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Five Things for Migraine Patients to Question

The American Headache Society (AHS), a membership organization for medical professionals who treat Headache Disorders patients, recently released a list of Five Things Physicians and Patients Should Question. The recommendations were timed to coincide with the AHS’s annual Scottsdale Headache Symposium, an educational meeting for medical professionals.

toc12(1) Don’t perform neuroimaging studies in patients with stable headaches that meet the criteria for Migraine.

While it is incredibly common for patients dealing with a Headache Disorder to have an MRI and/or CT scan, after reviewing what is known about Migraine, the doctors who developed these guidelines suggest it is unnecessary to perform imaging in patients who have been diagnosed with Migraine according to the International Classification of Headache Disorders. However, they caution that not all serious headaches are Migraines and recommend careful examination of each patient’s history and symptoms to make a determination.

(2) Don’t perform computed tomography (CT) imaging for headache when magnetic resonance imaging (MRI) is available, except in emergency settings.

There are a few reasons for this recommendations. MRI imaging is more sensitive in helping doctors diagnose many conditions associated with headache. CT imaging exposes a patient to substantial radiation, a risk that doesn’t make sense if an MRI is sufficient for the situation. But if stroke, head trauma or hemorrhage is suspected, a CT is the appropriate imaging test.

(3) Don’t recommend surgical deactivation of Migraine trigger points outside of a clinical trial.

The rationale behind this recommendation is straightforward: At this time there is no scientific basis for recommending surgical deactivation for Migraine. There have been no placebo controlled, double blind, randomized research studies on this procedure. So while the evidence we have suggests it may help, more research is needed.

(4) Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent Headache Disorders.

Both of these types of medication are strongly associated with an increased risk that a patient’s episodic Migraine pattern will transform into a chronic Migraine pattern and with a condition called Medication Overuse Headache. Anything we can do to minimize these risks is important. Further, there are medications called triptans that have been developed to abort a Migraine attack. Opioids and butalbital compounds only treat the pain symptom of a Migraine attack. Finally, these medications can impair the person’s ability to function in his or her day-to-day life and may lead to dependence.

(5) Don’t recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache.

Patients who frequently use OTC pain medications to treat their attacks are at an increased risk for developing Medication Overuse Headache. Another important issue is the liver damage that can result from overuse of acetaminophen and products that contain it. Finally, prolonged use of nonsteroidal anti-inflammatory medications (NSAIDs) can result in gastrointestinal bleeding. None of these risks are worth it considering we have targeted, effective medications in the triptan category that help many Migraineurs.1

Please share any questions you have about these recommendations in the comments.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

1. American Headache Society, Five Things Physicians and Patients Should Question handout.


  • knittingmomof3
    5 years ago

    I do hope for some this article is helpful, for me, most of the tips do not apply. I have had severe and chronic migraines with aura for almost 35 years. I have tried all the medications, and have gone from terrible reactions to no help whatsoever. Triptans are wonderful if they work, but there are some of us with very severe allergic reactions, so the “magical” abortive is useless to us. “butalbital compounds only treat the pain symptom”, true and what I need at the time my pain is at a 8-10. As for MRI verses CT, a lot of insurance companies will not pay for an MRI until a CT scan is done (makes no sense to me, but it is how some insurance companies operate). And my ER does CT scans, since if I am in there, it is possible it is a stroke, I had one in 2007, better safe than sorry.

  • Head-Throbbing-Woman
    5 years ago

    Who wrote this article and where did the info come from. The statement – “Further, there are medications called triptans that have been developed to abort a Migraine attack.” really bothers me because it would lead people to think that everybody can take triptans and that they work for everybody, when we know full well that they don’t and that there are those who cannot take them.

  • Jeff Scott
    5 years ago

    I just found this site and am interested to learn more. I first suffered with migraines as a child with dibilatating pain and nausea. Now, I guess I am lucky. I don’t have the pain but only horrible optical distortions and some nausea. I have been to doctor’s who tell me that there is no known treatment for these optical migraines. I know that lack of sleep, weather, moldy conditions and perfume will trigger me. It can be annoying as I cannot work or drive in the throes of one of these attacks. Has anyone had experience in treating these? right now, the best I can do is take Advil and Sudafed which seems to keep swelling down in my sinuses and prevent an attack. If I have an attack and take those OTc meds I can usually end it in about a 1/2 hour. Thanks for your help.

  • lmwilber
    5 years ago

    I’m in the middle of a long bout of migraines and I’m so fed up with seeking help from the medical community and being experimented on when I know what works and doesn’t work. I’ve had them for over 30 years, recently shifted into the chronic category. I just want some relief and to have something resembling a life. My latest ER experience resulted in me getting lectured about rebound headaches like I’ve never heard of them, a CT scan for a “regular” migraine that came back as normal (big surprise), a cocktail of pills that have never worked before even when given in an IV, an attempt to give me a Haldol injection when I clearly stated that the two previous experiences with that drug had about sent me out of my mind. Thankfully I had a friend with me to advocate on my behalf when I was reduced to tears. Their final attempt at help before just giving up and sending me home was an injection of Imitrex which worked. Clearly a migraine med, why didn’t we try that first? So frustrated by whole situation and tired of being treated with suspicion. Thank you all for listening to my whining. It helps to talk with others that understand.

  • Gail
    5 years ago

    I am right there with you. I know Imitrex works, and I can’t help it that I need more than 20 in a month (2 per day per episode is all that controls them), and my current doctor SAID at the beginning (a year and a half ago) when I started seeing him that he understood that I knew what I had (migraines for over 32 years, recently chronic) and that I know what works. So why NOW does he suddenly want to send me to a neurologist? This after I recently had to go to the ER in fear of having a TIA because of a preventive med he also recently decided he wanted to “try” on me, and they gave me a CT scan that was – surprise – completely normal. As if I haven’t tried everything under the sun over the last 32 years. Anyway, you are not alone, and you are not whining! Hang in there!

  • Amy
    5 years ago

    Well I have to agree with schrisman. I know it states, “As the first line of treatment.” However, when one is in such pain and OTC medicines just aren’t cutting it, it’s becomes pretty obvious that “something” is wrong. And once your PCP finds out just how much of OTC medicines you’ve been taking, you get yelled at and lectured about what could happen to your liver, etc…you then get told to go see a neurologist. That’s when it all starts…
    I was diagnosed with chronic migraine over three years ago. I’ve tried Imitrex, Demitrex, Relpax (all three didn’t work and made me feel like I was having a heart attack!), Topamax (was taken off-extreme weight loss-down to 102 lbs from 130 lbs in less than two months), Nortriptyline (couldn’t keep it down), Botox (24 injections in my head-temples, neck, nape of head, and shoulders. BACKFIRED!! I ended up in the hospital because I couldn’t swallow, walk, sit, stand and lost work/money due to all of these side effects. Injections were done in Feb. and didn’t wear off until late June.) Since then, my neurologist has put me back on the Topamax at the same dosage (100 mg per day) and closely monitored (holding at 108 lbs) has not had the same effect. At my last visit he also decided to add Propranolol (40 mg per day and it’s kicking my rear). I do have to say that I am REALLY TIRED of being the EXPERIMENT. When the Botox backfired my neurologist put me on display for his interns to observe, it was quite embarrassing and looking back I was just in so much pain and discomfort I didn’t care. I just wanted something for PAIN so I could get out of there, go home and try and rest. I think what really gets my goat here is that I KNOW my body. I know when something isn’t right. If I’m in pain I want it gone like yesterday! Not when they tell me I can have it gone. What I find strange is that my neurologist gives me a hard time about giving me Vicodin and doesn’t understand my pain. That what he’s giving me, Topamax and Propranolol, only lessen the severity of the pain, they AREN’T CURES. This “rebound” migraine isn’t flying with me. I was experiencing migraines and diagnosed with chronic migraines BEFORE I came to him. He’s my second neurologist and I think I may need to find another. He also needs reminding that he isn’t a “MIGRAINE SPECIALIST.” The closest one to me is in California and I live in Arizona. My PCP will write a prscription for anything I need. He sees me when I go into his office, which is the same as I look when I go into my neurologist’s office, and can’t understand. He seems to know there isn’t a CURE. He doesn’t want me to “DAMAGE” my liver so he writes away. It’s a catch 22 at both ends but there’s no need to suffer.
    The fact is, I don’t abuse my pain meds. I am a single parent with a single income. If I’m not working, there’s no income. If there income, there’s no food, gas, electricity, etc…I NEED to be able to “FUNCTION.” I’m not wacked out of my mind at work. Believe me, if I was, they would send me up for a drug test in a heartbeat!! But I’ll tell you something else, a lot of people are always telling me that I should get myself a Marijuana card but it just isn’t my thing. Should the day come that “MY OPTIONS” are lessened or taken from me because some “EXPERT” thinks it unwise to write priscriptions anymore, I’m sorry, I might just have to. I REFUSE to live in pain!!! I follow the rules and have tried MORE than MY fair share of medications. They DARE, to try and take my PAIN MEDS from me! I’m in total AWE!!

  • Ellen Schnakenberg
    5 years ago


    I don’t know who you are seeing, but the truth is, some of the best Migraine specialists in the country are in Arizona. Here is a list of links you can go to to find those who have chosen to be listed. Mayo’s in Phoenix is an A.Ma.Zing resource pool, and some of my favorite specialists treat patients there.

    Here is that link for you:

    Please understand, nobody wants you to live in pain, and if your Migraine itself is treated, you won’t be in pain anymore. Finding a good combo of treatments that eventually help you can be time consuming, but also life changing. I know you’re frustrated, but getting hold of a really great specialist will be a great first step in figuring this out and getting better management so you feel better. Hopefully soon!


  • schrisman
    5 years ago

    As a sufferer for more than 30 years, I find #4 to be more and more infuriating as time goes on. The only part of the med conversation that has eased up in regards to which meds when is that triptans are FINALLY becoming more affordable. Telling someone they cannot or should not take the affordable meds that allow them to function until a migraine passes when the alternative is cost-prohibitive for every attack and comes with nasty side effects (and is now being found to be a risk for rebound, too) isn’t acceptable.

    I have found for myself through years of trial and error what works best for me on any given day to get through based on my activities for the day and type of pain I’m experiencing. Not only have I NEVER experienced any type of dependence, I’ve not dealt with any MOH/chronic migraine from any opioid or butalbital compound. Being unable to obtain Vicodin, which is the ONLY rescue med that is able to temper the at times debilitating pain escalation from muscle tension- with a 1/2 pill dosage and zero side effects, to boot- makes me angry in a manner that’s hard to explain except that I know I shouldn’t have to suffer and yet… here I am. It’s not for every migraine. I like many others in my situation have a responsible use history- a single 20-pill script lasting 8 months on average. My Esgic scripts used to have to be re-written because more than half the bottle was left and they’d expired 6+ months ago. My family doc doesn’t prescribe Vicodin as a rule because he’s had issues in his practice w/drug seekers. When I’ve asked about it, I’m told it’s virtually guaranteed that I’ll have rebound headaches AND become addicted, despite my history of neither.

    The irony… he recently began writing me Adderall prescriptions for ADD. Not a single word about dependence, or my ‘additional risk’ for dependence based on having a 50hr/wk job plus running a business. I’m not saying that the risks aren’t there, and I’m not trying to say that dependence to opioids doesn’t happen. But that conversation needs to be tempered with the fact that for some patients it IS a valid and very useful part of the toolbox. This reframing of the opioid/butalbital conversation is harming patients that use them responsibly and find relief in a very real way.

  • Head-Throbbing-Woman
    5 years ago

    Same for me and the statement about triptans is written in a way that suggests everyone can take them and that they always work. Some people cannot take them – such as those with hemiplegic migraines, cardiac problems, etc. I agree overwhelmingly that feeding into the media frenzy about opoids and butalbital is just making things harder for those who take them responsibly and need them – and sometimes for more than just migraine. This stuff against narcotics is all fed to us from the DEA and MSM. And yet so many just buy into it.

  • Diana-Lee author
    5 years ago

    Further, you might be surprised how many patients and physicians who treat Headache Disorders patients have no idea to try triptans first in most patients.

  • Diana-Lee author
    5 years ago

    Please note that the guidelines say first line treatment.

  • mindzfuleez217
    5 years ago

    Good article, valuable information reiterating my personal stand against these medications of which over many years has only contributed to more health issues. So “not” acceptable is the first line treatments of opioid or butalbital-containing medications.

  • Jen Fra
    5 years ago

    As an MRI technologist and MRI sufferer I am glad to see points 1 and 2. Diagnostic imaging is greatly overused by many physicians for the lack of clinical skills. As for the use of MRI, not everyone is a candidate and must be carefully screened prior to entering the MRI suite. Many implants and procedures currently under trial are contraindicated for MR imaging. In situations where the patient is unable to provide a medical history they may not be able to receive an MRI unless someone can speak for them or near full body x-rays are performed to query for any foreign body. When time is of the essence in trying to rule out acute stroke or bleeds CT may be the better option.

  • Diana-Lee author
    5 years ago

    Yes. I think it’s all about balance, and I appreciated the way the physician experts who developed these guidelines worked hard to achieve that balance.

  • lara
    5 years ago

    #1 is sort of funny in an unfunny way. It shows how absolutely clueless the disability determination set is. I just round and round with a social worker in Washington who was SURE an MRI would prove/disprove migraine as a disability. She opted… disproved.

    Now, of course, I have to go through several appeals to prove how incompetent she is because… no. ARRGGHH. It’s sad when patients know more than the people evaluating cases.

  • Newdancerco
    5 years ago

    I think at this poiny we ALWAYS know more than the “experts”. We focus on our issue, study it, learn it’s intricacies. They have to learn numerous diseases, so they can’t be as good with any one.
    That’s why I am my own advocate. I seek out ideas and options to present. Most get dropped after a discussion, but I need to keep trying. If I don’t, I’ll give up completely.
    I’m to the point we are talking surgical intervention. I have a gabapentin gel I’m using in conjunction with trigger point injections. If they work, I’ll be a candidate for neural ablation. I’m also looking into nerve decompression.
    Triptans don’t work. Topamax doesn’t work.
    After being diagnosed for over 20 yearsgoing through 7 different NEUROLOGISTS (never mind PCPs) including headache specialists and idiots (what else do you call someone who says your migraine is because you don’t have a hobby [bored housewife, nevermind the full time job] and are breathing too much??).
    I’m tired of everyone telling me I’m nuts, I’m lying, I’m making it up for attention.
    I HURT. I want it to STOP. Like, last week. Don’t tell me I can’t take these surgical steps- they are my lastchope.

  • Diana-Lee author
    5 years ago

    Very sad and very frustrating. 🙁

  • Sherri
    5 years ago

    Hello. This is my first post. I have a question. I’ve had chronic migraine for 3 years. I take Percocet daily in order to continue working and taking care of my family. Has anyone quit Percocet before? And how long did it take for the “rebound ” headaches to go away. I’m going to need time off of work to do this. My pain is constant , not episodic. It started that way (without Percocet) and it stayed that way. God help me, I haven’t had a day without pain for 3 straight years !!! Sherri

  • Diana-Lee author
    5 years ago

    If you’re not sure if you’re dealing with Medication Overuse Headache (MOH), working with your doctor to take time away from the Percocet would be a good idea.

    Unfortunately, it the time it takes to move on from MOH can vary widely from patient to patient, but some experts think it could possibly take anywhere from 3-6 months based on what we’re hearing at the most recent physician conferences.

    Unfortunately, there are some of us with Chronic Migraine who aren’t experiencing MOH and whose attack frequency will not be impacted by a vacation from a potentially offending medication. In which case it’s important to carefully evaluate your management options with your care team. But if you haven’t done the experiment, so to speak, to rule out MOH, I think it’s incredibly important to do so.

    I hope this helps!

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