Why Migraine Care Starts in Primary Care

Hope O'Brien, MD:
Welcome everyone to the National Headache Foundation's podcast NHF InSights where we unpack the science and strategy for caring for people living with migraine. I'm today's host, Dr. Hope O'Brien, and I'm a board-certified neurologist, a headache specialist, and founder and CEO of the Headache Center of Hope based out of Cincinnati, Ohio. I'm also president of the National Headache Foundation.

We're kicking off episode one with a powerhouse guest, one of the leading voices in migraine care, Dr. Andy Blumenfeld. Andy, thanks so much for joining us. Would you please share a little bit about your background and what brought you to headache and migraine therapeutic space, and why primary care is an important community to talk about this issue?

Andy Blumenfeld, MD:
Sure. I came to migraine basically because both my daughters suffer very badly with migraine. And I wanted to make sure that they were getting the best possible care, so I wanted to learn as much about it as I possibly could. Certainly, we know that most migraine patients are cared for in primary care, and it's crucial that primary care providers know about migraine, how to diagnose it and manage it because today we have so many options to help our patients. This can be a very rewarding group of patients to treat because we can really make a difference to their lives.

Hope O'Brien, MD:
Absolutely. And I think we often forget that 70% of individuals with migraine never walk into a neurology office. And they often see their primary care doctors or APPs, which means these providers carry the weight of diagnosing, validating, and initiating treatment for most people living with migraine.

Andy Blumenfeld, MD:
Absolutely. And this is why it's so important that these providers become familiar with the American Headache Society and the International Headache Society's guidance on how to manage patients in terms of their diagnosis, recognizing the disease early on, and then really getting them on effective treatments as soon as possible.

Hope O'Brien, MD:
So, let's set the stage for this episode. We're talking foundations, the why it matters before we get to the what to do about it. And I want to start with the evolution of our understanding of migraine pathophysiology.

Andy Blumenfeld, MD:
Yeah. Well so migraine has come a long way. Certainly, when I was in medical school, we used to think this was a vascular disorder, that blood vessels dilated and that could activate these nerve endings and cause a neurogenic inflammation. It turns out that the predominant change that's occurring in the brain is that the trigeminal nerve is getting activated. So, it's more of a trigeminal nerve problem than a vascular problem. The trigeminal nerve does release chemicals, these vasoactive neuropeptides. The most important one that we have now got treatments to focus on is calcitonin gene-related peptide (CGRP). And this gets released from fibers in the trigeminal nerve called C-fibers. And that released CGRP will dilate blood vessels, but more importantly it will bind back onto other trigeminal nerve fibers, which are termed the A-delta fibers. So, it binds onto receptors on the A-deltas, and it causes a vicious cycle where this released CGRP is activating the trigeminal nerve to keep it firing.

And this leads to a concept of peripheral sensitization. And this trigeminal activation feeds back into the brain stem to the trigeminal nucleus caudalis. And it will activate that nucleus. These are second order neurons. And now the message is sent up pathways to the thalamus and then to the cortex. And this becomes the central pathways that become active. And this leads to the second phase of migraine which is called central sensitization. So, we have both a peripheral activation and a central activation.

Now there are some schools of thought that believe that the headache process starts in the trigeminal nerve with activation of that first. And then there's another school of thought that believes the activation starts in the central pathways first and then stimulates the trigeminal. Probably both schools of thought are correct.

Hope O'Brien, MD:
Exactly. And we used to choose treatments based on the side effects or guesswork. Now we choose them based on mechanisms. So, let's talk about the big goal or the big picture, migraine freedom, not being less miserable or fewer bad days, but clear, pain-free, interference-free days.

Andy Blumenfeld, MD:
Sure. So, this term migraine freedom is actually a very important concept because what it does for providers is it sets an aspirational goal for us to strive to achieve this. And then we might not get all the way there, but at least in the back of our minds, we need to have this concept of getting our patients to the highest level of control that's possible. So, to some patients, this might mean no headache, no migraine symptoms, no non-headache symptoms, total freedom from migraine. And it might also include lack of side effects from medications. To other patients, it might mean that they're able to go to work and they're not in the emergency room. They might still be having some of the other symptoms. So, this is an individually defined goal that is set out between the provider and the patient. And then we strive to achieve that by layering different treatments onto each other over time so that we gradually build up and get more and more control of these patients.

Hope O'Brien, MD:
And that's where multimodal management really comes in. And the current narrative review, multimodal migraine management and the pursuit of migraine freedom frames this beautifully.

Andy Blumenfeld, MD:
Yeah. It's important to understand that it's the pursuit of migraine freedom. It's an effort to achieve that. It's not a guarantee that we're going to get there. It's a goal that we're setting. And that we’ll explain to patients that we're striving for it, but we might not make it. It has to be set up correctly so that there isn't false hope and disappointment.

Hope O'Brien, MD:
Absolutely. And I think that starts with an accurate diagnosis, making sure that we understand the right personalized acute care that would benefit that patient, talking about prevention that matches the patient's biology, talking about tools such as behavioral management, trigger management, improving sleep, stress, hormones, and environmental factors that may be involved.

Andy Blumenfeld, MD:
Yes, that exactly right. We start with the diagnosis. We have to make sure that there are no ongoing drivers for headache. So, let's say the patient was overusing caffeine. They might be going into a caffeine withdrawal headache. We try them on different medicines. It looks like the medicine isn't working. It's not because the medication isn't effective. It's because the caffeine is continuously driving the headache. It could be over-the-counter medication overuse. It could be that there's hypothyroidism or anemia that is inhibiting the full effect of the medication from happening. So, we want to set the stage. We want a good foundation in order for the medicines to work at their best. And then we want to combine medicines using different mechanisms of action to create a synergistic approach to our pharmaceutical treatment approach. So, we might use something that blocks CGRP, but we might also use an anticonvulsant that blocks some of the central pathways from becoming active. And we would combine those two together over time in a layering technique.

Hope O'Brien, MD:
I like how you frame that. And I think before we can actually use these treatments, I think again, making sure they get the right diagnosis is going to be key. Because if we don't get the right diagnosis, then we're not going to be able to offer these treatments. And with that, I think that diagnosing piece may be a little bit tricky for providers. And so, utilizing a tool like ID Migraine may be something that providers may be able to implement in your clinic. So, can you talk a little bit about ID Migraine and what questions are asked about that?

Andy Blumenfeld, MD:
Yeah. So, this ID Migraine tool is a validated tool that only uses three questions. And actually, you can even make it a bit simpler. It really comes down to two questions. And the two questions are is the headache associated with light sensitivity or is the headache associated with nausea? The third factor that goes into ID Migraine is recurrent disabling headache. But the point that the patient has come into the clinic to see you complaining about headache implies that they have a disabling headache. So as far as I'm concerned, that first factor is already achieved. So now all we really have to ask once a patient tells us I'm here with the recurrent disabling headache is do you have nausea or are you sensitive to light. If they answer either one of those positive, you have over a 90% chance that you're dealing with migraine.

Hope O'Brien, MD:
And some of the questions that I've been asked is how do we tell the difference between a migraine and a tension-type headache?

Andy Blumenfeld, MD:
Well, as a provider in the primary care setting, if you default to migraine for your diagnosis, you're more likely to be correct because what the studies have shown is that if a patient is in your office complaining about a recurrent headache, the odds are that that's a migraine headache, not a tension headache. Tension is a mild headache disorder. It's not disabling. The chances that the patient would come in and complain about it is not likely. It's very common. Most of us have had a tension-type headache. But if they come into the doctor with the complaint of headache, odds are that's migraine.

Hope O'Brien, MD:
That's really key. And I like how you explain that Dr. Blumenfeld. Now let's dig deeper into something we've touched on, preventing how much time the brain spends in migraine, because that concept really changes everything.

Andy Blumenfeld, MD:
Absolutely. So, a nice way to think about this is that the longer your brain stays in migraine, the more likely it is to remain in migraine. So that's a simple statement. It carries a lot of weight. Because what it means as providers is that we need to get these headaches under control so that the attack doesn't last as long and it doesn't occur as frequently. So that means a preventative approach to reduce the frequency, and an acute approach to reduce the duration. The longer the brain spends in migraine, the more likely it is that the patient's brain will become sensitized. The threshold to fire into the next attack will decrease, and the patient will start to progress over time.

So, in a subgroup of patients, migraine is a progressive disease. And this is directly linked to sensitization of both the peripheral nervous system, the trigeminal system and the central nervous system, those pathways that are going up from the brainstem nucleus to the cortex. Both of these systems are becoming sensitized over time. So, in a chronic migraine patient, these pathways are sensitized even between attacks. And the key factor that you can find clinically when this happens is allodynia, so patients will become sensitive to touch. Lightly stroking their hair will be painful for a patient who is allodynic. And this is something that happens with sensitization. In an acute attack it happens, but then if you develop and evolve to chronic migraine, even between attacks it will happen.

Hope O'Brien, MD:
That's really empowering for clinicians because it means that if we can intervene early, then we can lessen the likelihood of the brain staying pretty much hypersensitized and hopefully be able to decrease the chronicity of migraine attacks. Now, we really can't end this episode without talking about stigma and the fact that migraine is not just a headache. And that it still lingers in society the fact that migraine is a stigma, and unfortunately sometimes it occurs in medical settings.

Andy Blumenfeld, MD:
Sure. I mean, stigma is a huge problem. One of the main reasons that I think this happens is that people often get a tension-type headache. Tension-type headache, as we've said, is a mild headache. The individuals that experience only tension-type headache, when they come across a patient with migraine who's complaining about headache, their mindset is framed by their tension headache. And so, they perceive that the headache that they've experienced which was mild and easily dealt with, that this individual is obviously a lot weaker and can't tolerate the discomfort like they did.

And it's this total disconnect and misconception because not all headaches are the same. And so, I think this is a big problem that people don't realize the disability of migraine, which is the headache, but then it's the cognitive slowing and the nausea and the lights and the noise sensitivity that really adds to all the disability. And this does mean that these individuals cannot participate with social activities and occupational activities and often are missing these events which they have no control over but then are viewed as being weak because of that.

Hope O'Brien, MD:
Yes. And I find that surprisingly many people have migraine, even those who are considered highly functioning. And I think that's a problem that I feel like we have as clinicians is recognizing the fact that migraine can look like anyone. Right? It can look like somebody who doesn't look like they have migraine, or you can find that somebody suffering from migraine or struggling with it as the headache is occurring or those negative symptoms are occurring, they're down and out. So, as providers, we need to make sure that we take migraine seriously and give patients permission to also take it seriously too, because that improves outcomes overall.

Andy Blumenfeld, MD:
Absolutely. I mean, this is a disease of the brain. And it's a real disorder. But as you mentioned, these patients from a distance look normal. But the World Health Organization has rated migraine one of the leading conditions in terms of disability, higher than many other neurological diseases that are very obvious like dementia or stroke or quadriplegia, which are very obvious. And yet migraine is considered as one of the leading disabling conditions.

Hope O'Brien, MD:
To end this, I'm going to just summarize episode one, that PCPs and APPs are essential because they see the majority of patients with migraine. And also, recognizing that the American headache Society and the International Headache Society's guidance on management and understanding basic pathophysiology improves the care of patients dramatically. The goal of migraine, it should be migraine freedom and emphasizing those crystal-clear days. Accurate diagnosis and administering tools that can help with diagnosis like ID Migraine sets the foundation. Preventing time in migraine reduces sensitization and disability. And finally, breaking stigma starts in the clinic during that interaction with the patient. So, Andy, do you have any additional closing thoughts before we end this episode?

Andy Blumenfeld, MD:
I've spent most of my career taking care of migraine patients, and I can tell you it is a very rewarding group of people to look after. We have so many treatment options today that can dramatically influence these people. And the American Headache Society's position statement on using these medications, the newer anti-CGRP medications as first-line treatment, has dramatically changed the way we manage migraine. It means getting a patient on a specific, well-tolerated treatment with high efficacy as soon as possible because of the risk of progression.

Hope O'Brien, MD:
Thank you for that, Dr. Blumenfeld. Well, stay tuned for episode two where we're going to build on this foundation by exploring exactly what primary care clinicians and APPs can do right now, the practical tools, acute treatment options, preventive strategies, and how to match the right therapy to the right patient. Dr. Blumenfeld, thank you so much for this discussion.

Andy Blumenfeld, MD:
Thank you Hope. Thanks for having me.

Hope O'Brien, MD:
And we'll see you all next time. But until then, know that clearer days lie ahead.

©2026 National Headache Foundation. All Rights Reserved.

This episode of NHF InSights™ was supported by AbbVie. Content was developed independently by the NHF.

Resources:
1. ID Migraine https://headaches.org/resources/headache-tests

2. AHS and IHS Position Statements https://headaches.org/insurance-pharmacy-coverage/ahs-position-statements

3. AHS Primary Care Resources https://americanheadachesociety.org/resources/primary-care

4. AHS Migraine Management Flowchart https://americanheadachesociety.org/resources/primary-care/migraine-flowchart

5. Multimodal Migraine Management and the Pursuit of Migraine Freedom: A Narrative Review https://pmc.ncbi.nlm.nih.gov/articles/PMC10444724