Migraine: physiology, new medications, and integrated approaches to management (Dacre, 1/14/2026)

A recording of this presentation is available HERE.

Many thanks to Dr. Mike Dacre for a presentation this week on Migraines. 

My notes:

Migraine syndrome is super common (~10% of all people), 1 billion people globally, 2nd cause of disability worldwide, 50% underdiagnosed and undertreated. 2:1 female to male ratio

• Migraine headaches 4-72 hours
• Note Pediatric usually max 2-4 hours (often not unilateral)
• Classic pattern of prodrome>> aura>> headache>> postdrome

What causes migraine? Has long been thought of as a blood vessel problem (spasm vs dilation)>> pain often pulsatile, worse with movement/position changes, vasoconstrictors (caffeine, ergo alkaloids) then migraines get better, vasodilators (Viagra) make migraines worse. 

BUT this understanding is now known to not be true. In actuality, the blood vessel changes are SECONDARY. Now belief is that migraine is primarily a disease of neuronal activity: large ion shifts (potassium, glutamate, ATP across cell membranes)>> two receptors particularly notable now, include CGRP receptor and PACAP

• CGRP is potent vasodilator, but is a side effect of activation of this cascade>> mast cell degranulation, inflammation and sensitization
• get irritation and inflammation around the blood vessels, causing painful vasodilation

Migraines tend to start in the brainstem (where trigeminal nerve originates), direction impacts the type of migraine a person experiences. Where it moves, impacts the symptoms/manifestations

I love this simple diagram of how genetic set point+ cumulative burden push people toward migraine thresholds and lead to migraine syndromes:

Migraine headaches can move from being episodic to being chronic/intractable. Once you get migraines frequently enough, you can get medication overuse headaches, which then push you to central sensitization, which makes you more likely to get migraines. Similar to chronic pain syndrome progression>> it is not uncommon for people with headache syndromes to not seek care, overtake meds, and then have their disease progress to central sensitization and "chronification".

Abortive Treatments

Medications 

• NSAIDs are very effective (shouldn't be taken more than QOD due to risk of medication overuse headache)
• acetaminophen and caffeine can potentiate/help (care with overuse)
• Excedrin is "worse" for medication overuse (no more than 5 times/month)
• Corticosteroids + PPI
• short course of prednisone has good evidence (NNT 9)
• Triptans (actually inhibit CGRP release)
• should be used in episodic migraine, more effective when done before pain starts (aura phase), not useful after 1 hour after onset of pain
• NNT 4-5
• Sumatriptan and Rizatriptan are most commonly used (familiarity)> no head to head trials
• Care with vasoconstriction effect (e.g. contraindicated in CAD, uncontrolled Htn)

• Opioids don't work well, high risk for misuse/dependence
• Caffeine is very effective in some people for aborting migraine, but people with > 2 cups coffee/day have more frequent and worse migraines
• Ditans: not available in US (schedule 5) but do see them in Middle East and Latin America

Nerve Blocks

Greater occipital nerve block>> safe and effective even in people who don't have predominant occipital pain, helps to abort migraine. 

• can be done with or without ultrasound
• Can do block + anti-emetic + steroid
• lidocaine+ bupivacaine
• very safe (low vascular, infection risk)

Preventive Treatments

Medications

• Beta blockers all work (propranolol, metoprolol)
• TCA: Amitriptyline
• SNRIs
• ARBs
• Anti-seizure meds (e.g. valproate, topiramate)>> best responders are people who failed other classes
• Anti-CGRPs: American Headache Society released guidelines in 2024 that these meds are first line for anyone with migraine >15 days/month ($600-700/month)
• safe and effective
• can be prescribed by PCPs
• can get covered by PHP (prior auth)
• one comparison study vs. topiramate, better tolerated
  
  
• Gepants
• remigapant, ubrogopant (can be used for ppx and abortive)
• Supplements
• Magnesium 400mg/day (moderate evidence)
• Riboflavin 400mg/day (good evidence)
• Coq10 (not great evidence) 100 TID
• Botox NNT 9 (50% reduction in HA days)
• Acupuncture NNT 11 (weekly acupuncture, 50% reduction in HA days)
• OMT/PT/massage are all also very effective, studies to support their use in reducing HA days

Summary:

Integrative Medicine for the Skeptic (Meckler, 1/24/2024)

 A recording of this presentation is available HERE. 

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Many thanks to Dr. Gabriela Meckler, senior resident for her excellent presentation titled Integrative Medicine for the Skeptic. She covered the evidence behind some important herbs and supplements for common primary care conditions.

Dr. Meckler wanted us to feel comfortable knowing the data for some specific integrative remedies for common medical problems:

• Ginger for nausea and vomiting of pregnancy 
• 500-1500 mg BID to TID
• A metanalysis of 10 RCTs found that ginger at these doses is as effective as pyridoxine and metoclopramide, and dimenhydrinate
• Most common side effect: heartburn
• There is also some evidence for ginger in migraine, dysmenorrhea, metabolic syndrome, respiratory diseases, and milk volume in the early post partum period
• Take home: consider recommending ginger either alone or as an adjunct to the traditional rx'd in pregnancy. Stop ginger when nausea starts (to prevent heartburn)
• Daily Magnesium for migraine headache prophylaxis 
• 400-600mg/daily
• Safe in pregnancy
• Most common side effect: diarrhea
• PO magnesium alleviates frequency and intensity of migraine (statistically significant)
• IV magnesium has the best evidence for treatment of acute migraine, but oral has good evidence as ppx
• IV magnesium helped migraine within 15-45 minutes after initial infusion, and lasted up to 24 hours
• Additional supplements that may be useful in migraine: 
• Riboflavin 400mg/day reduces headache from 4 days/month to 2 days/month (must be taken for 3-6 months), 
• Butterbur (but careful, must come from trusted source to remove pyrrolizidine alkaloids)
• Ginger 400mg + ibuprofen, can also be used for dysmenorrhea (2 days prior to onset of menses)
• Side note on Licorice safety in pregnancy (licorice is often found in combination in ginger tea products)
• Licorice contains glycyrrhizin, which can act as a mineralocorticoid
• Side effects: hypertension, hypernatremia, hypokalemia, renin suppression
• Glycyrrhizin is often present in low doses in these teas, about 31mg/cup of tea. 

• A longitudinal cohort study in Finland found licorice consumption in pregnancy to be associated with  lower intelligence and memory scores, higher HPA-axis activity, and higher incidence of ADHD in offspring. This high dose of glycyrrhizin was >= 500mg/week, So a pregnant person would have to drink upwards of two cups of tea containing licorice every day to get an adverse event

• Turmeric for osteoarthritis pain
• 100-2000mg daily for knee OA
• In a study of turmeric vs. paracetamol 500 BID vs. 650 TID x 6 weeks for OA, both arms showed decrease in pain and stiffness, increase in function =equivalent to tylenol!
• 1000mg should be paired with 6 mg piperine -- black pepper extract -- (just a tiny amount) for improved absorption 
• Warming up turmeric increases absorption and likely efficacy
• Most common side effect: GI upset, diarrhea

Recommended Resources for practitioners and patients 

• Institute for Functional Medicine (ifm.org)
• Nurtritionfacts.org (Dr. Michael Greger)
• IHerb.com
• Consumerlabs.org (requires subscription)