As a physician trained in family medicine who now specializes in headache treatment, I’ve seen migraines from both sides. Here are the five things every primary care provider should know when caring for migraine patients.

The ‘sinus headache’ is largely a myth

When a patient says they’re experiencing a sinus headache, 90% of the time it’s a migraine. The true sinus headache almost never exists. Congestion, watery eyes and a runny nose are all autonomic features common with migraines. If a patient points to those symptoms as evidence of a sinus headache, take a more detailed history. It goes without saying that treating a migraine with antibiotics won’t do a thing.

Start with the highest dose of Imitrex

Standard protocol for treating patients as a primary care provider is to start with the lowest therapeutic dose and work your way up. This is generally a prudent strategy. Not with migraine. With Imitrex for migraine, start with 100 milligrams. I would use 50 milligrams if you are worried about side effects due to the patient being slightly underweight.

When to image

Everyone worries about when to order diagnostic imaging. Red flags that warrant imaging follow the mnemonic SNOOP4: systemic symptoms, neurological symptoms or signs, onset that is sudden, older age of onset (over age 50), pregnancy, precipitated by valsalva, pulsatile tinnitus, pattern change. An example of a pattern change might be a patient who frequently has dull, throbbing headaches but all of a sudden has a sharp stabbing pain.

Over-the-counter drug overuse causes migraines

Overuse of over-the-counter (OTC) medications can result in frequent headaches. If a headache is present more than 15 days a month, regular overuse of OTC medication may be the cause. Simple pain relievers such as aspirin and acetaminophen can lead to “rebound” headaches.

Combination pain relievers, such as Excedrin, that combine aspirin, acetaminophen and caffeine, and medications that include opiates, such as Tylenol with codeine, can result in overuse headaches. These OTC medications can make migraines worse or prevent migraine medications from helping. Weaned off the OTC pain relievers, up to 50% of patients will experience fewer migraines and some will no longer need migraine medications at all.

New migraine drugs for patients with cardiovascular disease

Traditional acute migraine medications are off-limits for patients with cardiovascular disease. These drugs are triptans and cause vasoconstriction, meaning they carry a risk for stroke.

Now, within a span of a few months, there are the three new migraine drugs for these patients. Ubrelvy (ubrogepant) and Nurtec ODT (rimegepant) are approved for migraine with or without aura. The drugs block a protein called calcitonin gene-related peptide (CGRP).

The Food and Drug Administration also recently approved Reyvow (lasmiditan), a serotonin receptor agonist. Unlike triptans, which target the smooth muscle cells of blood vessels, lasmiditan works on serotonin receptors in the brain. Lasmiditan comes with a lot of “baggage.” You can’t drive a car or operate machinery for at least eight hours after you take the drug. Still, these exciting new drugs offer real options for cardiovascular patients with migraines. When I was a primary care physician, I had nothing to offer them but Tylenol.

Mandy J. Whitt, M.D., is a headache neurologist with Norton Neuroscience Institute.