A neurologist specializes in disorders of the nervous system and manages complex and chronic headache conditions, particularly migraines. While routine migraines are often managed by a primary care provider, a neurologist’s expertise is sought when cases are refractory (difficult to treat) or when the diagnosis is unclear. The specialist brings advanced training in the underlying neurological processes of migraines, allowing for a personalized and intensive treatment strategy. This approach addresses the frequency, severity, and overall impact of the migraine disorder.
Specialized Diagnostic Approach
A neurologist’s evaluation begins with an exhaustive patient history, the most informative tool for diagnosis. The physician documents the frequency, duration, and intensity of attacks, along with accompanying symptoms such as nausea, light sensitivity, or visual disturbances (aura). Patients are encouraged to maintain a detailed headache diary to track potential triggers, including hormonal changes, specific foods, or sleep patterns.
This process aims for a differential diagnosis, ruling out serious conditions that mimic migraine symptoms. A detailed neurological examination assesses reflexes, motor strength, coordination, and sensory responses to ensure symptoms are not caused by an underlying structural issue. Neuroimaging (MRI or CT scan) is typically ordered only if “red flag” symptoms are present, such as a sudden onset of the worst headache or a change in headache pattern after age 50. Imaging tests exclude secondary headaches caused by issues like tumors, infections, or vascular problems.
Pharmacological Treatment Strategies
Neurologists develop a balanced pharmacological strategy combining acute and preventive therapies. Acute (abortive) medications are taken at the first sign of a migraine to stop the attack from progressing. Preventive medications are taken daily to reduce the frequency and severity of future episodes. Selection is based on the patient’s migraine type, frequency, and overall health profile.
For acute treatment, neurologists prescribe Triptans, a class of drugs that target serotonin receptors to constrict blood vessels and block pain signals. Newer, migraine-specific options include Ditans (like lasmiditan), which selectively bind to a specific serotonin receptor subtype, and oral Calcitonin Gene-Related Peptide (CGRP) receptor antagonists, known as gepants (e.g., ubrogepant or rimegepant). Gepants block the CGRP peptide, a potent signaling molecule implicated in migraine pain transmission, offering an alternative for patients who cannot tolerate triptans.
Preventive strategies focus on reducing monthly migraine days, often employing medications initially developed for other conditions. These repurposed drugs include anti-seizure medications (e.g., topiramate), beta-blockers (e.g., propranolol), and tricyclic antidepressants (e.g., amitriptyline). The neurologist titrates these medications to balance efficacy against potential side effects, aiming for at least a 50% reduction in migraine frequency.
Advanced Interventional and Non-Drug Therapies
Neurologists manage advanced, procedural treatments when oral medications are insufficient. One therapy is OnabotulinumtoxinA injections (Botox), approved for chronic migraine (15 or more headache days per month). The treatment involves a precise protocol of 31 small injections into seven muscle areas of the head, neck, and shoulders, repeated every 12 weeks. The toxin works by blocking the release of pain-signaling neurotransmitters at nerve endings.
Neurologists also manage injectable CGRP monoclonal antibodies (mAbs), such as erenumab, fremanezumab, and galcanezumab. These preventive treatments specifically target the CGRP peptide or its receptor, offering a highly focused mechanism of action with fewer systemic side effects than older preventive drugs. mAbs are typically administered via subcutaneous self-injection monthly or quarterly; eptinezumab is given as an intravenous infusion every three months.
The specialist may utilize nerve blocks or trigger point injections, involving an anesthetic and sometimes a steroid near specific nerves in the head and neck for temporary relief during acute periods. Neurologists can also prescribe non-invasive neuromodulation devices, such as those using remote electrical stimulation or transcranial magnetic stimulation. These devices offer a non-pharmacological approach to interrupting pain signals in the nervous system for complex cases.
When to Seek a Neurologist Consultation
A consultation with a neurologist is necessary when migraines are frequent, severe, or significantly impact quality of life. A clear sign requiring specialist management is the failure of two or more preventive oral medications tried for an adequate duration. Individuals experiencing 15 or more headache days per month should seek a specialist to evaluate for chronic migraine and discuss advanced treatments like Botox or CGRP injectables.
Specific neurological “red flags” require immediate specialist attention to rule out a dangerous underlying condition. These include the sudden onset of a “thunderclap” headache, a new headache pattern developing after age 50, or any headache accompanied by concerning symptoms like weakness, slurred speech, confusion, or a prolonged visual aura. Seeking a specialist ensures an accurate diagnosis and access to the full spectrum of advanced, targeted therapies.