Discusses how to attack migraine using a multimodal approach. The treatment pie includes the following slices: sleep, diet, movement, supplements, medications, miscellaneous, hydration, meditation, therapy | Migraine Strong
Chronic Migraine,  Migraine,  The Treatment Pie,  Vestibular Migraine

The Treatment Pie – A Multimodal Approach to Treating Migraine

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Danielle Aberman

Medically reviewed by Danielle Aberman, RD

The Migraine Strong team developed the treatment pie as a way to illustrate the need to attack migraine using a multimodal approach. These nine slices represent the medical interventions and lifestyle changes that are known to best affect migraine outcomes. When applied together, they have a greater chance of reducing the frequency and severity of migraine attacks than any one slice alone. The slices are described below.

** While Migraine Strong writes about the latest in migraine treatments, this is not medical advice. We are patient educators and all information you read should be discussed with your doctor.

The Treatment Pie:

  • Medications – Refers to Acute medications (taken at the onset of an attack) and Preventive medications (taken daily to reduce the number of attacks). Rescue medications can also be prescribed to treat migraine symptoms even if they don’t abort an attack. This also refers to neuromodulation devices.
  • Miscellaneous – Many therapies can find their way into this category including chiropractic, massage, cranial sacral, acupuncture.
  • Hydration – The Institute of Medicine (IOM) recommends 74 ounces per day for women and 101 ounces per day for men.
  • Meditation – This is an intentional practice, focusing inward to increase calmness, concentration, and emotional balance.
  • Therapy – Encompasses many different forms of therapy including Cognitive Behavioral Therapy (CBT), Talk Therapy, Biofeedback Therapy etc.
  • Sleep – Waking and sleeping at the same time each day and avoiding naps is part of having a well ordered sleep schedule. The migraine brain likes routine and having too much or too little sleep can disrupt its happy balance. Our sleep blog explains it in depth. 
  • Diet – A migraine oriented elimination diet, like Heal Your Headache, (limited in scope and time) can be helpful in allowing the brain to calm from its hyper-responsive state. A Ketogenic diet can also be helpful and this blog explains how to get started from the beginning. 
  • Movement – Daily movement is helpful. This doesn’t have to be training for a 5K. It can initially be walking around the living room. 
  • Supplements – Several supplements have been shown to be beneficial to migraine including ginger, magnesium, Riboflavin (B2) and Feverfew. Our blog here explains how. 

Which Combination Of Slices Will Be Most Effective

It’s doubtful a day goes by in our closed Migraine Strong Facebook group without some reference being made to the treatment pie. It has become one of our favorite resources over the years and with good reason. In this one graphic we can reference every effective piece of treatment we can think of to fight migraine. While each of these slices will have a different percentage of effectiveness for every individual, we have found that combining them makes the greatest impact in our battle to gain control over migraine.

The Theory In Practice

When I first started working on this theory, I had been chronic and mostly intractable for 18 years. I had tried many medications to reduce and treat my migraine attacks to no avail and had recently been diagnosed with a migrainous infarction (stroke). At the end of my rope as far as treatments went, my headache specialist and I combed back through everything. We determined that I hadn’t really tried an elimination diet, but had previously done an avoidance diet. So I reread the Heal Your Headache book by Dr. David Buchholz and put that into action. I committed to the four months of his plan and looked at what else I could do to make this time most effective. 

Daily exercise is well known to help with migraine management, so that was added to my list. Several supplements have broad scientific support in their ability to reduce migraine symptoms and attacks so they were added to the mix along with cleaning up my sleep cycle. I kept track of my daily water intake to ensure I was well hydrated. The Calm app was a great way to bring in daily mindfulness and meditation. We also kept my preventive medication the same, but changed my acute/rescue medications.

The Result

I wouldn’t say that making all of these changes at one time was easy. It wasn’t. I threw more than one adult tantrum in the grocery store looking for foods that were diet compliant. Pausing the treadmill to deal with bouts of nausea was an exercise in sheer stubborn will. And the brain fog I was dealing with, along with copious amounts of pain made everything seem insurmountable. But I had made a commitment to my family to stick with it for four months. After about six weeks I had an amazing break of 22 days with no head pain! Of course, I thought I was cured. Spoiler alert! I wasn’t.

I had made great strides in figuring out some things that made migraine shrink away from the light…and I wasn’t going to give up. The treatment pie was in its infancy and would eventually be pulled together with the help of the wonderful Migraine Strong admin team. 

Deciding What To Try First

These questions come up quite often. Should I trial one medication or supplement at a time so I know what is working? Should I start diet first to see if that works by itself? What is reasonable in regards to change when it comes to attacking migraine?

These are all good questions and the answer is…it depends. As migraine falls on a spectrum, the mild end and the more severe end, how we attack it will vary. If you have episodic migraine, trialing things within some slices one at a time may work well for you. We would still recommend that you jump on a diet, hydrate, get your sleep cycle organized etc. But when it comes to supplements and medication, we might tell you that trialing one at a time is the right approach to see how things pan out. This way, you would be able to keep a good record of things to see how each addition affected your migraine attacks.

When Migraine Is More Complicated

However, with chronic, severe or complex migraine it becomes more complicated. Then we would recommend that you throw the entire treatment pie at migraine. And instead of trialing one supplement at a time, hit migraine with ALL of the scientifically recommended supplements as well. If you are trying a preventive with only limited success, we would recommend discussing with your doctor the option of adding another preventive to the mix to boost the one that you’re currently taking. 

Dosages for both medications and supplements seem best tolerated when started low and increased slowly, allowing for adjustments to any side effects. The majority of our group has sensitivities to medications and seems to do better with a ‘start low and go slow’ approach. We think this approach would help with adjustment to the side effects that so many of us find intolerable. This is important for people with migraine and may be even more important for Vestibular Migraine.

While it used to be the conventional wisdom to try one thing at a time, throwing everything at migraine (especially when you are chronic) has a greater chance of having a more satisfactory result. At the 2019 Migraine World Summit, Dr. David Dodick agreed that ‘throwing the kitchen sink’ at chronic migraine is how to get the best results. Once you feel better, you can peel back the layers and see what is working best for you, then eliminate the extraneous therapies. The most important goal is to make a significant impact on your migraine disease and be able to enjoy your life again.

Avoiding Analysis Paralysis

We want to hit migraine with everything we have to see what sticks. If we can make a dent in the frequency and severity of our migraine attacks, then we can figure out what is helping us the most. Trialing things one at a time could take months or years to figure out what is (or could be) helping us, when it could actually end up being a combination of treatments. By taking this multimodal approach, it also removes the dreaded ‘analysis paralysis’ we can all fall into. When we research every single option without being able to make a decision and analyze everything until we are paralyzed with indecision. Throwing all our options at migraine allows us to figure out what is helping the most! And as always, we will be here to help. 

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I began having migraine attacks when I was a teenager, but was never properly diagnosed until I was an adult. This began 18 years where I was chronic and mostly intractable, resulting in a migrainous stroke in the summer of 2014. By implementing the protocols from the Heal Your Headache book by Dr. David Buchholz and the Migraine Strong Treatment Pie, I have been able to reduce my migraine frequency to episodic and maintain that since 2015. The end result of continuing to practice these tools is being able to actively participate in my life as a wife, mother, family member and friend. My goal as a migraine advocate, educator, and wellness coach is to help others gain more control over migraine. Let us know how we can help.


    • Migraine Strong

      Thanks Jodie! I appreciate the kind words. Keep up the great work at migrainebuds.com and in Facebook land. 🙂

  • Susan Follett

    I so needed to read this. I have had migrsines for 47 years, I have tried and have gone to different hospitals but they didn’t help. I have chronic migraines every day. These last two days have been terrible. I just don’t know what to do anymore. I will be 67 on July 30th and I feel the older I get, the worse they get. I am tired of fighting. I will try what you suggested in your article. Thank you so much!

    • Migraine Strong

      I’m so sorry you have been dealing with migraine for so long. I was chronic and mostly intractable for 18 years before finally putting the pieces of the pie together and finding some relief. Don’t hesitate to reach out to us in the Facebook group if you have questions. Let us know how we can help. -eileen

  • Toria

    I am also grateful for this article and for this website. I have just realized that I need to take a much more intentional and consistent approach to treating my migraines. At 73, they are worse now than they were when I was much younger, a result, I fear of medication overuse. I hope to be much more proactive with various strategies to see if I can get some measure of control over them and at least some relief. Thank you for making this valuable information available. I look forward to reading all the information.

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