Migraine in Black patients: the under-treated neurological disease

Migraine is a paroxysmal neurological disease, the second most prevalent neurological disorder, affecting roughly 70 million people in the United States and women about three times as often as men. The headache is one symptom of an attack, not the whole thing. An attack moves through phases, and recognizing them is the first step to getting treated correctly.

• Prodrome (hours to a day before): mood changes, food cravings, neck stiffness, yawning, or trouble concentrating.
• Aura (about 5 to 60 minutes, in some people): temporary vision changes such as blind spots, zigzag lines, or shimmering stars, and sometimes tingling, numbness, or speech trouble. Most people with migraine do not get aura.
• Headache (4 to 72 hours): often one-sided, throbbing or pulsing pain, made worse by movement, with nausea and sensitivity to light and sound.
• Postdrome (up to a day or two after): the migraine hangover, drained, foggy, and tender.

A tension headache is usually a steady, pressing, band-like ache on both sides, without nausea or light sensitivity, and it does not get worse when you move. Migraine is typically one-sided, throbbing, and disabling, comes with nausea and light or sound sensitivity, and worsens with activity. That distinction decides which treatment works.

The bigger trap is the sinus headache. Most headaches people blame on their sinuses are migraine. In the Sinus, Allergy and Migraine Study, 9 of 10 patients with self-diagnosed or doctor-diagnosed sinus headache actually met criteria for migraine. In a separate clinic series, 81.5% of confirmed migraine patients had first been misdiagnosed with sinusitis, with an average delay of nearly 8 years before the right diagnosis. If your recurring sinus headaches come with nausea or light sensitivity and respond poorly to decongestants, the problem is probably migraine.

Triggers vary by person, which is why tracking yours matters. The most commonly reported ones:

• Stress, or the let-down after stress.
• Skipped meals, dehydration, and irregular sleep.
• Hormonal shifts, especially around menstruation.
• Specific foods and drinks: alcohol (red wine), aged cheeses, processed meats, and for some people caffeine or its withdrawal.
• Bright or flickering light, strong smells, and weather changes.

Black and White Americans report severe headache or migraine at similar rates, so the disease is not the variable. The treatment is. In a primary-care study of patients with moderate-to-severe migraine, only 46% of African American patients had ever sought care for it versus 72% of White patients, only 47% had a formal headache diagnosis versus 70%, and only 14% had been prescribed an acute migraine medication versus 37%. Black patients in that study also reported higher pain intensity and lower trust in the medical system, and the lower the trust and the worse the perceived communication, the less likely they were to be in care or on medication.

Four forces drive the gap. Access: fewer Black patients reach a clinician who takes head pain seriously, and headache specialists are scarce. Referral: Black patients are referred to neurologists and headache specialists less often, so they stay on whatever a primary-care visit produces. Cost: newer migraine-specific drugs carry prior authorizations and copays that fall hardest on the under-insured. And bias: being disbelieved about pain is measured, not anecdotal. In a 2016 study, half of White medical students and residents endorsed at least one false belief about biological differences between Black and White bodies (for example, that Black people feel less pain), and those who did rated Black patients' pain lower and recommended less accurate treatment. Migraine is invisible on every scan and lab, so it lives or dies on whether the clinician believes the patient. That is exactly where bias does its damage.

The cost of the gap is progression. Untreated and undertreated episodic migraine is more likely to turn chronic, meaning 15 or more headache days a month, which is harder to reverse and more disabling. Living with poorly controlled chronic pain also strains mental health. If migraine is grinding you down, our guide on anxiety symptoms in Black adults covers when to get that addressed too.

There is no blood test or scan for migraine. It is a clinical diagnosis based on your pattern of symptoms, so the quality of what you report is the diagnosis. Imaging is used to rule out other causes when red flags are present, not to confirm migraine. The single most useful thing you can bring to an appointment is a headache diary.

For 4 to 8 weeks before your visit, log each attack: the date, how long it lasted, where the pain was and what it felt like, other symptoms (nausea, light or sound sensitivity, aura), what you suspect triggered it, what you took, and whether it helped. A diary turns a vague my head hurts a lot into a documented pattern a clinician can diagnose and treat, and it makes you harder to wave off.

Effective migraine treatment exists, and it has expanded a lot since 2018. It splits into treating attacks (acute) and preventing them (preventive).

Acute, to stop an attack in progress:

• NSAIDs (ibuprofen, naproxen) and combination analgesics for milder attacks, taken early.
• Triptans (sumatriptan, rizatriptan and others), the migraine-specific workhorses for moderate-to-severe attacks.
• Gepants (ubrogepant, rimegepant) and ditans (lasmiditan), newer options that work when triptans fail or cannot be used, including in people with cardiovascular risk for whom triptans are off the table.

Preventive, to reduce how often attacks happen: consider prevention when migraine hits roughly 4 or more days a month, or when attacks are disabling or not controlled by acute treatment alone.

• CGRP monoclonal antibodies (erenumab, galcanezumab, fremanezumab, eptinezumab), monthly or quarterly injections designed for migraine. In April 2024 the American Headache Society stated these anti-CGRP therapies should be considered a first-line option for prevention, no longer reserved until older drugs fail.
• Older oral preventives repurposed from other conditions: certain blood pressure medications, antiseizure drugs (topiramate), and some antidepressants.
• OnabotulinumtoxinA (Botox), FDA-approved specifically for chronic migraine (15 or more headache days a month), given as injections every 12 weeks.
• Lifestyle and trigger management: consistent sleep and meals, hydration, stress management, and using your diary to spot and reduce personal triggers. This supports medication; it does not replace it for moderate-to-severe disease.

Start by keeping a headache diary for a month, then book a visit and lead with the pattern, not the pain alone. Say the word migraine, ask for it to be ruled in or out, and ask three questions: What acute medication should I have on hand to stop an attack, and is a triptan or a gepant right for me? Given how often I get these, should I be on a preventive, including a CGRP medication? Do I need a referral to a neurologist or headache specialist? If a clinician brushes off your pain or hands you only over-the-counter advice for disabling attacks, that is a reason to switch, not to give up. To find a clinician who will take your head pain seriously, find a Black neurologist or primary care clinician in our directory.