A neurologist is a medical doctor who specializes in disorders of the nervous system, which includes the brain, spinal cord, and nerves. Migraine is recognized as a complex neurological disorder involving altered brain activity and pain pathways, not merely a severe headache. When a patient experiences recurrent, debilitating headaches, the neurologist acts as a headache specialist. The specialist’s role is to accurately classify the patient’s condition and develop a personalized, multifaceted strategy for management. This specialized approach addresses the underlying neurological mechanisms of migraine to reduce its frequency and severity.
Initial Consultation and Specialized Diagnosis
The diagnostic process begins with a meticulous and comprehensive patient history, which is the primary tool for the neurologist. The specialist will ask detailed questions about attack frequency, pain severity, duration, and associated symptoms like nausea or sensitivity to light and sound. The neurologist uses this clinical information to apply the established criteria from the International Classification of Headache Disorders, 3rd edition (ICHD-3).
The ICHD-3 criteria define migraine attacks as lasting 4 to 72 hours and exhibiting at least two of the following characteristics: unilateral location, pulsating quality, moderate to severe pain intensity, or aggravation by routine physical activity. Furthermore, the attack must include either nausea and/or vomiting, or both photophobia (light sensitivity) and phonophobia (sound sensitivity). This structured approach allows the neurologist to classify the specific type of migraine, such as migraine with or without aura, or chronic migraine.
A crucial step is the differential diagnosis, which involves ruling out secondary headaches caused by underlying structural problems. The neurologist may order neuroimaging, such as an MRI or CT scan, if the patient presents with atypical symptoms or an abnormal neurological exam. Imaging is reserved for cases where the features suggest a need to exclude conditions like brain tumors, vascular issues, or stroke.
Acute and Preventive Pharmacological Treatments
The neurologist separates medication strategies into two categories: acute treatment, intended to stop a migraine attack in progress, and preventive treatment, aimed at reducing the overall frequency and severity of attacks. Acute medications are designed for rapid relief and are best taken at the first sign of an attack. This category includes nonsteroidal anti-inflammatory drugs (NSAIDs) for milder attacks, and migraine-specific drugs like triptans or gepants for moderate to severe attacks.
Triptans work by constricting blood vessels and blocking pain pathways in the brain. Newer acute treatments include oral calcitonin gene-related peptide (CGRP) receptor antagonists, known as gepants, which block the activity of the CGRP molecule involved in migraine pain transmission. The neurologist selects the appropriate acute medication based on the patient’s typical attack severity, speed of onset, and any existing medical conditions.
Preventive treatments are taken daily, even when the patient is headache-free, and are considered when attacks are frequent or severely disabling. Traditional preventive medications include certain anti-seizure drugs, such as topiramate, and beta-blockers, which were originally developed for other conditions but found to be effective in stabilizing neurological pathways. A modern class of preventive drugs is the CGRP monoclonal antibodies, which are typically administered monthly or quarterly via injection and specifically target the CGRP molecule or its receptor. The choice of preventive medication is highly individualized, often influenced by a patient’s co-existing conditions, such as anxiety, hypertension, or epilepsy.
Advanced Procedures and Interventional Therapies
For patients who do not achieve sufficient relief from oral medications, the neurologist can employ advanced, non-pill treatments that directly target pain mechanisms. OnabotulinumtoxinA injections, commonly known as Botox, are an approved treatment specifically for chronic migraine, defined as 15 or more headache days per month. This procedure involves administering injections into several sites across the head, neck, and shoulders every 12 weeks. The neurotoxin works by blocking the release of pain-related neurotransmitters at nerve endings, reducing the transmission of migraine signals.
The neurologist also performs peripheral nerve blocks, which involve injecting a local anesthetic, sometimes combined with a steroid, near specific nerves involved in headache pain. Common targets include the greater and lesser occipital nerves at the back of the head, or the supraorbital and supratrochlear nerves in the forehead region. A sphenopalatine ganglion (SPG) block, delivered through the nasal passage, may also be used to interrupt a major nerve pathway. These blocks can provide rapid, temporary relief and serve as a diagnostic tool to confirm the source of pain.
Neuromodulation devices offer another non-invasive option by using electrical or magnetic stimulation to alter nerve activity. These devices can be used for both acute and preventive treatment and are applied externally to specific nerve pathways. Examples include external trigeminal nerve stimulation and non-invasive vagus nerve stimulation, which work by sending mild electrical impulses to disrupt pain signaling. These targeted therapies are reserved for patients who have not responded well to traditional oral medications or who experience significant side effects.
Establishing a Long-Term Management Plan
The neurologist guides the patient in establishing a continuous, long-term management plan. A central component of this plan is the consistent use of a headache diary, where patients record the frequency, severity, duration, and associated symptoms of each attack. This tracking provides objective data that the neurologist uses to measure treatment effectiveness and identify specific triggers like sleep disruption or dietary factors.
Monitoring for medication overuse headache (MOH), also known as rebound headache, is a continuous priority. The neurologist educates the patient to limit the use of acute medications, such as triptans, to no more than 9 days per month to prevent the cycle of medication-induced daily headaches. Treatment goals are set collaboratively, such as achieving a 50% reduction in monthly migraine days, and the plan is regularly adjusted based on diary data and treatment response.
The management plan also incorporates lifestyle modifications as a supportive foundation for medical treatment. The neurologist may recommend consistent sleep schedules, regular exercise, and stress management techniques, all of which can influence migraine susceptibility. The overall strategy is one of continuous evaluation, where the neurologist titrates medication doses, switches therapies, or introduces advanced procedures to maintain control over the chronic condition.