Migraine: Risk Factors and Management

The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study estimates that over one billion people had a migraine headache in 2016. This burden is significant, and migraines are ranked among the most common causes of “years of life lived with disability” (YLDs). Migraines caused 45.1 million YLDs globally in 2016, with the burden falling most heavily on women aged 15-49 years old. In this age group, migraines and tension-type headaches account for over ten percent of all YLDs.1 The management of migraine is also difficult, due to an incomplete understanding of their mechanism.

Researchers have achieved major advancements in understanding the pathophysiology of migraines, which are now recognized as manifestations of nervous system dysfunction rather than mere vascular headaches; while changes in blood flow to the brain perhaps contribute to pain, they likely do not initiate it. Diverse clinical features (including premonitory symptoms, aura, nausea, and dizziness) demonstrate the complexity of the condition. At least 38 genetic loci have been associated with migraines, but their functions differ; it is highly likely that complex gene-environment interactions cause migraine headaches and therefore must be considered in their management.2

Stress, exacerbating medications, metabolic changes associated with diet and neuroendocrine function, and hormonal changes (especially those induced by pregnancy and menstruation) may all also play a role in stimulating migraines.2 In some individuals, the attack frequency of episodic migraine can increase to the point of chronic migraine (at least 15 headache days per month for 3 months, with at least 8 of the headache days fitting the criteria for migraine headaches). Risk factors for chronification include overuse of acute migraine medication, obesity, depression, and stressful life events. Low socioeconomic and education statuses are associated with migraine chronification as well.3

Triptans and non-opioid analgesics (nonsteroidal anti-inflammatory drugs) are common medications used to treat migraines.2 However, the overuse of acute migraine medication (analgesic intake on more than 15 days per month or triptan intake on more than 10 days per month) is considered to be likely the most important cause of migraine progression, and therefore their usage must be carefully monitored.3

Beta-blockers are used as a preventative measure to limit the frequency of migraine. Local anesthetics (with or without steroids) are also sometimes injected in headache centers as preventative measures, particularly in the regions of the occipital nerves.2 Additional management options exist for those with chronic migraine: In 2010, the U.S. Food and Drug Administration approved Botox for the management of chronic migraine. The injection blocks the release of neurotransmitters implicated in perceptions of pain and has been shown to be an effective treatment, even for patients with concomitant medication overuse.4 Still, studies show that reducing medication overuse leads to significant migraine alleviation in chronic migraine patients.3

Because many people who experience migraines also report musculoskeletal issues like neck pain (reported by 75 percent of patients), there has been interest in incorporating chiropractic practices into neurological treatment plans. Harvard Medical School established the Osher Clinical Center (OCC) for Complementary and Integrative Therapies in 2007 at Brigham and Women’s Hospital, making it one of the first integrative medicine clinics at a tertiary care academic medical center. A 2019 case series published by Dr. Carolyn Bernstein and OCC researchers shared three cases demonstrating improvements in pain scores, increases in pain-free days, decreased medication usage, and decreased patient-reported anxiety/dysthymia with integrative approaches to treatment. The treatments included soft tissue therapies (including myofascial release, massage, and trigger point therapies), as well as spinal manipulation, which has been hypothesized to activate descending pain inhibitory pathways responsible for pain modulation.5

A 2019 systematic review that included six randomized clinical trials found that spinal manipulation may be an effective therapeutic treatment to reduce pain levels and slightly decrease migraine days. Larger-scale studies, however, are needed to further understand how chiropractic treatment may benefit those afflicted with migraine headaches.6


  1. GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17(11):954-976. https://thelancet.com/journals/laneur/article/PIIS1474-4422(18)30322-3/fulltext
  2. Charles A. The pathophysiology of migraine: implications for clinical management. Lancet Neurol. 2018;17(2):174-182.
  3. May A, Schulte LH. Chronic migraine: risk factors, mechanisms and treatment. Nat Rev Neurol. 2016;12(8):455-464.
  4. Escher CM, Paracka L, Dressler D, Kollewe K. Botulinum toxin in the management of chronic migraine: clinical evidence and experience. Ther Adv Neurol Disord. 2017;10(2):127-135.
  5. Bernstein C, Wayne PM, Rist PM, Osypiuk K, Hernandez A, Kowalski M. Integrating chiropractic care into the treatment of migraine headaches in a tertiary care hospital: A case series. Glob Adv Health Med. 2019;8:2164956119835778.
  6. Rist PM, Hernandez A, Bernstein C, et al. The impact of spinal manipulation on migraine pain and disability: A systematic review and meta-analysis. Headache. 2019;59(4):532-542.