Q&A: Expert Talks Migraine Myths, Resources for Migraine Awareness

The migraine landscape is complicated. Although more than 1 billion people worldwide experience the condition,¹ research in the field has under paced, patients in need of care vastly outweigh the amount of headache specialists available, and migraine triggers and presentations vary from person-to-person, generating a lot of conflicting information.

In 2019, headache disorders were found to be the third highest cause of disability-adjusted life years globally, following stroke and dementia.² What’s more, the condition has been estimated to cost employers up to $78 billion annually, largely due to lost productivity and absenteeism.³ Given migraine’s significant impact on quality of life, it’s important for health care professionals to provide patients with factual counseling on courses of treatment, triggers, and referrals. Pharmacists, with their expertise and accessibility, are well suited to take on this role.

For Migraine and Headache Awareness Month, Drug Topics spoke with Shivang Joshi, MD, MPH, RPh, FAHS, director of headache medicine and director of clinical research at Community Neuroscience Services, as well as Association of Migraine Disorders board member and Shades for Migraine medical ambassador, to debunk migraine myths and explore resources to promote migraine awareness and education.

READ MORE: Migraine and Headache Awareness Month: Resources Roundup

Drug Topics: There’s a lot of misinformation around migraine triggers. Why do you think myths persist about headaches and migraines compared to other conditions?

Shivang Joshi, MD, MPH, RPh, FAHS: I think that's a very good question. Certainly, you hear about triggers all the time—what's different about that is that triggers are not always triggers all the time. For example, barometric pressure is a trigger for some patients, but sometimes it's not. Sometimes skipping a meal is a trigger for some patients, but sometimes it's not. We like to say [it’s] the perfect storm. For example, you skipped your meal, you didn't hydrate well, maybe you ate something that was a food trigger. So, it's really a combination of different things that can sometimes bring on a migraine, or if you're susceptible to having migraines, [that] might bring it on more so. Triggers have been studied, but it's very difficult, historically, to have a good clinical article examining triggers because of so much variability in the way it presents.

Drug Topics: One myth has to do with caffeine. Although it’s often used to treat migraines, it can also make them worse. Can you clarify the role of caffeine and migraines?

Joshi: That’s a complicated one. I personally don't like to take away my patients’ caffeine. What we don't like is caffeine in a tablet form, because sometimes it can cause rebound headache. If a patient wants to have 1 or 2 cups of coffee, and they sip it slowly, I think it's okay. For some patients, caffeine is specifically a trigger. So, every time they have a cup of coffee, it immediately triggers a migraine. That's more on the rare side. I'm not opposed to having my patients have some coffee. Now, it becomes an issue when you're having 1 pot, 2 pots, several pots—a lot of caffeine in that form. The caffeine acts like a drug, right, anything is a drug if you use it in certain quantity amounts. The other part of this is caffeine is a well-known diuretic so it can dehydrate you, which again promotes migraines. So, I think a little bit of caffeine is okay as long as it's regular [and] it's not causing reflux or any other adverse effects.

Drug Topics: Some say that stress is a migraine trigger. Is stress really that big of a culprit, and are there relaxation techniques patients can use that might help?

Joshi: If you look at some of the top answers that patients give, stress is really high up there. The way I like to frame it with my patients is, what happens when you're having stressful events, like what does it do to you? If it's disrupting your natural sleep, if it's affecting your ability to make sure you're hydrating while keeping a regular schedule, then you can clearly see the impact of stress and then how it indirectly can cause or affect migraines. I think that there's still some research being done for how stress affects the muscles and tightening of things, and so certainly, those can be factors as well. I'm all for relaxation techniques, meditation, anything that will affect your ability to react or respond to stress is very helpful.

Drug Topics: Sugary foods have been said to cause migraines. Is there any truth to this, and are there other dietary factors patients with migraine should be aware of?

Joshi: I really like that question, because there's another myth I'm going to clear up. I'm sure we've heard that chocolate is a trigger for migraines for some patients. Now, there's some data that suggests that there's a part of the brain called the hypothalamus which deals with cravings, yawning a lot, peeing a lot, mood changes, but also salty and sweet cravings. So, it turns out that sometimes people are maybe craving something sweet or maybe salty, and that craving is an early sign that the migraine is coming. It's called the prodrome phase, or early phase, of a migraine. When they eat something sweet or eat something, say chocolate, and they have a headache, they attribute the headache with that sweet food component, but the reality was that it was an early sign that the migraine was coming. I think you have to be really careful attributing sugary foods to a migraine trigger. I do have to mention that the brain does like balance. If you're diabetic and your sugar is high or low, or if your thyroid is off, high or low, it can predispose you to having more migraines. So, when it comes to sugar, [it’s] not necessarily a trigger, but you want to always keep things in balance.

Drug Topics: For patients with headache and migraine, what are the most effective OTC medications available at the pharmacy? How can patients choose the right 1 for their specific needs?

Joshi: Patients will migrate towards over-the-counter stuff. Access to a headache specialist is sometimes limited, so they'll self-medicate. I think you have to be careful with over-the-counter medications. They should still be used with the guidance of your neurologist, headache specialist, or primary care doctor. I think what [patients] should avoid, [and] what they tend to migrate towards, is combination medications with Tylenol or aspirin or caffeine. Again, caffeine in a tablet form should be avoided. But we generally sometimes do recommend patients take sometimes an [non-steroidal anti-inflammatory drug] along with their migraine medication, and so those are some adjuncts that we sometimes use. Sometimes we will recommend using Tylenol, [but] there are some different formulations that may work better. For example, there's a rapid release formulation of Tylenol that may work better for migraine patients versus a regular formulation.

Drug Topics: Beyond medication selection, how can patients best utilize the pharmacy’s resources to manage migraines?

Joshi: That's a great question because I was a pharmacist at some point too, so I've worked behind the counter and retail. Pharmacists, historically, are ranked by patients as the most trusted health care professionals. Most pharmacies offer a counseling service scenario. So, I encourage you to go and speak to your pharmacist about your medications. I think the pharmacists play a very key role in health care delivery. And part of that is that if they see that a patient is consuming a lot of over-the-counter analgesic medications with caffeine in them, or just a lot of medications, they might want to have a conversation and say, “Hey, maybe this is not working for you. There are better migraine medications available.”

Another aspect of it is if they're on many antihypertensive medications, and let's say they're on the older generation triptan-type medications, typically blood pressure is uncontrolled, triptans are contraindicated. So, those are things that pharmacists can pick up [on] as well. Or, if they're using barbiturates or opioids to treat their migraines, that can lead to [a] rebound component as well. I think pharmacists really play an important role in helping patients maybe stay away from the harmful aspects, but also maybe get to newer, better tolerated medications, or more effectively use some of their older generation medications without adverse effects.

Drug Topics: Can you tell us a little bit about how people can get involved with shades for migraine?

Joshi: Anyone can get involved with Shades for Migraine, so, we encourage you to do so. Participating is fun, it's easy, it's during the month of June, which is Migraine and Headache Awareness Month. You can post a photo wearing sunglasses to social media with #ShadesForMigraine, and by doing so you'll show your support for anyone that's living with migraines. You also create some more awareness for research, as well. You can learn about this more by going on to shadesformigraine.org.

If you're really interested, you can also obtain some of the signature purple glasses and educational materials for your clients and patients. You can also visit the website to request the materials, and I'll show you a sample of some that I've received myself. These are the glasses that I have. So, they're kind of cool.

READ MORE: Headache and Migraine Resource Center

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References

1. Amiri P, Kazeminasab S, Nejadghaderi SA, et al. Migraine: A review on its history, global epidemiology, risk factors, and comorbidities. Front Neurol. 2022;12:800605. doi:10.3389/fneur.2021.800605

2. Migraine and other headache disorders. Fact Sheet. World Health Organization. Accessed June 20, 2024. https://www.who.int/news-room/fact-sheets/detail/headache-disorders#:~:text=Not%20only%20is%20a%20headache,the%20individual%20to%20other%20illnesses.

3. Migraine At Work. Accessed June 20, 2024. https://migraineatwork.org/about/