Neurologist vs Primary Care for Migraines: Who to See

What can a primary care clinician do for migraines?

A great deal. Primary care is the right first stop for most people with migraine, and many patients find their headaches well controlled without ever needing a specialist. At the primary care level, your clinician can:

• Confirm the migraine diagnosis using established criteria
• Review your headache diary and identify contributing patterns
• Order imaging if a secondary cause needs to be ruled out
• Prescribe acute (as-needed) treatments — including triptans, NSAIDs, and anti-nausea medications
• Start preventive medications when frequency warrants it (typically four or more migraine days per month)
• Address contributing conditions such as sleep disorders, anxiety, medication overuse, and hormonal factors
• Provide lifestyle counseling on triggers and behavioral strategies 1Ref 1Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E (2012).Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society.Primary care-level management of migraine including preventive medication thresholds

For most people with episodic migraine — meaning fewer than 15 headache days per month — primary care management is appropriate and effective.

When does it make sense to see a neurologist or headache specialist?

A referral is reasonable in these situations:

Difficult-to-control or high-frequency migraine — If you have 15 or more headache days per month (chronic migraine), or if two or more preventive medication trials have not provided adequate relief, specialist input helps. Neurologists and headache specialists have access to a broader range of treatments, including CGRP-targeting medications (both acute and preventive) and procedures such as Botox injections for chronic migraine 2Ref 2Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society (2021).The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice.Specialist-level treatments for chronic migraine including Botox and CGRP agents; indications for specialist referral.

Diagnostic uncertainty — If the headache pattern does not fit cleanly into established migraine criteria, or if there are atypical features (unusual aura, very short or very long attacks, neurological symptoms between attacks), a specialist can clarify the diagnosis.

Hemiplegic migraine or other complex subtypes — These uncommon presentations require specialist management.

New neurological symptoms — Weakness, vision changes, or cognitive symptoms that accompany headaches and have not been fully explained.

Concern about a secondary cause — Headaches that started after age 50, changed character significantly, or are associated with features that raise concern for an underlying structural cause.

Pregnancy and migraine — This is a complex situation where specialist input is often helpful because treatment options are more restricted.

What is a headache specialist, and is that different from a neurologist?

All headache specialists are neurologists, but not all neurologists are headache specialists. A headache specialist has completed additional focused training in headache medicine and manages complex cases as a significant part of their practice. The United Council for Neurologic Subspecialties (UCNS) offers certification in headache medicine.

For most people with migraine who need a referral, a general neurologist is an appropriate first step. A dedicated headache specialist is particularly valuable for chronic migraine, medication overuse headache, cluster headache, or when several preventive medication trials have not worked.

What are CGRP medications, and do I need a specialist to get them?

Calcitonin gene-related peptide (CGRP) is a neuropeptide involved in migraine pain signaling. A new class of medications that block CGRP or its receptor — available both as monthly injections and as oral pills — has substantially expanded preventive options for migraine. The American Headache Society now considers these a first-line preventive option 3Ref 3Charles AC, Digre KB, Goadsby PJ, Robbins MS, Hershey A; American Headache Society (2024).Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update.CGRP-targeting therapies as first-line preventive option; access via primary care and specialists.

Primary care clinicians can prescribe CGRP-targeting medications, and many do. However, insurance prior authorization requirements and familiarity with the agents vary, and some patients find it easier to access them through a neurologist or headache specialist. This is something to discuss with your Gale clinician.

How should I start this conversation with my primary care clinician?

Come prepared with: - A headache diary or a count of how many headache days you have had in the past month - A description of your typical attack (duration, location, associated symptoms) - A list of medications you have tried and how they worked - Any questions about specific treatments you have heard about

Your Gale clinician can complete a full headache assessment, discuss acute and preventive options, and refer you to neurology when the situation warrants it. Most people do not need a referral right away — starting at primary care is the right approach.