled out, but in the meantime my migraines became chronic, 1-3 per week, lasting 2-4 days each, which continued until I lost my job. Subsequent MRI’s have shown new lesions with Dawson’s fingers. Can migraines cause these kinds of lesions? Or is there possibly another cause for these lesions that is causing my chronic migraines? Are the lesions a cause for concern? None of my doctors or neurologists seem concerned since M.S. was ruled out, but I am concerned for whatever damage they may be doing. Could they be the cause of any of the numerous medications I am taking?

  69. Becky Says:

    Dr.: I have experienced fewer migraines since menopause, but still have persistent migraines with pressure changes which are frequent in the Intermountain Region. Depending upon the degree of pressure change the migraine can be extreme to the point of losing partial sight on the side of the migraine, nausea, extreme sensitivity to sound and light to the point that I want to unplug the piped in music at the Dr.’s office, and sometimes sensitivity to touch. My issue is that I have encountered doctors who state that I have too many migraines. I only seek help four or five times a year even though I suffer from them six to ten times a month. I have had MRIs and other diagnostics. The result is a finding of migraines. I cannot take the meds such as Frova and others as the brain creates headaches. Is there something else I can do beyond cold packing, certain peppermint rubs, massage, etc. that only occasionally help when the headache gets out of control and lasts for two or more days? Many thanks.

  70. Stacy Ordoyne Says:

    I am a patient at Jefferson Headache Center and see Dr. Silberstein. We are starting a trial soon for the peripheral nerve stimulator to see if this helps! If it I a candidate for having the surgery where the stimulator is implanted? And what are the success rates between the two?

  71. Clemmie King Says:

    A life-long migraineur, I am also now (at age 56)taking three preventatives nightly for mixed hypnic/cluster headaches. Do hypnic headaches ever “go away?” And do you accept new headache patients? If yes, how do we register? Thank you.

  72. Macattack Says:

    I’m a chronic migraineur (24 yrs of migraines, 6 yrs chronic) who is always looking into new options to supplement medications. Have you heard of Nutrition Response Testing as an option. I’ve had a few folks tell me this made all the difference for them, but i can’t find much information/research to support it.

  73. Lorraine Calvert Says:

    I am a 52 year old woman who is going through menopause. During my 30’s and 40’s I suffered migraine about 3 time/week. In the beginning a simple triptan would take care of it and I could go to work the same day as the headache. To help with my frequent migraines I started taking birth control pills on a 3 month cycle, sort of how Yaz works. I ended up with Breast Cancer and 4 Pulmonary Embolisms, both when I was 49. However, I would say that starting about two years ago, when beginning menopause I only would have a migraine when I had a period, which was once every two months or so, making me relatively migraine free. However for the past 3 months I’ve been getting migraine more and more frequently and since I have Fibromyalgia a migraine is no longer a one day event. The headache goes approx 3 hours after taking a triptan. What remains is incredible nausea and a horrible flaring of Fibromyalgia, leaving me unable to do much the next day as well. My hormones have been measured and I am hormonally post menopausal, but I am not completely post menopausal until I haven’t had a period in a year, so I have about 6 months to go. Finally my question is how likely it is that I will stop having migraine all together once I am officially post-menopausal? Also I belong to Kaiser so I’m in no way getting state of the art treatment. Could you suggest some treatments, other than triptans which could be prophylactic? Like botox or nerve blocking. To give you an example of how bad my current treatment is I had botox shots for my migraine and the doctor gave me 27 shots, all in my scalp and forehead. Following I had migraine for 5 days. That came from a doctor in their pain management program! I have again been referred to him for management of both my migraine and fibromyalgia pain. I really need some help, even just your answer so I can show my doctor.
    Thank you very much for reading this very long post.
    Lorraine Calvert

  74. Bret Says:

    Hi Doctor and thank you for time. I’ll try to give you just a brief background history then get to it. Plus just getting back from the infusion center isn’t helping :)

    I’ve had migraines with auras since I can remember. One of my earliest memories is an auditory hallucination watching a cartoon during an aura. Remember thinking the “voices” are back. I’m 41 now the auras and aphasia have progressed to me blacking out sometimes and being unaware of it. Topamax thankfully controls this for most part.

    During childhood I had 3-5 migraines a month. I was hospitalized twice in high school. Disabled 2000-2004 due to 3-5 severe ones a week. Moved from Nashville to Seattle strictly for climate change. Migraines 1-2 a week, controlled by triptans yea, back to work. 2008 triptans slowly stop working. Migraines worsen. May 2009 4-6 severe ones a week. Lost 55K job and upcoming promotion.

    Since then I’ve had nerves burned off my neck for photo and sound sensitivy, sinus surgery, and occipital nerve implant. These have helped a lot but things are still bad. My pain specialist had me on Fentora but I quit taking it for a couple reasons can’t afford it and I started using medical marijuana about a year ago. Pot virgin before then. I’m finding it does give me a lot of relief and lessens the amount of other drugs I have to take even elimanating narcotic completely. My mom and my friends all seem to think it has helped a lot. I don’t smoke it, vaporize or eat it. My infusion visits have gone from once a month down to onec every 3 months now.My concern is marijuana prone to cause the rebound effect? Can’t find much info on it. I look at my headache diary and don’t see any increase in number. When I hit bad spells like winter months but which those are normally worse for me. Is there any way to tell given my history? It does help and I don’t touch it much on good days.

    Also any hope on a new class of drugs to replaces triptans?

    Thank you

  75. karen Says:

    I get migraines from gluten, but also from food additives such as annatto, vannillin, molasses, caramel coloring, and other unknown ingredients. California has asked Pepsi and Coke to change the caramel coloring in their sodas, so I suspect there is some chemical used across these additives in the processing? What happens in our bodies (stomach to brain) that causes the neurological pain of migraines?

  76. Bret Says:

    Hi again. One more question. I’m borderline glaucomcic, my pain specialist who has done most of my surgeries says it is probably due to that my migraines are centered above my optic nerve. Is this common? Or maybe more due to Topamax and some of my other meds? Also how good would the preventative measures be for glaucoma if it is the optic nerve? My ophthalmologist had not heard of this.

    Thanks again.

  77. Janet Jones Says:

    I am 57 and got my first migraine when I was 20. I have had hundreds of prescribed preventatives over the years that failed and inpatient headache treatment in 2004 for 9 days at the diamond headache clinic in Chicago and exactly 1 year ago DHE treatment at eh nevada headache institute by doctor Abraham Nagy. Both failed attempts and still suffering side effects of DHE. in the past few days the aura has chamfered with the migraine and the spots I see are now colors…green smears and silver flashes. I am rally scared and don’t know if this is migraine related…abortive med related or 37 years of migraines…advice please. with respect,
    Janet Jones
    Las Vegas resident for the past 20 years ..moved to Atlanta 7 weeks ago

  78. Sharon K. Says:

    Thank you for taking our questions! I have two:

    1) I have visual aura, including a blank spot in my vision, before migraines. The migraine pain is controlled by medication (the aura is actually helpful for that!) but the aura itself prevents me from reading, driving, and watching TV (as I can’t see a central part of whatever I’m looking at), which prevents me from either working or playing during the aura period. Are there any known ways to stop or shorten the time span of visual aura once started? Are there any studies into treating/stopping/shortening visual migraine aura, apart from trying to prevent migraines more generally?

    2) What is the relationship between migraines and epilepsy? There is a history of both in my family, and I’ve been told that there may be a genetic link. What is the current state of research on migraine-epilepsy links?

  79. Ann Pianetta Says:

    I have had migraines since my son was born 22 years ago. In addition to that I suffered from Bells Palsy just after having him. This has caused my whole right side of my head to hurt when I have a headache/migraine and it even affects my eardrum.

    I now manage my headaches with whole salt (Celtic Sea Salt, 1/4 tsp in 8 oz warm water) and with breathing exercises that help oxygenate my body better. Occasionally I will use 625mg Tylenol (2) and relaxation techniques.

    I was wondering if you have ever heard of these ways or other alternative ways of managing headaches?

  80. Becky Says:

    What do you do when your previous Migraine Specialist retires and you have tried 2 new “top of the line” specialists, who refuse to take your case, because you have already tried all the preventatives and abortives they would recommend with either side effects or no help in reducing pain/frequency with a diagnosis of Refractory severe chronic daily Migraines. Have done 6 rounds of Botox and 3 nerve blocks with no relief. How do you find a Specialist to treat you when they all pretty much say “you have tried it all”?? As my 22 year old daughter says, “This is not living, this is surviving!!” Any help or suggestions. We live in Chicago, but are willing to travel!! Thank You.

  81. Heather Says:

    I’ve had migraines for years; typically they’ve been a quarterly occurrence, but at times I have a few months where I have a couple a week, usually without an aura. But for some reason, the last three mornings in a row, I’ve gotten an aura between 6-6:15am. My pattern is to have the aura for 30 minutes, then a quiet period of about 30 minutes and then the migraine hits hard (pain level 8) and lasts for about 4 hours. My question is, what could cause a migraine to cycle almost exactly every 24 hours?

  82. Kerrie Smyres Says:

    Cyproheptadine is the first preventive medication that reduces the severity of my migraine attacks, though I’d tried three dozen before it. I’ve found additional relief by sticking to a low histamine diet. Can you summarize the research on migraine and histamine and why researchers hypothesize a connection between the two?

    Thank you!

    Kerrie Smyres
    The Daily Headache

  83. Teri Says:

    Dr. Cowan,

    First, thank you for this great service to patients. Your time and expertise are greatly appreciated.

    What’s your opinion of a holistic approach to Migraine treatment where behavioral therapies are included in the treatment plan?

  84. Teri Says:

    What is your philosophy of combining “traditional” and “complementary” therapies for Migraine management?

  85. Giuliana Scarano Says:

    I live in Italy, I have been a migraneur since I was twelve, my migraine attacks became more severe and more frequent since I was 28. I was diagnosed “migraine with and without aura”. Amitryptiline is the the only preventive medication among those I have been precribed I can tolerate and that reduces the severity of my migraine; the only effective drug for the immediate treatment is indomethacin. Now I am 47, and reading about the approach you have in treating headaches, I mean considering lifestyle, diet, physical therapy and so on, I think it would be very suitable for me. For instance I realized that my migraine gets worse after I felt very worried for something, or when deadlines get near and I am afraid I can’t manage them.
    The problem is in the area where I live there are no specialists with a complete approach like yours.
    My question is, except of course the conventional therapies, could some books be useful for me to learn how I could improve my lifestyle and what kind of physical therapies may relieve my condition ?
    Thank-you for your time

  86. Julie Fleck Says:

    With so many individual being affected with migraine disease, there is only a small number of true headache specialists. How do those of you who specialize in this field encourage other talented clinicians to pursue headache medicine?

  87. Lia Steakley Says:

    Thanks for all the great questions for Dr. Cowan! We’re done taking questions for this round of Ask Stanford Med. Dr. Cowan will answer a selection of your questions in future Q&A on Scope. We’ll let you know when his responses are posted.


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