ENT Disorders
Migraine Disease
Migraine disease is often underestimated as a health condition when thought of only as a severe headache, characterized by light, smell and sound sensitivity and/or nausea. Migraine is an inherited disease that causes many different symptoms from one day to the next. In fact, it affects many parts of our body – the nervous, vascular and immune systems
Common Migraine Symptoms Of The Head
Migraine symptoms other than a headache.
Head & Neck pain
- Brain Fog
- Fatigue
Balance
- Dizziness
- Loss of Balance
- Motion Sickness
Auditory
- Ear pain noise sensitivity
- Difficulty understanding what is said
Facial
- Sinus Pressure / Pain
- Nasal Blockage
- Runny Nose
- Jaw / Ear Pain
- Tooth Pain
Sensory
- Painful skin or hair on light touch
- Light sensitivity
- Visual auras
- Dislike of smells or odors
- Phantom smells
Common Comorbidities
When a person with migraine disease has another chronic health conditions, such as anxiety or insomnia, this is called a “co-morbidity”
Neurological
- Anxiety
- Depression
- Insomnia
- Epilepsy
Gastrointestinal
- Colic
- Irritable bowel syndrome
- Cyclic vomiting syndrome
Gynecological
- Genital Pain
- Pelvic Floor Dysfunction
- Interstitial Cystitis
- Endometriosis
Cardiovascular
- Postural Orthostatic Tachycardia Syndrome (Dysautonomia)
- Raynaud’s Phenomenon
- Stroke and Heart Attack
- Hypertension
- Erectile Dysfunction
Immune
- Asthma
- Allergy
- Arthritis
- Lupus
- Sjogren’s Disease
- Scleroderma
- Multiple Sclerosis
Skin
- Psoriasis
- Rosacea
Ocular
- Dry eye
- Glaucoma
Endocrine
- Obesity
- Hypothyroidism
Musculoskeletal
- Fibromyalgia
- Ehlers Danlos Syndrome
How To Be An Advocate
Migraine Treatment
Since there are many problems with our nervous system that might make it quirky and hypersensitive, there is no single treatment that if effective, or “works”, for more than half the population. The mainstay of treatment is to use medicines that help the brain work more normally. Unfortunately, we do not know what is going to work for you. Also, we don’t know if the medicine will cause a side effect. Your clinician will need to try one or more medicines before finding the best one for you. Please be patient.
“Rescue” medicines
- Take these medicines when you have a headache or other migraine symptom
- More effective when taken at the onset of an attack
- Have to limit the use of these medicines because if over-used, they will start to cause more headaches
Caffeine, Ginger and other natural products
Analgesics
- Acetaminophen (Tylenol)
- Aspirin, acetaminophen and caffeine (Excedrin Migraine, Excedrin Extra Strength and others)
- Acetaminophen, Isometheptene, Dichloralphenazone (Midrin)
- Nonsteroidal anti-inflammatory drugs (ibuprofen, Motrin, Naproxen and others)
Antiemetics
(metoclopramide, ondansetron, prochlorperazine, dimenhydrinate, trimethobenzamide)
- Help with nausea but also some mild pain relief
Triptans
(medicine specifically designed for migraine headaches)
- preferred because more effective
- 7 different triptans – some last longer than others but also slower to relieve pain
- Sumatriptan, rizatriptan, almotriptan, eletriptan, frovatriptan, naratriptan, zolmitriptan
- Delivered as pills, nasal sprays, injections
- Not for those with a history of heart and related problems
- Limited to 9 pills per month
Gepants
- Good alternative to triptans because they do not cause blood vessels to constrict – a risk for people with heart disease, history of stroke or uncontrolled high blood pressure
- Few other side effects or interactions with other medicines
- Expensive. Some medical insurance policies may make this more difficult to obtain.
Bbrogepant (Ubrelvy 50 or 100 mg tablet, its effect may last less than 24 hours)
Rimegepant (Nurtec ODT 75 mg dissolves in mouth, its effect may last up to 48 hours)
Ditans
- Good alternative to triptans because they do not cause blood vessels to constrict – a risk for people with heart disease, history of stroke or uncontrolled high blood pressure
- Few other side effects or interactions with other medicines
- Expensive. Some medical insurance policies may make this more difficult to obtain.
- Side effect: drowsiness makes it unsafe to drive or operate machinery for 8 hours
Lasmiditan (Reyvow 50,100 or 200 mg per day)
Ergots
- Available as a nasal spray
- Not as popular because more side effects
Barbiturates (sedative) - avoid
- ioricet (butalbital, caffeine, acetaminophen)
- Associated with over-use headaches
- Risk of intoxication, drug dependency, and withdrawal syndrome
Opioids (narcotic) - avoid
- Hydrocodone (Vicodin and others), oxycodone (Percocet and others)
- Associated with over-use headaches Risk of intoxication, drug dependency, and withdrawal syndrome
“Preventive” medicines
- Take these medicines every day whether you have a headache or not because they are intended to reduce the sensitivity of the brain. The goal is to reduce the number and severity of migraine symptoms
- They are to be used for people who have a headache at 50% of the days over at least a 3-month period. They are appropriate for some people who have fewer headaches but are unable to function when they have a headache for an average of more than 4 days a month.
- Check for safety in pregnancychildren and when combining with an antidepressant or blood thinner
Supplements
- Effective in 50% of people with migraine, but may take 4 months of daily use to know if they work for you.
- You may take one or more of these supplements.
- They are available in combination pills
- They generally have few side effects, but, while they are thought of as “natural”, they are, in fact, drugs too.
Magnesium 400 mg daily
Riboflavin 400 mg daily
Coenzyme Q-10 300 mg daily
Melatonin 1-3 mg daily
Feverfew 100-300 mg daily
Butterbur 50-75 mg daily (check for purity)
5-HTP 400-600 mg daily
Ginger
Antidepressants
- Tricyclic antidepressants (amitriptyline/nortriptyline)
- Serotonin-norepinephrine reuptake inhibitor (SNRI)
High blood pressure medicines
- Beta-blockers (propranolol, timolol, metoprolol, nadolol, atenolol)
- ACE inhibitor (lisinopril)
- Angiotensin receptor blocker (candesartan)
- Calcium channel blockers (verapamil, flunarizine)
Anti-seizure medicines
(topiramate, valproic acid, lamotrigine, zonisamide)
CGRP blockers – Monoclonal Antibodies
- Each of these injectable medicines work for 30 days, except eptinezumab which lasts 3 months. Like all of the best migraine medicines, they work in only 60% of people with migraine disease. But they have few side effects and can be used with other migraine medicines and interact rarely with other medicines.
- Expensive. Some medical insurance policies may make this more difficult to obtain without having tried 2-3 oral preventive medicines
Erenumab
- Episodic and Chronic Migraine with and without aura
- Self-injection once a month (70 mg or 140 mg SC)
Galcanezumab
- For migraine: loading dose of 240mg SC, followed by once monthly injections of 120mg SC
- For cluster headache: 300mg SC (3 injections) every 30 days while in an active cluster cycle
Fremanezumab
- 225mg SC once monthly OR 675mg (3 injections) SC once every 3 months
Eptinezumab
- Intravenous every 3 months
Gepants
- Rimegepant can be taken every 48 hours
OnabotulinumtoxinA (Botox and others)
- Your clinician needs to inject this medicine every 3 months
- Expensive. Some medical insurance policies may make this more difficult to obtain without having tried 2-3 oral preventive medicines.
Nerve blocks
- Your clinician can inject local anesthetic medicine into specific locations
How To Be An Advocate
Migraine Frequently Asked Questions
Have questions? We are here to help.
An ‘insurance referral’ is a referral that is obtained by your PCP, directly through your insurance provider’s dedicated referrals portal. There is usually an associated referral number that is added to the claim that is submitted to your insurance with the claim for the services we provide. If your insurance requires a referral, we do not schedule an appointment until we have received this from your PCP. The reason for this is to protect the patient from receiving a large bill for services that normally would have been covered, if a referral had been obtained.
A ‘clinical referral’ is documentation from your referring provider, explaining the reason why they are referring you to our practice, and any past treatments, diagnostic testing, or other pertinent information that will assist our MD’s in treating you optimally.
As specialists, we have certain providers that require a ‘clinical referral’, prior to scheduling, to ensure that the referral is appropriate, and that necessary testing has been performed prior to seeing our physician. This is to ensure that a visit is not ‘wasted’ if the physician is not able to help you, or if necessary testing for optimal treatment has not been ordered and performed.
Univoto’s specialists, and especially our sub-specialists, are very unique in their expertise, and this means that we are sometimes the sole resource for patients with complex head and neck disorders. This does mean that our schedules fill up quickly, and it may take up to three months to get a ‘New Patient’ appointment with one of our providers.
We can assure you that if you have an urgent need to be seen quickly, we have a process in place to get you in within 24 to 48 hours. Urgency is determined by a referral from a primary care physician, so if you feel your case is urgent, please reach out to your primary care physician as a first step.
We also are happy to offer appointments with our Physician’s Assistant, much more expediently. Please ask your patient coordinator if your diagnosis is one that our PA can treat, to decrease your wait time.