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Neurology Last reviewed:

Migraine

Also known as: Migraine headache, migraine with aura, migraine without aura, chronic migraine

Reviewed by the Black Health editorial team Last reviewed

~17%

one-year migraine prevalence in Black women (Lipton et al., AMPP study, Neurology, 2007)

Overview

Migraine affects Black adults at roughly the same rates as white adults: approximately 15 to 16 percent of the population. The disparity is not in who gets migraine; it is in who gets diagnosed and treated. Only 47 percent of Black patients with headache symptoms have a formal migraine diagnosis, compared to 70 percent of white patients. Only 14 percent of Black headache patients receive a prescription for acute migraine medication, compared to 37 percent of white patients. (American Migraine Foundation, Racial Disparities in Migraine Care) Those gaps represent millions of people in unnecessary pain.

How Migraine affects Black patients

Three documented patterns shape how migraine plays out in Black patients in the U.S. health system.

Diagnosis gap. In the AMPP cohort, only about 47 percent of Black participants who met International Classification of Headache Disorders criteria for migraine had ever received a migraine diagnosis from a clinician, compared with roughly 70 percent of white participants (Loder et al., Headache 2015). A separate analysis of the National Ambulatory Medical Care Survey by Charleston and colleagues found Black patients presenting with headache were significantly less likely than white patients to have migraine specifically coded, even when symptoms fit. The label matters because triptans, CGRP antagonists, and preventive care follow the label.

Triptan versus opioid prescribing. Triptans (sumatriptan, rizatriptan, eletriptan, others) are the guideline first-line acute treatment for moderate-to-severe migraine attacks, per American Headache Society (AHS) consensus (Ailani et al., Headache 2021, PMID 34160823) and American Academy of Neurology guidance. Multiple claims-data analyses, summarized in Charleston and Burke 2018, show Black patients with confirmed migraine are prescribed triptans at lower rates than white patients with the same diagnosis, and prescribed opioids at higher rates. Opioids are not recommended as first-line migraine treatment, can worsen medication-overuse headache, and carry addiction and overdose risk that lands disproportionately on Black communities.

Emergency department pain treatment. Pletcher et al. (JAMA 2008, PMID 18167408) analyzed roughly 374,000 ED pain visits and found Black patients were significantly less likely than white patients to receive opioid analgesia for severe pain, including severe headache, after adjustment for pain score and visit factors. Subsequent ED-specific migraine studies and the AHS position paper on ED migraine care echo the pattern: Black patients with severe migraine attacks wait longer for analgesia and receive less aggressive abortive treatment.

CGRP-era under-enrollment. The monoclonal antibody and gepant classes (erenumab, fremanezumab, galcanezumab, eptinezumab, atogepant, rimegepant) have reshaped migraine prevention since 2018. Pivotal trials including STRIVE for erenumab (Goadsby et al., NEJM 2017, PMID 29171821) and ADVANCE for atogepant (Ailani et al., NEJM 2021, PMID 34379916) reported Black participant enrollment in the low single digits, often under 5 percent. The drugs work in the patients who got into the trials. Whether subgroup efficacy and tolerability hold in Black patients at scale is a question current real-world registries are still answering.

Symptoms

Migraine is more than a bad headache. The International Classification of Headache Disorders (ICHD-3) defines an attack by a cluster of features that show up together.

  • Throbbing or pulsing pain, often on one side of the head, lasting 4 to 72 hours untreated
  • Moderate to severe intensity, worsened by routine activity (walking, stairs, bending over)
  • Nausea, vomiting, or both
  • Sensitivity to light (photophobia) and to sound (phonophobia)
  • Aura in roughly a third of patients: visual zigzags, blind spots, or shimmering lines, sometimes numbness or speech changes, usually 5 to 60 minutes before or during the headache
  • Prodrome hours to a day before the attack: yawning, food cravings, irritability, neck stiffness, fatigue
  • Postdrome after the attack: migraine hangover, fogginess, exhaustion that can last a day
  • Triggers vary by patient: hormonal shifts (menstrual migraine in particular), skipped meals, dehydration, poor sleep, stress letdown, weather changes, red wine, aged cheese, MSG in some patients

Chronic migraine, distinct from episodic, means 15 or more headache days a month for at least three months, with at least 8 of those days meeting migraine criteria.

When to see a doctor

Two categories of urgency.

Emergency, call 911 or go to the ED: a sudden thunderclap headache that hits maximum intensity within seconds to a minute, the worst headache of your life, headache with fever and stiff neck, headache after a head injury, headache with new weakness, numbness, vision loss, slurred speech, or confusion, or a headache during pregnancy or postpartum with vision changes or swelling. Those can signal subarachnoid hemorrhage, meningitis, stroke, or preeclampsia, and they are not migraine until proven otherwise.

Schedule a visit with a primary care clinician or neurologist if: you have recurring headaches that disrupt work, school, sleep, or parenting; you are using over-the-counter pain medication more than 2 days a week (medication-overuse headache risk); your headache pattern has changed in frequency, location, or character; you are pregnant or planning pregnancy and need migraine treatment compatible with that; or you have been getting headaches called sinus, stress, or tension for years without a formal evaluation. The AMPP data says that last group is disproportionately Black.

Screening

There is no blood test or imaging study for migraine. Diagnosis is clinical, made by a clinician applying ICHD-3 criteria to a careful history. Brain MRI or CT is ordered when red flags suggest a secondary cause (thunderclap onset, focal neurologic deficits, age over 50 with new headache, immunocompromised status, cancer history), not to confirm migraine itself.

Two validated disability instruments are used to grade severity and track treatment response: MIDAS (Migraine Disability Assessment Score) and HIT-6 (Headache Impact Test). Bring a headache diary to the first visit: dates, duration, intensity 0-10, suspected triggers, what you took, whether it worked. Two months of diary data is more useful to a neurologist than any single description of my headaches.

If you suspect your headaches have been labeled tension or sinus for years, ask directly: do my symptoms meet criteria for migraine? The label changes the medication options.

Treatment overview

Acute treatment (stop the attack). Mild attacks may respond to NSAIDs (ibuprofen, naproxen) or acetaminophen, ideally with an antiemetic if nausea is prominent. Moderate-to-severe attacks: triptans are first-line per AHS 2021 consensus. Sumatriptan (oral, nasal, subcutaneous), rizatriptan, eletriptan, and zolmitriptan are widely used; the injectable and nasal forms work faster when nausea blocks absorption. Patients with cardiovascular contraindications to triptans now have gepants (rimegepant, ubrogepant) and the 5-HT1F agonist lasmiditan as alternatives. Opioids and butalbital-containing combinations are not first-line and should be avoided when possible. If your prescriber's instinct is to send you home with hydrocodone or Fioricet for a migraine, ask explicitly about triptans or gepants and document the conversation.

Preventive treatment is considered when attacks occur 4 or more days per month, when acute treatment fails or is contraindicated, or when disability is high. AAN/AHS guidelines support beta-blockers (propranolol, metoprolol, timolol), topiramate, valproate (not in pregnancy or in patients of childbearing potential without contraception planning), candesartan, and amitriptyline as oral preventives with Level A or B evidence. OnabotulinumtoxinA is approved for chronic migraine specifically.

CGRP-pathway preventives are the major addition of the last decade: erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti) are monoclonal antibodies given monthly or quarterly. Atogepant (Qulipta) and rimegepant (Nurtec ODT) are oral CGRP receptor antagonists used preventively. These drugs have shifted what's possible in migraine prevention; Black enrollment in the pivotal trials was low, so real-world data in Black patients is still accumulating.

Non-drug treatment with evidence: cognitive behavioral therapy for headache, biofeedback, regular aerobic exercise, sleep regularization, and for some patients, neuromodulation devices (Cefaly, Nerivio, gammaCore). Magnesium, riboflavin (vitamin B2 400 mg), and CoQ10 have modest preventive evidence and are often layered in.

Questions to ask your doctor

Bring this list to your next appointment.

  • Is this a migraine diagnosis? If not, what is your reasoning?
  • How many headache days per month qualifies me for preventive therapy?
  • What are my options beyond ibuprofen and acetaminophen?
  • Am I a candidate for a triptan or gepant for acute attacks?
  • Should I try an anti-CGRP injectable for prevention, and how do I navigate insurance coverage?
  • What does medication-overuse headache look like and how do I avoid it?

Find care for migraine

Not sure where to start? Describe what you're experiencing and we'll help you find the right kind of care, including a neurology.

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The numbers

  • Only 47% of Black patients with headache symptoms have received a formal migraine diagnosis, compared to 70% of white patients. (American Migraine Foundation)
  • Only 14% of Black headache patients receive a prescription for acute migraine medication (triptans and similar), compared to 37% of white patients. (American Migraine Foundation)
  • Only 46% of Black patients with headaches seek care from a provider, compared to 72% of white patients. The gap is driven by prior experiences of dismissal, lack of insurance, and shortage of local specialists. (American Migraine Foundation)
  • More than one-third of Black patients reported experiencing discrimination from healthcare providers in the context of headache care. (American Migraine Foundation)

What it is

Migraine is a neurological disease characterized by recurrent episodes of moderate to severe head pain, typically on one side, that can last four to 72 hours. Pain is often throbbing or pulsating and worsens with physical activity. Most migraine episodes include nausea or sensitivity to light and sound.

About one-third of people with migraine experience an aura before the headache phase: visual disturbances (flashing lights, zigzag lines, blind spots), sensory changes, or speech difficulties lasting 20 to 60 minutes. Aura without headache occurs in some patients.

Migraine is not "just a bad headache." It is a neurological condition with a clear biological basis, including changes in brainstem activity, cortical spreading depression, and the role of calcitonin gene-related peptide (CGRP) in triggering attacks. Understanding the biology matters because it directly informs treatment.

Common triggers include hormonal changes, sleep disruption, dehydration, certain foods, stress, and sensory stimuli. Trigger patterns are individual.

Why the care gap exists for Black patients

The access and diagnosis gap is driven by several intersecting factors:

Provider bias. Physician implicit bias contributes to undertreating Black patients' pain. The Hoffman et al. (2016) PNAS study documented that false biological beliefs about racial differences in pain sensitivity remain common in medical training. These beliefs have no basis in fact but do affect prescribing. (Hoffman et al., 2016, PNAS)

Misdiagnosis as "nonspecific headache disorder." Black and Hispanic patients are more likely to receive the vague diagnosis of "nonspecific headache disorder" rather than a precise migraine diagnosis, which limits access to targeted therapies. (American Migraine Foundation)

Lack of specialist access. Headache specialists and neurologists are disproportionately absent from communities where Black patients live. Many patients can only access a primary care provider who may be less familiar with migraine-specific treatments.

Underrepresentation in research. An analysis of 16 migraine studies published in neurology journals in 2019 found white participants comprised 74.7 to 97 percent of samples. When most clinical evidence comes from white patients, its application across racial groups carries real uncertainty. (American Migraine Foundation, Black History Month resource)

Trust deficit. Documented discrimination in healthcare encounters drives lower care-seeking rates. When 35 percent of Black patients report experiencing provider discrimination, the decision to delay or avoid care is rational, not negligent.

Treatment, plainly

Migraine has effective treatments. The goal is to treat acute attacks quickly and, for frequent migraine, to prevent attacks from happening.

Acute (attack-time) treatment:

  • Triptans (sumatriptan, rizatriptan, others): First-line for moderate to severe migraine attacks. They work by targeting serotonin receptors and narrowing blood vessels. Available as tablets, nasal sprays, and injections. Black patients receive these prescriptions at one-third the rate of white patients despite similar symptom burden.
  • Gepants (ubrogepant/Ubrelvy, rimegepant/Nurtec): Newer CGRP receptor antagonists approved for acute migraine; do not carry the cardiovascular contraindications of triptans, making them options for patients with vascular risk factors.
  • Lasmiditan (Reyvow): A newer acute treatment targeting serotonin 5-HT1F receptors. Controlled substance (Schedule V).
  • NSAIDs and combination analgesics: Appropriate for mild-moderate attacks; overuse (more than 10-15 days per month) causes medication-overuse headache.

Prevention (if 4 or more migraine days per month, or if attacks are severely disabling):

  • Anti-CGRP monoclonal antibodies (erenumab/Aimovig, fremanezumab/Ajovy, galcanezumab/Emgality, eptinezumab/Vyepti): Monthly or quarterly injections or infusions. The American Headache Society now supports these as first-line prevention options, not second-line. Access remains inconsistent due to insurance restrictions. (American Migraine Foundation, CGRP Barriers to Access)
  • Oral preventives: Beta-blockers (propranolol, metoprolol), antiepileptics (topiramate, valproate), and tricyclic antidepressants (amitriptyline) have the longest evidence base for prevention but require monitoring and have more side effects.
  • Rimegepant (Nurtec) and atogepant (Qulipta): Oral CGRP antagonists approved for both acute treatment and daily prevention.

Non-drug strategies with evidence: Regular sleep, hydration, aerobic exercise, and stress management reduce attack frequency for many patients. Biofeedback has the strongest evidence among behavioral approaches.

When to seek emergency care

Seek emergency care immediately for:

  • The "worst headache of your life" (thunderclap onset within seconds): this can indicate a brain bleed, not migraine
  • Headache with fever, stiff neck, or rash: possible meningitis
  • Headache with sudden vision loss, weakness, numbness, slurred speech, or confusion: these are stroke symptoms, call 911
  • Headache following a head injury
  • New or significantly different headache in someone over 50

For a migraine in progress that is not responding to home medication and lasts more than 72 hours (status migrainosus), urgent care or an emergency department is appropriate.

If this is a mental health crisis, call or text 988 (Suicide and Crisis Lifeline) any time.

How to find care

The American Migraine Foundation maintains a provider directory searchable by location. For clinical trial opportunities, visit clinicaltrials.gov and search "migraine" with your ZIP code.

Sources

  1. American Migraine Foundation. Racial Disparities in Migraine Care. https://americanmigrainefoundation.org/resource-library/racial-disparities-in-migraine-care/
  1. American Migraine Foundation. Black History Month: Disparities in Headache and Migraine Care. https://americanmigrainefoundation.org/resource-library/black-history-month-disparities-in-headache-and-migraine-care-2/
  1. American Migraine Foundation. Barriers to Access: New CGRP Class. https://americanmigrainefoundation.org/resource-library/potential-barriers-access-new-cgrp-class
  1. Nicholson RA, Buse DC, Andrasik F, Lipton RB. Nonpharmacologic Treatments for Migraine and Tension-Type Headache. Expert Opinion on Drug Delivery. 2006; Headache; Nicholson et al. Migraine Care Among Different Ethnicities. Headache. 2006;46(5):754-765.
  1. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between Blacks and Whites. Proceedings of the National Academy of Sciences. 2016;113(16):4296-4301. https://www.pnas.org/doi/10.1073/pnas.1516047113
  1. Migraine Science Collaborative. Racial and Ethnic Disparities in Chronic Pain, Including Migraine: More Than Black versus White. https://migrainecollaborative.org/racial-and-ethnic-disparities-in-chronic-pain-including-migraine-more-than-black-versus-white
  1. Harvard Health. Health disparities and headache treatment. 2022. https://www.health.harvard.edu/blog/health-disparities-and-headache-treatment-202202152685

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Medical disclaimer

This content is for informational and educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about a medical condition. If you are experiencing a medical emergency, call 911 or your local emergency number immediately.

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