Migraine Diagnosis and Treatment: Dr. Robert Cowan of Stanford Headache Clinic

Meet Dr. Robert Cowan, founder of Stanford Headache Clinic

Navigating migraine can be so confusing and overwhelming—but it doesn’t have to. 

To help cut through the confusion, we hosted a Neurologist Ask-Me-Anything with Dr. Robert Cowan, founder of the Stanford Headache Clinic and one of the nation’s leading migraine experts. With more than 35 years of treating patients and living with migraine himself, Dr. Cowan shared practical, empathetic answers to some of the most common questions.

If you missed the live session or want to revisit the gems Dr. Cowan shared, we've got you covered. Here's a breakdown of every question we covered, because we know how valuable this expert guidance is for navigating migraine relief and headache care.

"How do I get diagnosed with migraine in the first place?"

This was one of our top questions, and honestly, it's where so many of us start our migraine journey. You know those days when you're wondering, "Is this just a tension headache, or is something bigger going on with my body? Could this be chronic migraine?"

Dr. Cowan's advice here was golden for anyone seeking a migraine diagnosis. Before you even step into a doctor's office, start tracking your headache patterns. Notice your migraine triggers, headache frequency, pain intensity, and the specific ways your headaches show up. This isn't just helpful – it's essential information that helps healthcare providers understand exactly what type of headache disorder you're experiencing.

The key is self-advocacy in headache care. You know your body better than anyone, and coming prepared with detailed information about your migraine symptoms, headache diary entries, and pain patterns puts you in the strongest position to get the migraine treatment you need.

"When should I see a headache specialist vs. my primary care doctor?"

Ugh, this question hits home for so many of us dealing with chronic headaches. Especially when you're looking at a six-month wait just to get through a headache neurologist's door!

Dr. Cowan broke down the decision-making process for choosing between primary care and specialized migraine care, helping us understand when your family doctor might be the right starting point versus when it's worth the wait for a migraine specialist or headache clinic. He also touched on when emergency headache care becomes necessary – because sometimes we really need to know if what we're experiencing requires immediate medical attention.

The reality is that navigating headache medicine and the healthcare system can feel like a maze, but having a clear roadmap for migraine care makes all the difference.

"I've tried Nurtec, Zomig, and almost every triptan – what other migraine medications are out there?"

When you've cycled through multiple headache medications, tried different migraine drugs, and you're still struggling with breakthrough migraines, it can feel like you're running out of migraine relief options.

Dr. Cowan reassured us that there's actually much more optionality in migraine treatment than many people realize. The key is understanding that headache medicine often requires a systematic approach to find effective migraine prevention, and what doesn't work for one person's migraine attacks might be perfect for another.

He dove into both acute migraine medications (those "rescue" treatments to take when you're in the thick of a migraine attack) and migraine preventatives (long-term medications to reduce headache frequency and severity). The trial-and-error process for finding your optimal migraine treatments isn't fun, but it's often necessary.

"My Botox for migraines is wearing off at week 8, but my doctor won't do it earlier."

This question was so practical and relatable for anyone using Botox injections for chronic migraine. When you've found a migraine preventive treatment that works but it doesn't quite last as long as the standard schedule allows, you're stuck in this frustrating gap where your migraine symptoms return.

Dr. Cowan addressed strategies for bridging these headache treatment gaps – whether it's with Botox for migraine, monthly CGRP inhibitors, or other migraine preventatives that might wear off before your next scheduled dose. It's about creating those layers of migraine defense and having backup plans for breakthrough headaches when your primary treatment needs some support.

"I have multiple chronic conditions and feel like I'm getting siloed headache care."

This question resonated with so many of us dealing with comorbid conditions. When you're managing chronic migraine plus chronic fatigue syndrome (CFS), fibromyalgia, or cardiovascular issues, coordinating care between different specialists can feel like an impossible game of telephone. Many migraine patients also deal with other pain conditions, making comprehensive headache management even more complex.

Dr. Cowan's advice focused on becoming your own best advocate in migraine care coordination across different specialists. From our community perspective, we've seen folks create comprehensive migraine medical binders or prepare detailed "elevator pitches" that include all their conditions, current headache medications, dosages, migraine triggers, and key headache diary information. Whether you're at primary care, seeing a headache specialist, or ending up in the ER with a severe migraine, having this migraine management information ready ensures everyone's working with the complete picture of your headache disorder.

"How can I better support someone with chronic migraine?" AND "What resources can I share with family and friends about migraine?"

We loved that we got both sides of this equation! One person asking how to support their partner with chronic migraine, and another asking how to help their loved ones understand what living with migraine is really like.

Dr. Cowan's approach was very self-validating—it starts with the person living with migraine identifying what they actually need during migraine attacks, then communicating to their loved ones about those needs. It's about moving away from assumptions and toward real, open dialogue about what migraine support looks like in practice.

The key is that everyone's migraine needs are different. Some people want to be left alone in a dark room during a migraine attack, while others want gentle check-ins about their headache pain. Some need help with specific tasks when experiencing migraine symptoms. The magic happens when you can communicate your needs clearly and your support system can respond accordingly.

"I'm thinking about having kids but worried about pregnancy and migraine."

This question is deeply personal and shows how migraine can impact major life decisions. The person was concerned about how pregnancy hormones might affect their migraine patterns and their future ability to care for children while managing chronic headaches.

Dr. Cowan provided guidance on pregnancy-safe migraine treatments and broader considerations for family planning with chronic migraine—in fact, many medications today are now safe to take in the duration of pregnancy, so it's critical to work with your doctor to build out a transition plan. It's about preparing for hormonal changes that might affect migraine frequency while also recognizing that many people successfully navigate pregnancy and parenting with migraine.

"Can you stack CGRP medications like Ajovy and Nurtec?"

Dr. Cowan addressed both the potential benefits and safety concerns of combination therapies. As CGRP medications become more prevalent, questions about how they work together and the long-term impacts on people’s health are becoming increasingly important for treatment optimization.

“What's giving us hope about the future of migraine care?”

The landscape has changed dramatically – from the limited options previous generations had to today's expanding toolkit of targeted therapies.

As a community, we're also seeing broader social recognition of migraine as a legitimate medical condition. The dismissive attitudes that past generations faced are giving way to greater acceptance and understanding. That cultural shift matters just as much as the medical advances.

What this means for our migraine community

This AMA reinforced something we already know – you're not alone in this migraine journey, and the questions you're asking are exactly the right ones. Whether you're just starting to seek diagnosis, navigating treatment options, or supporting someone you love, there are paths forward.

The key takeaways we're holding onto:

• Preparation and tracking are your superpowers

• Advocacy is essential – you know your body best

• Treatment is highly individual and often requires patience

• Communication makes all the difference in relationships

• There's genuine reason for hope as treatment options continue to evolve

Huge thanks to Dr. Cowan for sharing his expertise and to everyone who submitted questions. Here's to more conversations, better care, and supporting each other through it all. 🍑

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