Expert migraine treatment and management
Dr. Robin Warner is a board-certified neurologist specializing in the diagnosis and treatment of migraine headaches. Get comprehensive, personalized care for all types of migraines, including chronic migraine and migraine with aura.
Currently offering in-person visits in New York City near Grand Central Terminal (Midtown East) and telemedicine appointments for patients located anywhere in New York State.
What we offer
Accurate diagnosis
Comprehensive evaluation to identify your migraine type and pattern.
Treatment planning
Personalized treatment strategies tailored to your needs.
Ongoing management
Regular follow-ups to monitor and adjust your treatment.
Botox for chronic migraine
Botox injections available when appropriate (in-person visits).
What is migraine?
Understanding migraine
Migraine is a complex neurological condition that affects millions of people worldwide. It's more than just a headache—migraine can significantly impact your daily life and ability to function.
Unlike regular tension headaches, migraine attacks typically involve moderate to severe pain that can be disabling. The headache is often described as throbbing or pulsating and may be on one side of the head, though it can affect both sides. Many people find that the pain worsens with physical activity or movement.
Migraine attacks can last anywhere from a few hours to several days. Some people experience attacks occasionally (episodic migraine), while others have frequent attacks that occur 15 or more days per month (chronic migraine).
Key facts about migraine
- Prevalence: Affects approximately 1 in 7 people worldwide
- Gender: More common in women than men (about 2-3 times more frequent)
- Age: Most common between ages 25-55, but can occur at any age
- Genetics: Often runs in families, suggesting a genetic component
- Impact: Can be disabling and significantly affect quality of life
- Treatment: While there's no cure, effective treatments can reduce frequency and severity
Migraine symptoms
Migraine attacks typically occur in stages, and symptoms can vary from person to person. Understanding your symptoms helps in getting an accurate diagnosis and effective treatment.
Headache phase
- Moderate to severe throbbing pain
- Often one-sided (but can be both sides)
- Worsens with movement or activity
- Lasts 4-72 hours if untreated
- Can be disabling
Sensitivity symptoms
- Light sensitivity (photophobia)
- Sound sensitivity (phonophobia)
- Smell sensitivity (osmophobia)
- Preference for dark, quiet spaces
Gastrointestinal
- Nausea
- Vomiting
- Loss of appetite
- Stomach upset
Migraine with aura
About 1 in 3 people with migraine experience aura—neurological symptoms that typically occur before or during the headache phase. Aura symptoms usually develop gradually over several minutes and can include:
- Visual disturbances: Flashing lights, zigzag lines, blind spots, or temporary vision loss
- Sensory changes: Tingling or numbness, often starting in the hand and moving up the arm
- Speech difficulties: Trouble finding words or speaking clearly
- Motor symptoms: Weakness on one side of the body (in rare types like hemiplegic migraine)
- Duration: Aura symptoms typically last 5-60 minutes
- Timing: Usually occurs before the headache, but can happen during or even without headache
Other phases of migraine
Prodrome (warning phase): Occurs hours or days before the headache. Symptoms may include:
- Mood changes (irritability, depression, or euphoria)
- Fatigue or excessive yawning
- Food cravings or loss of appetite
- Neck stiffness
- Increased thirst or urination
Postdrome (recovery phase): Occurs after the headache subsides. You may experience:
- Fatigue and exhaustion
- Difficulty concentrating
- Mood changes
- Feeling "washed out" or "hungover"
- May last hours to days
Types of migraine
There are several types of migraine, each with distinct characteristics. Understanding your specific type helps guide treatment decisions.
Migraine without aura
Also called "common migraine," this is the most frequent type. It involves moderate to severe headache with associated symptoms like nausea, vomiting, and sensitivity to light and sound, but no aura symptoms.
Migraine with aura
Previously called "classic migraine," this type includes reversible neurological symptoms (aura) that typically occur before or during the headache. Visual disturbances are most common, but sensory, speech, or motor symptoms can also occur.
Chronic migraine
Defined as having headache on 15 or more days per month, with at least 8 of those days having migraine features, for at least 3 months. Chronic migraine can significantly impact daily functioning and often requires preventive treatment.
Episodic migraine
Headache and migraine symptoms occur on fewer than 15 days per month. This is the most common pattern, with attacks occurring occasionally rather than frequently.
Other migraine types
- Hemiplegic migraine: Rare type with temporary weakness or paralysis on one side of the body
- Vestibular migraine: Involves dizziness, vertigo, and balance problems
- Retinal migraine: Involves temporary vision loss in one eye
- Menstrual migraine: Occurs in relation to the menstrual cycle
- Abdominal migraine: More common in children, involves abdominal pain rather than headache
- Status migrainosus: Severe migraine attack lasting more than 72 hours
Causes and triggers
What causes migraine?
Migraine is a complex neurological condition. The exact cause isn't fully understood, but research suggests that people with migraine have a more sensitive nervous system. During an attack, the nerves in the brain become overstimulated, leading to a cascade of changes involving nerve signals, brain chemicals (neurotransmitters), and blood vessels.
There's a strong genetic component—if you have a family member with migraine, you're more likely to develop it. However, genetics alone don't explain everything, and environmental factors also play an important role.
Migraine attacks often occur without any clear trigger, but certain factors can make an attack more likely. These triggers vary significantly from person to person, and what triggers one person's migraine may not affect another.
Common migraine triggers
Lifestyle factors:
- Stress or stress letdown (weekend migraines)
- Changes in sleep patterns (too much or too little)
- Skipping meals or irregular eating
- Dehydration
- Physical overexertion
Environmental factors:
- Bright lights or flickering screens
- Loud noises
- Strong smells (perfume, chemicals, smoke)
- Weather changes or barometric pressure changes
- High altitude
Hormonal factors (in women):
- Menstrual cycle changes
- Pregnancy
- Menopause
- Hormonal medications
Food and medication triggers
Food triggers (varies by individual):
- Aged cheeses
- Processed meats (nitrates)
- Alcohol, especially red wine
- Caffeine (or caffeine withdrawal)
- Chocolate
- Monosodium glutamate (MSG)
- Artificial sweeteners
Medication-related:
- Medication overuse headache (from frequent use of pain medications)
- Certain medications can trigger migraines
- Hormonal birth control (can help or worsen migraines)
Note: Not everyone with migraine has food triggers, and triggers can change over time. Keeping a headache diary can help identify your personal triggers.
Migraine treatment
While there's no cure for migraine, effective treatment can significantly reduce the frequency and severity of attacks, helping you regain control of your life. Treatment is typically personalized based on your specific symptoms, attack frequency, and medical history.
Acute treatment
Acute (or abortive) medications are taken at the onset of a migraine attack to stop or reduce symptoms. The goal is to treat attacks quickly and effectively, ideally within 2 hours of onset.
Common acute medications include:
- NSAIDs: Ibuprofen, naproxen, or aspirin (often combined with caffeine)
- Triptans: Prescription medications specifically designed for migraine (sumatriptan, rizatriptan, etc.)
- Gepants: Newer medications that block CGRP receptors (ubrogepant, rimegepant)
- Ditans: Lasmiditan, a newer option for those who can't take triptans
- Anti-nausea medications: Metoclopramide, prochlorperazine, or ondansetron
- Combination medications: Medications that combine multiple active ingredients
Important: Overuse of acute medications (more than 10-15 days per month) can lead to medication overuse headache, making migraines worse. Your doctor will help you use these medications appropriately.
Preventive treatment
Preventive medications are taken regularly to reduce the frequency and severity of migraine attacks. They're typically recommended if you have frequent attacks (4+ per month), severe attacks that don't respond well to acute treatment, or attacks that significantly impact your daily life.
Types of preventive medications:
- Beta-blockers: Propranolol, metoprolol, timolol
- Antidepressants: Amitriptyline, venlafaxine
- Anticonvulsants: Topiramate, valproate
- CGRP monoclonal antibodies: Monthly or quarterly injections (erenumab, fremanezumab, galcanezumab, eptinezumab)
- CGRP receptor antagonists: Oral medications (atogepant, rimegepant)
- Botox: OnabotulinumtoxinA injections every 12 weeks for chronic migraine
Preventive medications typically take several weeks to months to reach full effectiveness. Your doctor will work with you to find the right medication and dosage.
Non-medication treatments and lifestyle modifications
Lifestyle strategies:
- Regular sleep schedule (consistent bedtime and wake time)
- Regular meals (don't skip meals)
- Stay hydrated
- Regular exercise (but avoid overexertion)
- Stress management techniques (meditation, yoga, relaxation)
- Identify and avoid personal triggers when possible
Complementary therapies:
- Acupuncture
- Biofeedback
- Cognitive behavioral therapy (CBT)
- Supplements (riboflavin, magnesium, coenzyme Q10—discuss with your doctor first)
- Migraine devices (Cefaly, gammaCore, Nerivio)
- Physical therapy for neck-related triggers
When to see a doctor
Schedule a consultation if:
- You're experiencing frequent or severe headaches
- Headaches are interfering with your daily activities
- Over-the-counter medications aren't providing adequate relief
- You need to take pain medications more than twice a week
- Your headache pattern has changed
- You're experiencing new or different symptoms
- You want to explore preventive treatment options
- You're concerned about medication overuse
Seek immediate medical attention if:
These symptoms may indicate a medical emergency:
- Sudden, severe headache (thunderclap headache)
- Headache after head injury
- Headache with fever, stiff neck, confusion, or seizures
- Headache with vision loss, weakness, or numbness
- Headache that's different from your usual pattern
- First severe headache if you're over 50
- Headache that worsens with coughing, sneezing, or straining
If you're experiencing any of these symptoms, call 911 or go to the nearest emergency department immediately.
How Dr. Warner can help
As a board-certified neurologist with expertise in headache disorders, Dr. Warner provides comprehensive migraine care tailored to your individual needs.
Comprehensive evaluation
Detailed assessment of your symptoms, medical history, and headache pattern to establish an accurate diagnosis and identify any contributing factors.
Personalized treatment
Development of a customized treatment plan that may include acute medications, preventive therapies, and lifestyle modifications based on your specific needs.
Ongoing management
Regular follow-up visits to monitor treatment effectiveness, adjust medications as needed, and help you achieve better migraine control over time.
What to expect during your visit
- Thorough discussion of your headache history and symptoms
- Review of your medical history and current medications
- Assessment of headache frequency, severity, and impact
- Identification of potential triggers
- Review of any prior imaging or test results
- Development of a treatment plan
- Education about migraine and treatment options
- Coordination of care with other providers if needed
Tip: Keeping a headache diary before your visit can be very helpful. Record when headaches occur, their severity, duration, associated symptoms, and any potential triggers you notice.
Get started with expert migraine care
Don't let migraine control your life. Get expert evaluation and treatment from a board-certified neurologist specializing in headache disorders.
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