Dr. Amaal Starling was in college when she first started getting intense headaches. But it wasn't until she developed symptoms of a visual aura along with the pain that she realized they might have been something more than headaches.
"I had a couple of episodes of visual aura, where I would lose a part of my vision, and that was a very, very scary experience," Starling, a migraine and headache expert at Mayo Clinic in Arizona, tells TODAY.com.
In one particularly serious episode, Starling recalls vomiting and laying on the cool floor of a public bathroom, "which just sounds disgusting," she says. "But that tells you how severe an attack can be."
For Dr. Susan Broner, the headaches began in fifth grade. "I remember exactly where I was, I remember how painful it was," Broner, neurologist and medical director of the Weill Cornell Medicine Headache Program, tells TODAY.com.
And she experienced her first migraine aura around age 20 while eating at a Chinese restaurant in New York City. "I was scared. My vision sort of closed in. I couldn't see. It was hard to walk home," she recalls. Later, in her late 30s and early 40s, Broner started to get nauseous with her migraine attacks and began to take them more seriously rather than simply pushing through.
“As I learned more about headache medicine, I learned to manage my headaches, and then over time they have improved a lot,” Broner says.
After initially being told she just needed to reduce stress in her life, Starling relied heavily on over-the-counter medications and developed medication overuse headaches. But, in medical school, Starling learned about migraine and prescription triptan medications.
"It was like the clouds parted and heaven opened up," she recalls.
Here, migraine specialists share the techniques they use to manage their own migraine attacks — and how they counsel their patients.
I stick to my routine as much as possible, but I also give myself grace.
Dr. Aruna Rao, an assistant professor of neurology at Johns Hopkins Medicine, remembers getting early migraine warning signs — motion sickness, ice cream headaches, blurry vision — as a child.
Two severe episodes, one after having her first child and one as a resident in medical school, confirmed that she had experienced migraine attacks, she tells TODAY.com. "In both situations, it was sleep deprivation that triggered it," she explains.
Rao’s main migraine triggers are sleep deprivation, skipping meals, dehydration and stress, she says.
Managing migraine starts with creating stability, Starling says. She follows the same advice she gives her patients, which is to focus on the "SEEDS for success in migraine management," she says.
That's an acronym for focusing on good sleep hygiene, eating regular, healthy meals, exercising regularly, keeping a headache diary and developing effective stress-management techniques.
Now, Rao says she's "very diligent" about the healthy behaviors to manage those triggers, including getting good sleep every night and practicing meditation and breathing exercises when she feels stressed.
But there are times when our schedules and responsibilities simply don't allow us to stick to those routines. And when that happens, the experts recommend accepting that and committing to the factors that are in your control.
“No. 1, I give myself grace at different time periods in my life,” Starling says, like when she's traveling through time zones. “I just know that things are not going to be as stable as when I’m home and on my regular schedule, so I try to maximize the other things (that I can control),” she explains.
For example, Starling tries to keep herself really well-hydrated and avoids caffeine when traveling. She also takes care to keep her hotel room stocked with healthy, filling snacks so she never has to go without food for too long. And, to ensure she gets good sleep, she'll rely on magnesium and melatonin supplements at night.
Broner loves to snorkel on vacation, but she knows the hot weather and dehydrating activity can trigger her migraine attacks. "If I'm on vacation in a warm place and I know I'm going to be doing a lot of activities, then I will start hydrating really early with electrolyte drinks that don't have sweeteners or artificial ingredients," she explains.
I know my triggers, but I don't obsess over them.
Some people find that certain activities, foods, smells or environmental changes can trigger their migraine attacks.
"It's so important to pay attention to your triggers and to put a lot of energy upfront into that," Rao says, "because prevention for migraines is much easier than the cure."
She recommends patients track the relationship between their migraine symptoms and things like stress and their menstrual cycle to know what to look for in the future.
Starling finds that fluctuations in blood sugar levels can trigger her migraine attacks, so "I try to stick to (foods) that have a really good glycemic index because you're trying to prevent those peaks and valleys in your sugar levels," she says.
For Broner, smells are major triggers — especially perfumes, she says. "I like perfume but there's very few that I can wear without giving me a headache," she says. "So I will ask for a sample and try it out. And if I start not feeling right in the first five minutes, it gets washed off immediately."
Broner also realized that sleeping in on the weekends was triggering her attacks, so she now wakes up at the same time throughout the week.
But many common triggers — like weather patterns and hormonal fluctuations — are largely out of our control. And each person will have a different set of triggers to think about, the experts say, which means your mileage may vary when it comes to avoiding the specific things you think may be bringing migraine attacks to the fore.
"Many people with migraine can't identify specific triggers, and I think it's probably because triggers stack," Broner says, meaning that the more triggers are present, the more likely it is that someone will have a migraine attack. But if just one trigger is present (a change in sleep schedule, for instance), they may not have an attack.
Starling is careful not to overemphasize the role of triggers in migraine with her patients due to the prevalence of internalized stigma about migraine, she explains. Focusing too much on triggers may cause patients to feel guilty for experiencing migraine attacks despite their best efforts to avoid those triggers.
"What I tell myself, as well as my patients, is if there's something very, very obvious that triggers your migraine attacks specifically, by all means, avoid it if at all possible," she says. "But you may be avoiding every trigger that you can think of and still have migraine attacks because it is a genetic, neurologic disease. Triggers are not the cause."
I have a go-to treatment plan for every situation.
Both Broner and Starling have specific treatment plans ready to go at the first sign of a migraine attack, but they reach for different medications depending on their circumstances.
"The triptans, like rizatriptan, I tolerate pretty well, and I can take that during the work day," Starling says, adding that she keeps some in every bag that she uses.
"But If I end up having to break a migraine attack cycle with steroids, that's not one I like to use during my work day because it makes me really shaky," she adds. "I usually will save that for the weekend when I may not have to do procedures."
Rao has success with using over-the-counter medications, like ibuprofen and naproxen, at the first inkling of a headache. But she's also careful not to use them too frequently to avoid a rebound headache: "Typically, I will take it two days in a row if I need to. But that's about it," she says.
For Broner, "I've worked my way through the triptans and found that they gave me more side effects than benefits," she says. Instead, she's found the class of medications known as gepants to be effective with fewer side effects. These drugs target receptors for proteins that contribute to inflammation in the tissues surrounding the brain.
"When I treat early, I don't lose my day," she says. "I can do everything I want to do on vacation or at work, and I don't have to miss out."
But I know that what works might change over time.
As specific symptoms and life circumstances change, so might your migraine treatment plan, the experts say.
"Migraine disease fluctuates," Starling explains. There may be times in your life when the attacks are more frequent, and it's beneficial to start using a daily preventive medication, for instance. But that doesn't have to last forever, she says.
“When I was a resident and when I was a new mom, it was really hard to get consistent sleep, eat three whole-food meals every day and get exercise,” Starling says. During those times when it's more challenging to stay consistent, your migraine attacks might come more frequently, which is when "I need more help from other treatment options in the toolbox," she says.
That could include supplements, a preventive medication or even a non-invasive migraine treatment device.
After a migraine attack, I focus on self-care.
Migraine symptoms don't always end when the attack is over. For some, a postdrome phase — or "migraine hangover" — leaves them feeling fatigued and with a lingering sensitivity to light and sound.
"During that postdrome phase, I feel like my threshold is low," Starling says. "I have to practice as much self-care as I can."
For her, that means dimming the lights in her office, being careful not to skip meals, staying hydrated, and "I just have the awareness that today is not going to be a day where I'm going to multitask 15 different things."
Broner doesn't usually have severe postdrome symptoms, "but even after the pain's gone, I can still feel not 100%," she says, adding that she may just take it easy and not be as lively in her interactions with others that day. "What I usually do is I just share that with people that I'm with," Broner explains. "I just want to let people know what's going on."
If you struggle with migraine attacks and need help with treatment, see your primary care provider, who can refer you to an appropriate specialist.
