Migraine is a complex neurological disorder affecting millions, involving moderate to severe pulsating head pain, nausea, vomiting, and extreme sensitivity to light and sound. Since migraine is a chronic condition with a broad spectrum of severity, finding the right medical professional can be confusing. The best doctor to see depends on the frequency, intensity, and complexity of an individual’s symptoms.
The Starting Point: Primary Care
The first step for most people experiencing new or infrequent head pain is a visit to a Primary Care Physician (PCP). A general practitioner, family doctor, or internal medicine specialist provides an initial diagnosis and rules out other common causes of headaches. They classify the head pain as episodic migraine, defined as 14 or fewer headache days per month, using a detailed patient history. Their primary role is to initiate a basic treatment plan, often involving over-the-counter pain relievers or first-line acute medications.
PCPs prescribe common acute treatments, such as triptans, which constrict blood vessels and block pain pathways in the brain. They also recommend lifestyle modifications, including consistent sleep patterns and trigger avoidance, as a foundational part of management. If a patient’s migraines are mild and respond predictably to these initial therapies, the PCP can manage the condition long-term. However, if a patient does not respond to first-line treatments, they will require a referral for more specialized care.
When to See a Specialist: The Role of the Neurologist
A neurologist specializes in disorders of the nervous system, making them the most appropriate specialist for complex migraine management. Referral is necessary for chronic migraines (15 or more headache days per month) or if the condition is refractory. Refractory migraine means the pain fails to respond adequately to multiple trials of standard acute and preventive medications. Neurologists perform advanced evaluations and may order imaging, such as an MRI or CT scan, to exclude other neurological conditions.
Neurologists manage advanced preventive treatments typically unavailable in primary care. This includes Calcitonin Gene-Related Peptide (CGRP) inhibitors, medications designed to block a protein involved in pain signaling during a migraine attack. These treatments come as monthly or quarterly injectable monoclonal antibodies or as small-molecule gepants used for daily prevention or acute treatment. A neurologist also determines a patient’s eligibility for procedural treatments, such as onabotulinumtoxinA (Botox) injections, which is approved for chronic migraine.
Specialized and Adjunctive Care Teams
Comprehensive migraine management often requires a multidisciplinary team approach. Pain Management Specialists, who may be anesthesiologists or neurologists, often lead procedural treatments. They administer nerve blocks using local anesthetics and steroids to target specific nerves, such as the greater occipital nerve, providing temporary relief. These specialists also deliver the 31 injections of onabotulinumtoxinA into seven specific areas of the head and neck every three months for chronic migraine prevention.
Physical Therapists are important, especially for individuals whose migraines co-occur with tension-type headaches or cervicogenic issues. They utilize manual therapy, posture correction, and strengthening exercises to address musculoskeletal dysfunction in the neck and upper back. Physical therapy acts as a supportive treatment by reducing muscle tension and improving cervical spine mobility to decrease the frequency and intensity of attacks. Mental Health Professionals, such as psychologists or psychiatrists, are essential for managing co-morbid anxiety, depression, and stress associated with chronic pain. They employ techniques like Cognitive Behavioral Therapy (CBT) to help patients develop coping mechanisms.
Urgent Care and Emergency Situations
While most migraine treatment focuses on chronic prevention, certain “red flag” symptoms necessitate an immediate visit to an Emergency Room (ER) or Urgent Care. The most critical sign is a “thunderclap” headache, described as the worst pain of one’s life that peaks within seconds, which can signal a subarachnoid hemorrhage or other life-threatening event. Patients who experience their first headache after age 50 should also seek immediate evaluation to rule out serious underlying causes.
Urgent Indicators
Other urgent indicators include a headache accompanied by:
- Fever
- Stiff neck
- New neurological deficits like weakness or confusion
- A seizure
The goal of treatment in the ER is to stop the severe attack, known as status migrainosus, and rule out dangerous secondary causes. Treatment involves a combination of non-opioid intravenous (IV) medications to avoid the risk of medication overuse headache. Common IV treatments include antiemetics, such as metoclopramide or prochlorperazine, which treat nausea and pain. These are often combined with an IV non-steroidal anti-inflammatory drug like ketorolac. Patients may also receive IV fluids to correct dehydration, which can worsen the severity of an attack.