Headaches and Migraine

Risk factors for headaches may vary by type of headache but generally relate to age, gender, family history, lifestyle choices, medications, medical conditions, food and drinks, sensory stimulation, and genetic predisposition/family members with similar headaches.

Migraine headaches tend to have a genetic link, with most people having a family history. Both tension-type headaches (TTH) and migraine tend to affect female patients more than male patients. Migraine can also affect children. Native Americans are more likely to have migraine than other racial/ethnic groups. People who are unemployed or experiencing poverty are also at higher risk for migraine (National Institute of Neurological Disorders and Stroke [NINDS], 2025).

Risk factors for trigeminal autonomic cephalalgias (TACs) may include male gender, age of more than 30, consumption of alcohol, prior brain trauma or surgery, and family history.

Various factors can trigger headaches. Most triggers relate to lifestyle factors, environmental factors, medical conditions such as high blood pressure or hormonal changes, dehydration, and even over-the-counter medication. It is important to understand that triggers may differ from person to person, and what triggers a headache in one person may not trigger it in another. Also, a patient can keep a headache journal to help recognize their personal triggers and learn strategies to avoid them.

Triggers for TTH include the following (Silberstein, 2025):

• Stress
• Sleep disturbance/lack of sleep
• Temporomandibular joint (TMJ) dysfunction
• Neck pain
• Low back pain
• Eye strain
• Poor posture
• Lack of food or too much alcohol

Triggers for migraine headaches include the following (NINDS, 2025):

• Sudden changes in weather or environment
• Too much or not enough sleep
• Strong smells or perfumes
• Stress (mental or too much physical stress)
• Loud or sudden noises
• Motion (motion sickness)
• Low blood sugar or skipped meals
• Tobacco
• Head trauma
• Too much alcohol
• Hormonal changes
• Bright or flashing lights
• Some medications

Triggers for cluster headaches include the following (Kandel & Mandiga, 2023):

• Watching television
• Alcohol
• Hot weather
• Stress
• Use of nitroglycerin
• Sexual activity
• Glares

Both migraine and TTH are associated with comorbidities, with some differences between the two headache types (Onan et al., 2023). TTH has a high correlation with neck pain (90%) and low back pain (80%), with a positive correlation with the frequency of neck pain to TTH (Onan et al., 2023). Anxiety and depression are more prevalent in patients with primary headaches than in the non-headache population (Onan et al., 2023), and there is a higher percentage of anxiety and depression in patients with migraine headaches (6.9% and 19.1%) than in TTH (4.5% and 12.1%) (Onan et al., 2023). Depression is associated with a higher risk of more chronic migraine, which, in turn, increases depression severity (Onan et al., 2023).

Primary headaches are standalone and not caused by another condition or underlying condition (American Migraine Foundation [AMF], 2024). They just happen. Secondary headaches are ones caused by other conditions. This may include medical conditions such as high blood pressure or hypertension, neurologic conditions, infection of the head and neck, or head trauma. Distinguishing between primary and secondary headaches is an essential first step in headache management to rule out differential diagnoses and not miss a life-threatening situation. In order to distinguish between primary and secondary headaches, it is important to note systemic symptoms such as fever, changes in headache frequency or characteristics, or abnormal findings on physical examination.

Findings consistent with primary headaches may include (AMF, 2024):

• Stable headache pattern over many months or years
• Long-standing headache history
• Family history of similar headaches
• Normal physical exam

Findings that may be more associated with secondary headaches include the following (AMF, 2024):

• Worst headache of your life
• Sudden onset without warning or build-up
• Significant change in the pattern of recurrent headaches
• Headaches before the age of five
• New onset of headaches past the age of 50
• Active cancer
• Presence of human immunodeficiency virus (HIV) infection
• New or severe headaches during pregnancy
• Headache associated with fever
• Headache associated with seizure
• Headache triggered by exertion

Common types of primary headaches include TTH, migraine, and TACs. Cluster headaches are the most common form of TACs. Other primary headaches include primary cough headaches, primary exercise headaches, headaches associated with sexual activity, thunderclap headaches, cold stimulus headaches, external-pressure headaches, stabbing headaches, nummular headaches, hypnic headaches, and new daily persistent headaches (NDPH) (International Classification of Headache Disorders 3rd Edition [ICHD-3], 2021a).

TTH is the most common type of primary headache and is estimated to affect two in three adults in the United States (AMF, 2023b; Shah et al.,2024). Other names for TTH include muscle contraction headaches, stress headaches, and psychogenic headaches, and, as the name indicates, they are often caused by contracting muscles in the neck, face, scalp, and jaw.

The pain is not localized or throbbing but is often described as pressing, tightening, squeezing, or vice like, with the pain originating in the occipital or frontal region bilaterally and spreading in a band around the head (Hassan & Asaad, 2020; Silberstein, 2025). The pain is often mild to moderate in intensity and is bilateral in the majority of cases. Tenderness can be palpated in the muscles around the face, temporal region, jaw muscles, sternocleidomastoid, trapezius, cervical paraspinal, and suboccipital muscles (ICHD-3, 2021b). TTH does not typically involve nausea, vomiting, photophobia, or phonophobia and is not aggravated by routine physical activity or minor exertional activity like walking (Shah et al., 2024). TTH can also coexist with other headache types (Shah et al., 2024).

Tension headaches can be classified into three subtypes: Infrequent episodic, frequent episodic, and chronic (ICHD-3, 2021b).

• Infrequent episodic: At least 10 episodes of headache, but occurring less than one day a month on average or less than 12 days per year.
• Frequent Episodic: At least 10 episodes of headache occurring for no more than 15 days/month or less than 180 days a year.
• Chronic TTH: Headaches that occur more than 15 days/month for more than three months or more than 180 days a year.

Probable TTH is one that is missing one of the features required to fulfill one of the above diagnostic criteria but does not fulfill the criteria for another headache disorder (ICHD-3, 2021a).

Frequent episodic TTH often coexists with migraine without aura; both types need to be identified as treatments of each differ considerably. Careful patient education is required to educate them to distinguish between these headache types so they can select the proper treatment while avoiding medication overuse and adverse consequences (ICHD-3, 2021b).

Migraine headache is the next most common form of headache and is often a disabling disorder. Migraines vary from person to person and are more than just a "bad headache." One of the most common symptoms of migraine is moderate to severe throbbing pain that happens on one side of the head (unilateral), although pain can occur bilaterally (NINDS, 2025). Some people have a migraine at predictable times, such as before their menstrual cycle or following a stressful week. Migraine has two major types: without aura and with aura, and similar to TTH, migraine headaches can be classified as episodic or chronic.

Migraine without Aura

Migraine headaches are diagnosed if the person has at least five attacks that last 4-72 hours, untreated or unsuccessfully treated, and has at least two of the following characteristics:

1. Unilateral location
2. Pulsating quality
3. Moderate to severe pain intensity
4. Aggravation or causing avoidance of routine physical activity such as walking

AND at least one of the following symptoms:

1. Nausea and or vomiting
2. Photophobia and phonophobia

Migraine with Aura

Approximately one-third of people who have migraine headaches experience an aura. A migraine aura is a collection of symptoms that people may experience before or during a migraine attack. Previously used terms for migraine with aura include classical migraine, ophthalmic, hemiparesthesia, hemiplegic, or aphasic migraine, migraine accompagnée, and complicated migraine (ICHD-3, 2021a).

Migraine with aura is diagnosed if a person has had at least two full attacks that have one or more of the following aura symptoms (ICHD-3, 2021a):

1. Visual
2. Sensory
3. Speech and/or language
4. Motor
5. Brainstem
6. Retinal

AND at least three of the following characteristics: 

1. At least one aura symptom spreads gradually over ≥ 5 minutes
2. Two or more aura symptoms occur in succession
3. Each individual aura symptom lasts 5-60 minutes
4. At least one aura symptom is unilateral
5. At least one aura symptom is positive
6. The aura is accompanied, or followed within 60 minutes, by a headache

Infrequent episodic migraine attacks may vary in frequency and severity and may resemble TTH, making diagnosis difficult.

Chronic Migraine

Chronic migraine happens when a person experiences a headache (either migraine or TTH) for 15 days or more per month, with at least eight or more of the days having migraine features (with or without aura) (AMF, 2021).

Migraine attacks happen in four phases: Prodrome, Aura, Headache, and Postdrome.  

• Prodrome: The prodrome phase is the beginning of the migraine attack and can happen a few hours to days before the headache starts. Some people can notice this phase and detect the oncoming headache through symptoms such as food cravings, mood changes, uncontrollable yawning, fluid retention, or increased urination (NINDS, 2025).
• Aura: The aura involves complex neurological symptoms that occur before the headache (ICHD-3, 2021a). Some people may experience an aura 10 minutes to one hour prior to the headache (NINDS, 2025). Typical aura symptoms may involve sensory disturbances, including:
  • Visual disturbances: Flashing lights, seeing spots, zig zags, stars, or wavy lights/lines, or partial field of vision loss. Of migraine sufferers with aura, 90% will experience some visual disturbance (AMF, 2023a).
  • Sensory changes: Feeling tingling or numbness in the face, hands, body, or fingers.
  • Speech or language problems: Unable to produce the right words, slurring, mumbling.

Aura Example 1

Aura Example 2

Aura Example 3

• Headache: The headache during a migraine attack usually starts gradually and gets more intense. The pain may happen without warning, is usually felt on one side of the head (unilateral), and may be described as moderate to severe and pulsating or throbbing. Other symptoms may include nausea, vomiting, photophobia, phonophobia, sensitivity to smell, confusion, blurred vision, mood changes, and fatigue (ICHD-3, 2021a; NINDS, 2025). The attack may last for hours to days.
• Postdrome: Following the headache, people are often exhausted or confused. They may have a hard time concentrating, feel dizzy, or experience mood changes. This postdrome period may last up to two days (NINDS, 2025).

Complicated migraine is a term used to describe migraine attacks that include neurological symptoms beyond the typical headache, such as weakness, numbness, vision changes, or difficulty speaking. These are often referred to as "complex migraine," though this is not an official diagnosis. There are several types of complicated migraine, which include hemiplegic migraine, migraine with brainstem aura (MBA), abdominal migraine, and status migrainosus.

Hemiplegic Migraine

Hemiplegic migraine is a rare form of migraine that is characterized by motor weakness on one side of the body (Kumar et al., 2023). The weakness is a form of aura and is associated with at least one other aura symptom, such as visual, speech, or sensation changes (Association of Migraine Disorders [AMD], n.d.; Kumar et al., 2023). Hemiplegic migraine is usually accompanied by or followed by a headache. The weakness is not always on the same side as the head pain and can vary from mild to severe. The unilateral weakness often starts in the hands and gradually spreads to the arm and face. Symptoms usually develop over 20-30 minutes but can develop acutely and mimic a stroke (Kumar et al., 2023). Symptoms can last for a few hours to days and can rarely last up to several weeks. Symptoms completely resolve in the majority of cases (Kumar et al., 2023).

There may be a familial connection (familial hemiplegic migraine), or it can occur in an individual without a familial history (sporadic hemiplegic migraine). Proper diagnostic testing is important to rule out other pathologies, such as stroke. Brain imaging via computed tomography (CT), magnetic resonance imaging (MRI), cerebrospinal fluid analysis, or electroencephalogram (EEG) may be needed, especially in individuals with new-onset, prolonged symptoms, and no family history (Kumar et al., 2023).

Migraine with Brainstem Aura

MBA is a classification that used to be known as basilar migraine (AMD, n.d.). Other names include basilar artery migraine, basilar-type migraine, brainstem migraine, vertebrobasilar migraine, and Bickerstaff migraine (Kadian et al., 2023). There is some controversy surrounding this diagnosis, and publications vary in regard to its prevalence and cause. It was once thought to be caused by a spasm of the basilar artery; however, there is no evidence of such, and it is now thought to occur because of the firing of nerves in the brainstem.

This type of migraine occurs when aura symptoms are of the kind thought to originate from the brainstem, but there is no motor weakness associated with the aura. The diagnostic criteria for MBA are migraine with aura, including at least two of the following symptoms: slurred or slow speech (dysarthria), vertigo, ringing in the ears (tinnitus), partial hearing loss (hypoacusis), double vision (diplopia), impaired coordination (ataxia), or decreased level of consciousness (AMD, n.d.; Kadian et al., 2023). The symptoms can mimic very serious diseases such as stroke, tumors, or infections. While the symptoms are frightening, they are completely reversible (Kadian et al., 2023). Similar to hemiplegic migraine, brain MRI and head magnetic resonance angiography (MRA) or CT angiography are often used to rule out other pathologies.

Abdominal Migraine

Abdominal migraine is characterized by recurrent episodes of moderate to severe belly pain with nausea, with or without vomiting. The pain can feel like a dull ache or soreness, but may also be moderate to severe pain. Additionally, patients may experience loss of appetite, nausea, vomiting, and pale pallor. Often, there is no associated headache. It lasts from two hours to three days, without symptoms between episodes. Abdominal migraine is most commonly seen in children under 10 years old, but it can affect adults. This type of migraine affects 1-4% of school-age children, with girls being affected more often than boys (AMF, 2022).

Status Migrainosus

Status migrainosus is a rare but serious complication of migraine during which the migraine attack causes debilitating pain for longer than 72 hours and may involve pain and nausea so intense that the person needs to be hospitalized (NINDS, 2025).

TACs are a group of primary headaches characterized by severe, unilateral pain around the trigeminal nerve area, accompanied by ipsilateral cranial autonomic symptoms like eye-watering, redness, nasal congestion, and eyelid drooping. The pain occurs on one side of the head, and additional symptoms affect the autonomic nervous system on the other side. Prominent examples of TACs include cluster headaches, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) (ICHD-3, 2021c).

Of TACs, cluster headaches are the most common. They are named as a result of the attacks occurring in groups or "clusters." In a cluster cycle, short, excruciating, severe headaches recur between one and eight times a day. Cluster headaches can last for weeks or months, separated by remission periods that last months or years (AMF, 2019).

A cluster headache is sometimes described as boring, burning, or a "hot poker in the eye" and is sometimes said to be the most painful of all headaches (AMF, 2019; Kandel & Mandiga, 2023). As with all TACs, cluster headaches occur on one side of the head and are associated with ipsilateral symptoms that can include red or teary eyes, runny or stuffy nostrils, and flushing or sweating of the face. Because there is often associated nasal congestion, cluster headaches are often misdiagnosed as sinus headaches and treated with decongestants, which are not effective for this type of headache.

Sinus Headache

A sinus headache is a headache caused by inflammation of the sinuses. Inflammation may be caused by infection, allergies, nasal polyps, or deviation in the shape or size of the sinus cavities. The traditional pain presentation of a sinus headache is pressure or pain in the forehead, cheeks, or bridge of the nose.

Thunderclap Headache

A thunderclap headache has a sudden and severe onset that reaches peak intensity within 60 seconds or less. It is often described as a "clap of thunder," leading to the nomenclature. Thunderclap headaches are uncommon but can serve as a warning of other serious or life-threatening conditions. A patient who experiences a thunderclap headache should seek emergency medical attention immediately (Mayo Clinic, 2020).

Medication Overuse Headache

Medication overuse headaches, also known as rebound headaches, are the result of long-term use of medicines to treat headaches. While it is acceptable to take pain relievers (including over-the-counter pain medication such as ibuprofen or acetaminophen), people who take them too often or for too long may develop a rebound headache (Mayo Clinic, 2025). The symptoms of medication overuse headaches include a headache that happens nearly every day, improves with pain medicine, but then returns when the pain medication wears off. These headaches usually stop after discontinuing the pain medication.

Pain Patterns per Headache Type

Debra Thompson is a 58-year-old female with a history of episodic migraine, typically characterized by severe, throbbing headaches, nausea, and light sensitivity. She presents to the emergency department (ED) with the sudden onset of a severe migraine headache accompanied by vomiting and left-sided unilateral weakness. Her symptoms began approximately 12 hours ago when she awoke with a throbbing headache, followed shortly by nausea and vomiting. Over the next three hours, she began experiencing weakness on the left side of her body; this led to difficulty walking and an inability to maintain balance. The patient denies any history of a stroke or stroke-like symptoms, neurological events, or trauma.

Ms. Thompson's past medical history includes obesity and high blood pressure. There is a maternal family history of migraine. She takes antihypertensive medications daily and occasionally takes ibuprofen.

Ms. Thompson's vital signs are stable; however, the neurological exam shows mild aphasia and left-sided weakness. No sensory loss or facial droop was noted; however, the patient cannot walk without assistance. Differential diagnoses include a transient ischemic attack (TIA) or stroke.

Initial Evaluation and Imaging:

To rule out a significant hemorrhagic stroke, a CT scan was performed. No acute infarction or hemorrhage was noted. To further assess the possibility of structural abnormalities or ischemic changes, an MRI with contrast of the brain was conducted, which showed no evidence of serious disease.

In addition to brain imaging, a comprehensive blood work panel was conducted to rule out other potential causes of the symptoms, including electrolyte imbalances, infection, or metabolic disturbances; all returned as normal.

Ms. Thompson was given intravenous (IV) fluids for hydration and a dose of an antiemetic (ondansetron) to address the vomiting. She was placed on a "migraine cocktail," which provided minimal/partial relief of the headache but did not resolve the associated weakness. Oral analgesics, including ibuprofen and a triptan (sumatriptan), were used to address the acute headache. Given her presentation, a more cautious approach to the use of triptans was employed, especially due to her possible vascular risk factors.

Ms. Thompson was admitted to the hospital for close monitoring due to concerns about evolving neurological symptoms. A neurologist was consulted to evaluate her condition further and confirm the diagnosis of hemiplegic migraine.

While in the hospital, Ms. Thompson received occupational and physical therapy to address balance and mobility concerns. Ms. Thompson is single and lives alone on the second floor of an apartment building, so ambulation and stairs were practiced to ensure safety in returning to independent living. Before discharge from the hospital, she could ambulate and go up and down stairs independently.

Long-Term Management Plan:

Given the diagnosis of hemiplegic migraine, Ms. Thompson was started on preventive treatment to reduce the frequency and severity of future episodes. She was also counseled on lifestyle modifications, including regular sleep patterns, stress management techniques, and dietary adjustments to avoid known migraine triggers (caffeine and chocolate were the biggest that she would need to overcome).

Debra was educated about hemiplegic migraine, including the potential for neurological problems during attacks and the importance of early intervention with medications. She was instructed on how to manage an acute attack at home with triptans and advised to seek medical attention if weakness or speech difficulties recur rather than driving herself to the ED as she had in this situation.

Ms. Thompson was scheduled for a follow-up appointment with a neurologist within two weeks to monitor her response to treatment and assess her functional status.

Over the course of her hospital stay, Ms. Thompson's left-sided weakness gradually improved. By the time of discharge, her neurological deficits had significantly diminished, and she regained near-full strength in her affected arm and leg. However, she continued to experience mild headaches, occasional nausea, and mild dizziness.

After she was discharged from the hospital, Ms. Thompson began taking preventive medications. She reported a significant decrease in migraine frequency, and she no longer had any neurological symptoms. Her quality of life substantially improved, and she was able to return to daily activities. She also felt confident in her ability to help manage her condition from the self-management education she learned from her provider.

By the time a month was up, Ms. Thompson had no more speech difficulties or residual weakness. With the occasional intense migraine, she still experiences dizziness. However, this is managed with medications and hydration.

Strengths:

1. Timely and Comprehensive Diagnostic Workup: Serious differential diagnoses, such as TIA or stroke, were ruled out through imaging and blood. The MRI was key in confirming Ms. Thompson's diagnosis.
2. Successful Early Intervention: Symptom alleviation occurred through the use of migraine-specific medications. This decreased the likelihood of further complications.
3. Multidisciplinary Approach: Collaboration occurred between the emergency care team, the neurologist, and physical and occupational therapy; this involved a tailored preventive care plan and the use of many appropriate treatments that were effective.
4. Patient Education and Empowerment: Ms. Thompson's understanding of her condition was greatly improved through education, which led to better self-management and fewer migraine. The emphasis on preventing triggers and managing stress was essential in her long-term care.

Weaknesses:

1. Initial Delay in Diagnosis: Because a hemiplegic migraine has presenting symptoms that can be similar to other conditions, such as a stroke, a delay in diagnosis can occur. A more immediate diagnosis would have expedited pertinent treatments.
2. Medication Risks: Many medications, such as triptans, may have cardiovascular side effects. This would require an increase in patient monitoring, especially when the patient has a past medical history of hypertension. Alternative treatments should be considered.
3. Incomplete resolution: While Ms. Thompson experienced a reduction in migraine frequency, some residual symptoms persisted, highlighting the difficulty in fully preventing a hemiplegic migraine. Future adjustments in preventive medications may be necessary if symptoms return.

This case study underscores the complexity of diagnosing and managing hemiplegic migraine, especially when the presentation mimics other neurological conditions. With prompt and comprehensive care, Ms. Thompson experienced significant recovery, both functionally and symptomatically. A combined approach of acute treatment, preventive strategies, and patient education led to an improved quality of life and greater control over her migraine condition. However, ongoing management and adjustments to treatment remain crucial to ensuring the best long-term outcomes.

There are many pharmacological classes that can be used for headaches and migraines. These classes and the drugs listed in them are not all-encompassing, though they are some of the more popular medication choices.

There are many reasons for using non-pharmacological approaches to treating headaches. These include avoiding medication overuse headaches, poor tolerance to pharmacological treatment, contraindication to or severe side effects of certain medications, cost-effectiveness, and personal preference (Licina et al., 2023).

Physical Therapy

Physical therapy can be highly effective in treating headaches by addressing underlying musculoskeletal issues, improving posture, and reducing muscle tension through exercise, stretches, and manual therapies. A systematic review and meta-analysis of manual therapy to the cervical spine (mobilization and manipulation) indicate a short-term (1-4 weeks) effectiveness in reducing headache pain and disability (Coelho et al., 2019). During this time, a patient may have an opportunity for improved success in other stretching, strengthening, and postural re-education exercises while experiencing less pain.

Pourahmadi et al. (2021) conducted a systematic review and meta-analysis on dry needling to treat TTH, cervicogenic, and migraine headaches. Their review concluded that dry needling could significantly improve headache frequency, health-related quality of life, trigger point tenderness, and cervical range of motion in patients with TTH and cervicogenic headaches. They concluded that dry needling produces similar effects to other interventions for short-term headache pain relief but better improvement in related disability than other therapies (Pourahmadi et al., 2021). When dry needling, the upper trap, the cervical paraspinal muscles, and the nuchal ridge along the suboccipital muscles are commonly involved. These muscles tend to have referral patterns in the location of pain described by headache sufferers.

Trigger Point Referral Patterns

Trigger Point Referral Patterns

Stress Reduction/Relaxation Techniques

Numerous studies have shown a positive role of yoga as an adjunctive therapy for migraine and headaches (Kachhadia et al., 2023). These studies have shown yoga to be effective in reducing associated stress and anxiety, along with the clinical symptoms of migraine headaches, and reducing the disability created by migraine (Kachhadia et al., 2023).

Other relaxation techniques may include meditation or mindfulness.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for problems such as depression, anxiety, and sleep disorders by having the individual change their thought patterns and behaviors (American Psychological Association [APA], 2017). A systematic review and meta-analysis performed by Bae et al. (2021) determined that CBT can significantly improve headache frequency and intensity in patients with migraine, with few adverse effects.

Biofeedback/Neuromodulation

Biofeedback therapy is a type of therapy that is being utilized to help control a person's stress response through breathing, imagery, and conscious pain control. This is accomplished through electromyography (EMG) electrodes that measure muscular activity and produce visual or auditory real-time information to the patient. Through the biofeedback approach, the patients can learn how to utilize relaxation techniques to decrease the muscle activation patterns noted through the EMG they receive when experiencing a headache. In a systematic review and meta-analysis conducted by Martino Cinnera et al. (2023), EMG biofeedback may be able to reduce the intensity of primary headache attacks. However, no difference was observed in the frequency and duration of headaches between biofeedback and controls. Martino Cinnera et al. (2023) also indicated that the literature is obsolete and the methodological quality is not satisfactory.

Neuromodulation is the process in which specific devices are used to excite the central or peripheral nervous system with electric or magnetic energy in order to regulate the abnormal behavior of neural pathways (Tiwari & Agrawai, 2022). While there are many invasive techniques being utilized, such as deep brain stimulation and spinal cord stimulation, there are other less invasive treatments also being investigated, such as peripheral nerve stimulation (occipital, vagus, trigeminal) and transcranial magnetic stimulation (Reffat et al., 2024). The Food and Drug Administration (FDA) has approved devices such as non-invasive vagus nerve stimulators, single-pulse transcranial magnetic stimulators, and transcutaneous supraorbital neurostimulators for use on patients with migraine (Tiwari & Agrawai, 2022). Neuromodulation is an advancing field that seems to have strong emerging evidence as an approach for the reduction of headaches and migraine days for chronic sufferers (Reffat et al., 2024; Tiwari & Agrawai, 2022).

Dietary Changes

Since diet-related triggers are a common cause of TTH, migraine, and cluster headaches, maintaining a dietary log in correlation with the onset of a headache can provide valuable information on ways to avoid certain foods and alcohol. Some studies have demonstrated that certain diets, such as elimination diets, ketogenic diets, dietary approaches to stop hypertension (DASH) diets, low-fat vegan diets, and gluten-free diets, may improve attack duration, frequency, severity, and medication use in migraine patients; however, the overall evidence is weak (Nguyen & Schytz, 2024).

The HIT-6 is widely used to assess the negative effects of headaches on normal activity. It was developed for the general headache population but has been validated for the use of patients with migraine as well (Houts et al., 2020; Yang et al., 2011). Higher scores indicate a greater impact on the patient's life.

(*Please click on the image above to enlarge.)

The MSQ v2.1 is a widely used self-report measure that assesses how migraine affects a person's ability to function in daily life, including work, social activities, and emotional well-being. The 14-question tool has been widely studied and validated for use in patients with chronic and episodic migraine headaches. Additionally, studies have demonstrated that the MSQ has good psychometric properties for migraine patients (Rendas-Baum et al., 2013). The MSQ uses a scale from 0 to 100, with higher scores indicating a higher quality of life. To view the MSQ, click here.

The CHQLQ is a modification of the MSQ (v2.1) and simply replaces the word "migraines" with "headaches" (Haywood et al., 2021). It is a 14-item tool that measures functional aspects of headache-related quality of life. The focus of the tool is on how headaches prevent the individual from engaging in desired activities, how headaches limit their ability to perform their usual roles or activities, and the impact of headaches on emotional well-being, such as mood, anxiety, and stress. The CHQLQ has been validated and compared to the HIT-6 and has been shown to be a high-quality, relevant, and acceptable measure for chronic headaches (Haywood et al., 2021). "While both measures are structurally valid, internally consistent, temporally stable, and responsive to change, the CHQLQ has greater relevance to the patient experience of chronic headache" (Haywood et al., 2021).

The PPMQ-R was initially validated in 2008 as a measure of patient satisfaction with acute migraine treatment. The 15-item questionnaire has been shown to be valid and reliable and is an important benchmark of quality and effective care (Dikmen et al., 2023; Kimel et al., 2008).

The MIDAS questionnaire was developed to measure headache-related disability and improve communication about the functional consequences of migraine. The test only takes a few minutes and can be used by physicians, nurses, pharmacists, and other healthcare providers. The questionnaire has been shown to be internally consistent, highly reliable, valid, and correlates with the provider's clinical judgment (Stewart et al., 2001). The questionnaire can be accessed here.