The End of Migraines: 150 Ways to Stop Your Pain by Dr. Alexander Mauskop offers an incisive, cutting-edge approach to migraine treatment. It is well researched, informative and hopeful, providing ingredients that migraine sufferers truly need and can benefit from.

What resonates most for the reader is how practical a resource this proves to be. Thus, through accessible advice, one is able to “own” one’s migraine tendencies and have the knowledge needed to improve his or her condition.

Mauskop’s approach includes understanding environmental triggers, the value of exercise, meditation and diet. The book also details alternative approaches, including acupuncture and reflexology, along with more traditional medications prescribed to migraineurs. The breakdown of medications, citing the positive and negative effects, is particularly useful.

This Q&A with the author provides a deeper look into the topic and some more ideas to help sufferers.

Q: In your many years in practice as a neurologist, have you witnessed a change in attitude and application for those with migraines? How has the medical community’s perspective altered? 

A: In the past three decades we’ve seen a major increase in research that has elucidated the biological basis of migraines. This has led to a sea of change in thinking; a migraine is a true brain disorder, not a psychological disorder of hysterical women. The first breakthrough came in the early 1990s with the introduction of sumatriptan. Sumatriptan and six other “triptans” represent the first group of designer drugs, that is, drugs specifically developed to treat an acute attack of migraine. Botox, which I’ve been using for over 25 years, was the first highly effective and safe preventive treatment for migraines. In the past three years, we’ve seen the introduction of six drugs that counteract CGRP, a chemical released during a migraine attack. 

Q: Your book lists environmental “triggers.” These are significant since some, such as bright lights and odors, can be avoided, while others, such as the weather, are more complicated. Can you explain why these evoke a migraine and what you specifically recommend if the weather is a primary issue?  

A: Some people are born with brains that are more sensitive and have a lower threshold for migraines. This means they are more prone to develop a migraine, and one with fewer triggers. These triggers include loud noise, air pollution, bright light, and strong odors, among others.

As far as the weather, a drop in barometric pressure before rain or storm is what triggers an attack. This drop in pressure often leads to an increase in migraines when people are at high altitudes or traveling by air. Acetazolamide is a medicine that can prevent barometric pressure-induced migraines. Other general health measures such as exercise can also reduce your susceptibility to these migraines.

Q: It is interesting that you cite stress as being involved in 85 percent of cases for migraineurs. What do you recommend to minimize stress? 

A: I want to emphasize that stress is not a cause of migraines but only one of the triggers, and most people need more than one of the aforementioned triggers to experience an attack. Some people develop a migraine after the period of stress is over; we call them let-down migraines.

The two best antidotes for stress are regular exercise and meditation. We have good science to prove that 40 minutes of exercise three times per week reduces the frequency of migraines and other types of headaches. Meditation has been shown on brain imaging studies to visibly change the structure of your brain.

Q: You mention that heredity plays a part in those who have migraines. Could you explain how this works? 

A: It is very common for people to have a family history of migraines. Sometimes generations of a family suffer from migraines. Extensive research shows that dozens of genetic factors can lead to the disease. It is unlikely that gene therapy will cure migraines, but what is likely is that this genetic information will allow the development of specific treatments for people with specific genetic abnormalities so we won’t have to use a trial-and-error approach when deciding which medicine to prescribe. 

Migraine, or what sounds like a migraine, has been described in ancient Egyptian manuscripts and the Bible. Having migraines may even offer some evolutionary advantage. If the intense pressure is not interrupted by a migraine that forces you to rest, you might develop a heart attack or another more serious problem.

Q: Diet seems to be a big part of the migraine equation. How does this affect a migraineur? 

A: Dietary factors may play no role in some people and can be the only trigger in others. In most, it is one of several triggers. Even wine, which is a very common trigger, can cause a migraine if you are under stress but not while you are on a vacation.

Besides alcohol, the most common dietary triggers are sugar or large amounts of simple carbohydrates, hunger due to not eating regularly, and foods with sulfites, nitrates, and nitrites. The latter group includes dried, pickled, smoked, cured, preserved, and fermented foods. Even healthy foods such as yogurt, bananas (especially overripe ones), onions, avocados, and citrus fruit can be a trigger. An occasional patient will tell me that avoiding gluten or dairy improved their migraines. 

Q: Your nontraditional approach is striking and broadens the options for pain relief. How effective is medical marijuana? 

A: Surprisingly, our brains have a large number of cannabinoid receptors. This means that we are wired to respond to cannabis. This is similar to the finding of endorphin and opioid receptors in our brains. Cannabis products have certainly benefited many patients. The problem is that we lack good scientific studies to tell us how to use them. This means that, just like with drugs, it’s a trial-and-error approach.

I’ve prescribed medical marijuana to hundreds of patients, and about half find it helpful. For most, it helps relieve nausea, anxiety, and other associated symptoms. In a small portion of patients, it also stops pain. I often prescribe it for insomnia because improved sleep leads to fewer migraines. Again, just like with drugs, cannabis has side effects and should be used judiciously.

Q: The newest group of drugs, CGRPs, has been very effective. What are the pros and cons? Do you view CGRPs as the future of migraine medication? 

A: Yes, the CGRP drugs represent another major breakthrough in the treatment of migraines. CGRP is a chemical released during a migraine attack. Blocking excessive amounts of it relieves symptoms. These drugs have been available for two and a half years, and so far appear to be extremely safe.

We have four preventive CGRP drugs. Three of them, Aimovig, Ajovy, and Emgality, can be self-administered once a month to prevent migraine attacks. The fourth, Vyepti, is given by an intravenous infusion every three months. Aimovig has a slightly different mechanism of action, and in some patients, it can raise blood pressure and cause constipation. There are two CGRP drugs available in tablet form which are taken as needed to treat an acute attack of migraine.

Q: During the time of COVID, are you hearing about more migraines and perhaps more headaches in general? Is there hope that when the world is restored to us this too will settle down? 

A: Early in the COVID epidemic, many patients were afraid to come to the office for their Botox, intravenous magnesium, and other treatments. This certainly led to the worsening of migraines. Increased screen time, the closure of gyms and subsequently reduced exercise, and interpersonal and financial stress are only some of the reasons. 

Interestingly, I’ve had some patients whose migraines improved during the pandemic. Not having to commute to work gave them more time to exercise, meditate and rest. For others, avoiding the commute or just going outside less often has reduced the exposure to noise, odors, bright lights and pollution.

About Alexander Mauskop:

Dr. Alexander Mauskop is the founder and director of the New York Headache Center. He is a board-certified neurologist and a world-renowned headache specialist as well as a Professor of Clinical Neurology at SUNY Downstate Medical Center. Dr. Mauskop has conducted and published groundbreaking research in the field of headaches; he has penned many scientific articles and serves as a reviewer for many medical journals including the New England Journal of Medicine, Headache, Neurology, and Cephalalgia. For more than 25 years Dr. Mauskop has led an educational symposium on headaches and has also trained hundreds of doctors from across the world. He has given hundreds of lectures, including grand rounds and lectures at institutions such as Cornell, Harvard, Columbia, NYU and Dartmouth Medical Schools, and Mayo and Cleveland Clinics. He has spoken at the meetings of the American Academy of Neurology, American Headache Society and International Headache Society. He is the author of two books on headaches for the general public and a textbook for doctors.