Migraines

Migraines: Causes, Differential Diagnosis, and Treatment Options


Migraines are a complex neurological condition characterized by recurrent, often debilitating headaches, sometimes accompanied by nausea, visual disturbances (aura), and sensitivity to light and sound. Migraines can be triggered or worsened by various systemic, hormonal, or environmental factors.


Hormonal Causes of Migraines

  • Estrogen Fluctuations: Sudden drops in estrogen, such as before menstruation or during perimenopause, are a common migraine trigger.
  • Progesterone Imbalance: Low levels of can amplify the effects of estrogen and trigger migraines.


Treatment of Hormonal Migraines:

  • Bioidentical hormone therapy (e.g., transdermal estradiol + oral/vaginal progesterone)
  • Magnesium glycinate or threonate (400–600 mg daily)
  • Riboflavin (Vitamin B2, 400 mg daily)
  • Continuous hormonal contraceptives in select patients
  • Stabilizing blood sugar and adrenal support



 Differential Diagnosis (DDx) of Migraines:

  • Tension-type headache
  • Cluster headache
  • Cervicogenic headache
  • Temporal arteritis
  • Sinusitis
  • Intracranial pathology (e.g., tumor, hemorrhage)
  • Idiopathic intracranial hypertension
  • Medication overuse headache
  • Occipital neuralgia
  • Trigeminal neuralgia



    Types of Migraines:

  • Migraine with aura
  • Migraine without aura
  • Chronic migraine (15+ headache days/month)
  • Menstrual migraine
  • Hemiplegic migraine
  • Vestibular migraine
  • Retinal migraine


Standard Treatments for Migraine:

  • NSAIDs (ibuprofen, naproxen)
  • Triptans (e.g., sumatriptan)
  • Gepants (ubrogepant, rimegepant)
  • Ditans (lasmiditan)
  • Anti-CGRP monoclonal antibodies (erenumab, fremanezumab)
  • Beta-blockers (propranolol)
  • Antiepileptics (topiramate)
  • Antidepressants (amitriptyline, venlafaxine)
  • Botox (chronic migraines)



 Mast Cell Activation Syndrome (MCAS) and Migraines

Mast cell degranulation can release histamine

and other pro-inflammatory mediators, triggering migraines.

Associated Symptoms:

  • Flushing
  • GI distress
  • Itching or hives
  • Brain fog

MCAS Treatment Options:

  • H1/H2 antihistamines (loratadine, famotidine)
  • Mast cell stabilizers (cromolyn sodium)
  • Low-histamine diet
  • Quercetin (500 mg BID)
  • DAO enzyme support



 Vitamin Deficiencies Linked to Migraines:

  • Magnesium
  • Riboflavin (B2)
  • Vitamin D
  • CoQ10
  • Folate/B12 (especially with MTHFR mutations)


   Hormonal Imbalance & Migraine Management

  • Saliva or serum hormone panels to assess estrogen, progesterone, testosterone, cortisol, and DHEA
  • Consider cyclic or continuous hormone therapy based on pattern
  • Address adrenal disbalance with adaptogens
  • Balance blood sugar and avoid insulin spikes


 Post-Traumatic Brain Injury (TBI) and Migraines

  • Migraine-like headaches are common after TBI
  • Contributing factors: neuroinflammation, pituitary dysfunction, altered cerebral blood flow

TBI-Related Migraine Treatment:

  • Omega-3s (EPA/DHA)
  • Anti-inflammatory diet
  • Low-dose naltrexone (LDN)
  • Neuroprotective supplements (creatine, NAC, curcumin)
  • Hyperbaric oxygen therapy (in some cases)
  • Referral to neurology or neurorehabilitation


Diet and Lifestyle Interventions

  • Eliminate common triggers: aged cheese, alcohol, caffeine, MSG, artificial sweeteners
  • Low-histamine or anti-inflammatory diet
  • Hydration and electrolyte support
  • Regular exercise (without overexertion)
  • Sleep hygiene
  • Mind-body interventions: meditation, breathwork, acupuncture, CBT



Migraines are multifactorial and require a personalized approach to diagnosis and management. Understanding underlying hormonal, inflammatory, nutritional, and neurological contributors can significantly improve outcomes and reduce reliance on acute medications alone.

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