Migraine attacks can strike suddenly and disrupt your life. Fortunately, there are several effective medications to help manage these episodes. This Instagram Live session, hosted by Migraine Strong and featuring Neura's medical director and headache specialist, Dr. Thomas Berk, is your go-to guide for understanding acute migraine medications. Discover how different medications work, learn about potential side effects, and get empowered to have informed conversations with your doctor about your treatment plan.
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Eileen Zollinger: I'll go ahead and take care of introductions. I'm Eileen Zollinger, and this is my colleague, Danielle Aberman. We have Dr. Berk joining us from Neura Health, an online neurology clinic. He's a headache specialist, and we're going to get some information from him. One of my first questions is, what exactly is a headache specialist?

We still have people in our community asking what a headache specialist is. Could you give us some background?

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Dr. Thomas Berk: Absolutely. A headache specialist is usually, though not exclusively, a neurologist with additional medical training in headaches. After medical school, I went to a neurology residency. You learn a lot about headache disorders in neurology residency, but you don't know everything. You haven't seen everything. You haven't seen rare headache disorders or patients who haven't done well with multiple medications. In residency, you're not familiar with all the procedures a headache specialist might do. In addition to residency, I did a fellowship in headache disorders. My residency was at NYU; my fellowship was at the Jefferson Headache Center. They have an inpatient unit, which isn't common, and clinical trials, and heavy procedure days. You can also become a headache specialist through physical medicine and rehabilitation residency or psychiatry. There's a board certification given every couple of years. I'm on the board, and we were just discussing the next questions for aspiring headache specialists. If you complete the training and pass your board certification, you're a fellowship-trained, board-certified headache specialist.

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Eileen Zollinger: That sounds like a lot. I see a headache specialist, and Danielle has been to Jefferson. We're very familiar with all of that.

Can you explain who should see a headache specialist?

Some people who follow us only have a migraine attack a couple of times a year, which may not warrant a headache specialist.

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Dr. Thomas Berk: I recommend a headache specialist if you've tried a few treatments without success, or if there's something unusual about your situation. Ideally, many people would start with a headache specialist, but access can be a problem. Anyone who hasn't had success for a while should see one.

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Eileen Zollinger: We talk about that a lot in our community, trying to get people to the right person.

Can you tell us how telehealth can help people with migraine and headache?

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Dr. Thomas Berk: We were just talking about access. You're asking what a headache specialist is, but another question is how many there are. There are fewer than 800 board-certified headache specialists. Over 40 million people in the United States have migraine. That's not everyone who needs a headache specialist. There's no way everyone who needs to see a headache specialist can. Telehealth is about access. It's important for people who wouldn't otherwise be able to see someone with expertise. Another major thing is ease and convenience. Imagine seeing your doctor 10–15 years from now. I don't think it'll involve driving an hour and a half, spending $60 on parking, waiting an hour and a half for a 20-minute appointment, and then driving back. You've spent your entire day. With telehealth, you can be at your dining room table, wherever is convenient. People can even do it at work, in their cubicle or a private area. In 20 minutes, you're done. With headache, many patients aren't dealing with neurological disorders requiring a hands-on exam. Much is standardized with a virtual exam. It's a safe option. If there are questions, we can refer you to a neurologist for an in-person visit or order imaging.

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Eileen Zollinger: That's one of the things we've been excited about with Neura: access is available to almost everyone in the United States.

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Dr. Thomas Berk: Absolutely. We can prescribe medications and order tests in most places. You can see our website for all the states, and it's always changing. We're getting more licenses. State by state, the laws on what you can do and prescribe change. In states where we can't prescribe, we offer an educational appointment. We review everything, give our opinions, and work with your local doctors to get you what you need, whether an MRI, preventative or acute medications. The subtleties can make a difference. Even in states where we can't directly prescribe yet – hopefully soon – it makes a huge difference.

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Eileen Zollinger: It does. We've been excited about this service because we regularly talk to people who say they scheduled with a headache specialist, but it's nine months out. We tell them to go to Neura because they'll see someone quickly and start treatment sooner.

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Danielle Aberman: People have an attack for five days and can't see their doctor for weeks. They're told to go to the ER. That's not acceptable.

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Dr. Thomas Berk: I agree. There are many options besides the ER. One concern might be that something terrible is happening. Virtually, we can help determine if you need to go to the ER for a new neurological issue. Sometimes the question is, "This is a little different than my aura. Should I be concerned?" Sometimes we say yes, sometimes no. That's common.

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Eileen Zollinger: You're focused on the United States now.

‍Can you see people in other countries?

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Dr. Thomas Berk: We can, the same way we give educational appointments. You need a U.S. phone number. A Canadian number works because it's the same country code, +1. We've seen people outside the country for an evaluation, a second or third opinion. They sometimes have trouble seeing a specialist where they are.

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Eileen Zollinger: That's good information. I saw those questions scrolling, so I wanted to address that. We have questions from the community. Our colleague Jennifer Bregman will be in the comments dropping links. Danielle, do you want to start with the questions?

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Danielle Aberman: I'd love to. Dr. Berk is a fantastic headache specialist, but he's not your headache specialist. Everything shared here is for educational purposes. We have a lot of questions; we'll get to as many as we can.

‍Can migraine be considered a disability if it causes you to miss too much work?

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Dr. Thomas Berk: Migraine can be a disability. We aim to control migraine before it becomes disabling. But for work, workplace accommodations, or school, absolutely. It's important to have accommodations, especially if migraine is frequent. If you need a quiet place to rest, a break from screens during an exacerbation, those can be accommodations. People may need long-term disability if they're significantly disabled.

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Eileen Zollinger: We've heard that a lot, having to go on disability. People say they have a better chance if they use legal representation. That's not our conversation today, but something to think about.

Can you give us information on allodynia and how we experience that with migraine?

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Dr. Thomas Berk: There are different abnormal sensations people experience with migraine. With aura, you might experience paresthesia, a sensation on top of what you normally feel, like numbness and tingling. "Numbness" can mean tingling or lack of feeling. It's important to distinguish between the two. There's dysesthesia, a painful sensation when there isn't any, like pain in a limb. Allodynia is different. A normal stimulus is perceived as painful. This happens with frequent migraine attacks, leading to chronic migraine and central sensitization. Brain areas are overloaded with pain signaling that even normal stimuli – someone touching you, your head on the pillow – are perceived as pain.

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Eileen Zollinger: So, pain receptors are turned on all the time?

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Dr. Thomas Berk: Correct.

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Danielle Aberman: Can people get migraine attacks with chest pressure or pain?

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Dr. Thomas Berk: If you have chest pain or pressure, discuss that with your neurologist and, more importantly, your internist or cardiologist. This is true for most symptoms with migraine. If it's not classic with migraine, it might be due to another condition. Is it common? Possible? It's not common. Could it be due to medications? Triptans are associated with the "triptan reaction" – soreness or tightness in the upper chest, jaw, shoulders. If you're sensitive to triptans, especially potent ones like sumatriptan (Imitrex), zolmitriptan (Zomig), or eletriptan (Relpax), those can cause it. Some people are sensitive to all triptans. Discuss it with your doctor. It's possible, but we need to ensure it's not a cardiopulmonary issue.

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Eileen Zollinger: Can you talk about retraining our brains and neuroplasticity? Learning to recognize pain-free moments when you have head pain 24/7?

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Dr. Thomas Berk: Much of our focus is on medication, what medicine equals the best treatment. The truth is, you want a holistic approach. Think not just about medical treatment but what else can help. Non-medical treatments can make a big difference, like biofeedback, tracking symptoms, educating yourself about what happens in the brain during migraine, even visualizing. Those can be helpful. Neura Health offers coaching as part of the membership. Coaching is relatively new to headache. These coaches are well-educated about migraine and make evidence-based recommendations. With nonmedical treatments, we try to tap into the autonomic nervous system, the parasympathetics. We're trying to overcome the pain cycle. You see neuroplasticity more with brain damage, where you use other brain areas to facilitate motor activities, sensory actions. It's not impossible that through deep breathing exercises, tapping into the parasympathetic response, there's some plastic benefit. It's a global goal, not something we talk about individually. It's more that as part of everything, you can have improvement.

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Danielle Aberman: I love this question: Is there a reason migraine attacks would develop slowly in the afternoon, almost every day?

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Dr. Thomas Berk: There are many reasons. It's a great observation. People say, "I'm experiencing so many migraine attacks," and you don't know when, how, or what it's associated with. There could be many causes. If it's related to your position and slowly worsens throughout the day as long as you're upright, and improves when you lie back, we might think it's a different cause, like a spinal fluid leak. Could it be a trigger? An office mate wearing perfume, something you eat every day at lunch, an environmental trigger like fluorescent lights? There are different reasons. Discuss this with your doctor and a headache coach, and talk about lifestyle modifications or workplace accommodations.

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Eileen Zollinger: Is there a relationship between migraine and the circadian rhythm?

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Dr. Thomas Berk: There are closer relationships between other headaches and circadian rhythm. With cluster headache, when someone is in a cycle, they wake up from a headache shortly after falling asleep, or it happens after they wake up or right before. There's hypnic headache, where people wake up at the same time every night. That's closely tied to circadian rhythm. With migraine, your brain thrives on predictability. Sleep is crucial for your brain to thrive. It spends about a third of its life asleep. The more predictable your sleep schedule, the better you'll be. That's something we see as a trigger: sleeping too much or too little. It's not a direct correlation, but sleep and migraine are intertwined.

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Eileen Zollinger: My headache specialist talks about how the migraine brain likes routine, and when you get too far outside that, it can trigger issues.

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Dr. Thomas Berk: That's true. Even daylight saving time can throw people off.

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Danielle Aberman: We have an engaged vestibular migraine community.

Is there a best medication for vestibular migraine?

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Dr. Thomas Berk: Just like migraine itself, you need an individualized approach. There isn't one best medication for everyone. There are different approaches. Your specialist might treat it like any other migraine and use migraine-specific treatments. Or they might see an additional benefit with lamotrigine or calcium channel blockers and try those first. The best thing is what works best for you.

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Eileen Zollinger: If one medication is working well, is there a reason to switch? Assuming no side effects, is there a reason to jump ship?

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Dr. Thomas Berk: There are two main reasons to jump ship: tolerance, side effects, and ineffectiveness. How long should you give a medication? Your doctor should know when specific medications will start working. Some are effective within days, weeks, or months. With Botox, it might take three cycles. It can take time. If you're tolerating it well, give it a chance to work. If you've exhausted the appropriate dose, been on it long enough, and you're not better, there's no reason to continue.

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Danielle Aberman: That brings up the next question: What's a good amount of time to give a medication a chance?

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Dr. Thomas Berk: Every medication is different. With Botox, if you tolerate it, I'd say three cycles before giving up. If one cycle was decent, maybe the third wasn't great, I might recommend continuing and adding another medication or treatment to boost effectiveness. There's more evidence for using CGRP medications (injectables or orals) with Botox, if your insurance covers it. With CGRP medications, I'd say at least three months, with tolerance in mind. If you're not tolerating it, it's not worth it. For most oral medications, four to six weeks, keeping tolerance in mind. Some have a faster benefit. Most headache specialists feel that with amitriptyline, people feel some benefit within the first week or two. If it's been three or four weeks, maybe we've increased the dose, and you're still not doing better, it might make sense to move on.

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Eileen Zollinger: I had good luck with CGRP combined with Botox.

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Dr. Thomas Berk: Insurance companies don't want to pay for two expensive treatments. There's growing evidence that they're synergistic.

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Eileen Zollinger: They were an issue for many of us initially.

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Dr. Thomas Berk: They don't want to pay for two expensive treatments. There's growing evidence that they're synergistic.

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Eileen Zollinger: This is complicated: How do headache specialists differentiate between migraine with aura where weakness is present, migraine with unilateral motor symptoms, and hemiplegic migraine?

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Dr. Thomas Berk: This is a nuanced question. Most neurology residents, and even great general neurologists, would have difficulty telling these apart. Headache specialists can get it wrong and decide afterward that it's something else. What are these three things?

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[ Eileen Zollinger apologizes for her dog making noise. ]

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Dr. Thomas Berk: It comes down to your aura symptoms. Is it numbness and tingling in the arm? That's not hemiplegic migraine or migraine with motor symptoms, or unilateral motor symptoms (MUMS), a term coined by Dr. Bill Young. What are the motor symptoms? For some, it's heaviness. That might be typical migraine with aura. If it's just heaviness, and you can still do everything, there's no true weakness. Another factor is duration. With hemiplegic migraine, you can't use the limb at all. It looks like a stroke. It usually lasts longer than an hour, which is the typical aura duration. With aura symptoms longer than 45–60 minutes, we recommend urgent medical evaluation to ensure it's aura and not turning into a stroke. Hemiplegic migraine usually refers to familial hemiplegic migraine, which runs in families. With familial hemiplegic migraine, about half the family on one side has the gene. It's autosomal dominant, with a 50% presence in the family. The first time it presents, the person often goes to the ER, where doctors might think it's a stroke and give clot-busting medication. The risk of stroke outweighs not doing that. MUMS involves other motor issues. It's not just heaviness; there's something there, but not true hemiplegia. It's between primarily sensory and hemiplegic. That's how I define these, but even the best headache specialists can be fooled.

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Eileen Zollinger: Are they treated similarly?

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Dr. Thomas Berk: They imply different things, especially hemiplegic migraine. There's an implication of something profoundly vascular. Most headache specialists wouldn't recommend vasoconstrictive medications like triptans or DHE, especially during an attack, unlike with typical migraine with aura, where you can still move the limb. We'd have no problem recommending a triptan. Dr. Young's research shows that people with MUMS tend to do better with injectables. If we think it's MUMS, we might recommend an injectable anti-inflammatory, Reglan, or even a triptan, depending on the situation and your symptoms.

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Danielle Aberman: That was comprehensive. We're mindful of your time.

Do you have time for a couple more questions?

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Dr. Thomas Berk: Absolutely.

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Danielle Aberman: What are options for intense nausea when preventatives aren't working?

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Dr. Thomas Berk: When preventatives aren't working, we think of them as staving off exacerbations. When an exacerbation happens, I wouldn't recommend taking more of the preventative. Exacerbation is usually associated with pain and other symptoms, like nausea, light and sound sensitivity. We recommend anti-nausea medication if it's profound. You can take that with your preventatives and acute medicines. That can be in the Reglan family: Reglan, Compazine, promethazine (Phenergan). Another is the Zofran family. Zofran is the most common, but there's also Tigan. There are other options, like Emend. Sometimes we use stronger, almost antipsychotic medications. Some traditional antipsychotics can help nausea significantly, like Haldol (haloperidol) or Thorazine (chlorpromazine). Sometimes we even use atypical antipsychotics short-term, like Seroquel (quetiapine) or Zyprexa (olanzapine).

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Eileen Zollinger: You wrote a great article on nausea and migraine. That's something for those watching to check out.

The next question is about vasodilation as a trigger. Can it be managed?

They struggle to go out in hot weather, exercise strenuously, or drink alcohol. They say it's very depressing and impacts their whole family.

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Dr. Thomas Berk: I can completely imagine. We see this frequently. Even though there's vasodilation in all those situations, we've moved on from understanding migraine as primarily due to vasodilation. We think it's more of an inflammatory condition. Your body produces inflammatory neurotransmitters in response to triggers, and those cause vasodilation. CGRP, for example, is a potent inflammatory and vasodilatory protein. It causes pain and vasodilation. If you only had pain, you'd likely still have migraine. There are debates about the nuances of migraine pathophysiology, but that's something most of us understand. Each trigger, even though they involve vasodilation, can trigger you in different ways.

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With alcohol, some people have specific triggers. If they avoid those – maybe red wines, things with tannins or sulfites – they do okay. Some do well with clear spirits. Some are triggered by all alcohol. With hot weather or exercise, try to mitigate those. If it's the combination, try exercising indoors and hydrate beforehand. If you notice many triggers – most people don't have one trigger that always causes a headache – think about better preventive options. You might still be triggered, but you'll be less sensitive daily.

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Danielle Aberman: Can you answer one more question? What are your thoughts on magnesium?

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Dr. Thomas Berk: Magnesium can help prevent lower-frequency migraine attacks. If you're experiencing a lot of migraine and doing many things, magnesium might be a drop in the ocean. But for someone with fewer than four headache attacks a month, where we'd recommend a preventative medication, it can be helpful. It's not a panacea or a cure, but it can be a helpful oral supplement. It might not be enough for many people. If you experience migraine a couple of times a year, it probably wouldn't help much.

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We also use it in status migrainosus. If you're experiencing migraine for 72-plus hours and getting a "migraine cocktail," one thing they might give you in the ER or infusion suite is magnesium.

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Danielle Aberman: I had that at Jefferson. It was part of my migraine cocktail.

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Eileen Zollinger: Just one more question.

What are the most effective treatment options for menstrual migraine?

So many people struggle with this, and perimenopause and menopause make it rough.

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Dr. Thomas Berk: Just like some of the other "what's best" questions, there may not be one best, but there are options. For migraine without aura, where we're not worried about using extra estrogen, a low-dose estrogen birth control pill can be helpful. Your neurologist or headache specialist might talk to your OB-GYN about potential options. A lower drop in estrogen than your body would normally have can be helpful.

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A longer-acting triptan like frovatriptan (Naratriptan) can be used around your period, or starting the day before. Similarly, a longer-acting anti-inflammatory like naproxen (Aleve) or prescription-strength nabumetone can be helpful. Gepants (Ubrelvy, Nurtec) haven't been studied for menstrual migraine, but we want more information on them. There might be benefits there, too.

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Eileen Zollinger: We appreciate your time and answering these questions. We'd love to do this again sometime.

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Dr. Thomas Berk: For sure.

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Eileen Zollinger: Thank you so much. Have a great day.

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Dr. Thomas Berk: You too. Thank you. Bye-bye.

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