Root Causes & Treatment Strategies for Chronic Migraine

Flat lay of omega-3s, salmon, and shrimp that make up the ketogenic diet, one of the functional medicine treatments for chronic migraines.
Read Time: 5 Minutes

An estimated 87 million people worldwide suffer from migraine, with a higher incidence among women.1 Chronic migraine has been noted as the most common type of daily headache seen by specialists and is a condition that often occurs as a typical progression from episodic migraine (less than 15 headache days per month) and displays its own unique physiology.2

Clinical, neurophysiologic, and functional imaging studies have suggested that alterations can occur in the brains of patients with chronic migraine compared to those with episodic migraine.2 Also, patients with chronic migraine often experience higher rates of comorbidities, including anxiety and depression,2 gastrointestinal (GI) disorders,2 and inflammatory diseases,3 all of which can greatly impact quality of life.

Migraine Complexity & Support

Migraine is a complex issue related to the interaction between genetic, environmental, and lifestyle factors. This interaction may manifest differently for each individual patient. While the exact pathophysiology of migraine is unclear, some etiologies have been suggested, such as:

  • An overall pro-inflammatory and oxidative state.4
  • Mitochondrial dysfunction.5-7
  • Common migraine triggers such as stress, hormonal changes, skipped meals, disturbed sleep, environmental allergens, and food allergens or sensitivities.8

Functional GI disorders such as irritable bowel syndrome (IBS), reflux, and dyspepsia have also been shown to be frequently comorbid with migraine.9-11 Further, the intestinal microbiome is suspected to play a role in the progression of migraine via the gut-brain axis.12,13

A range of underlying causes that potentially contribute to chronic migraine have been noted; however, if the exact causes for an individual patient are not known, this may create difficulty in selecting an appropriate treatment intervention. In the following video, IFM educator Lisa (Perry) Portera, DC, IFMCP, discusses possible chronic migraine etiologies, such as mitochondrial dysfunction, and specific nutrients that could be used as effective personalized treatment or prevention strategies.

(Video Time: 1 minute). Dr. Portera-Perry is an adjunct clinical faculty member of Bastyr University’s teaching clinic in San Diego, CA, as an integrative Doctor of Chiropractic. She is also a member of Bastyr’s adjunct teaching faculty, teaching courses in integrative nutrition and physical medicine.

Treatment Considerations

Nutrition is an important lifestyle-based treatment approach for clinicians to consider when working with a patient who has chronic migraine. Nutritional interventions that emphasize nutrients that support mitochondrial function are of specific importance.14 The following are examples:

  • The ketogenic diet is a therapeutic intervention that targets cerebral metabolism and has suggested relevance in migraine prevention, according to some observational studies.15,16 Some of the proposed pathways and mechanisms include levels of neuroprotection and mitochondrial function, serotoninergic dysfunction, calcitonin gene-related peptides (CGRP) levels, and neuroinflammation.17
  • Micronutrients such as riboflavin,18 coenzyme Q10,19 and magnesium20 may be beneficial in migraine prevention through support of the mitochondria. In addition, a recent cross-sectional study of US adults found a negative association between consumption of vitamin B6 and folate on severe headache and migraine incidence, suggesting that increased dietary intake of these two nutrients may be beneficial in the prevention of migraine.21


Primary goals of migraine treatments are to relieve pain, restore function, reduce frequency, and prevent progression from episodic to chronic migraine. From a functional medicine perspective, supporting mitochondrial function and gut health, avoiding potential triggers, and engaging patients in their treatments are strategies that may improve long-term outcomes.

Functional medicine is a model that can assess an individual patient’s genetic, biochemical, and lifestyle factors to help create a personalized treatment plan. Learn more at IFM’s Bioenergetics Advanced Practice Module (APM).

Learn More About Mitochondrial Function

Related Articles:

Food Reactions, Eczema, and Migraines

Mitochondrial Dysfunction and Chronic Pain Patients


  1. Fan L, Wu Y, Wei J, et al. Global, regional, and national time trends in incidence for migraine, from 1990 to 2019: an age-period-cohort analysis for the GBD 2019. J Headache Pain. 2023;24(1):79. doi:1186/s10194-023-01619-9
  2. Aurora SK, Brin MF. Chronic migraine: an update on physiology, imaging, and the mechanism of action of two available pharmacologic therapies. Headache. 2017;57(1):109-125. doi:10.1111/head.12999
  3. Min C, Lim H, Lim JS, Sim S, Choi HG. Increased risk of migraine in patients with psoriasis: a longitudinal follow up study using a national sample cohort. Medicine (Baltimore). 2019;98(17):e15370. doi:10.1097/MD.0000000000015370
  4. Razeghi Jahromi S, Ghorbank Z, Martelletti P, Lampl C, Togha M. Association of diet and headache. J Headache Pain. 2019;20(1):106. doi:10.1186/s10194-019-1057-1
  5. Fila M, Pawłowska E, Blasiak J. Mitochondria in migraine pathophysiology – does epigenetics play a role? Arch Med Sci. 2019;15(4):944-956. doi:10.5114/aoms.2019.86061
  6. Khan J, Asoom LIA, Sunni AA, et al. Genetics, pathophysiology, diagnosis, treatment, management, and prevention of migraine. Biomed Pharmacother. 2021;139:111557. doi:1016/j.biopha.2021.111557
  7. Kraya T, Deschauer M, Joshi PR, Zierz S, Gaul C. Prevalence of headache in patients with mitochondrial disease: a cross-sectional study. Headache. 2018;58(1):45-52. doi:10.1111/head.13219
  8. Pescador Ruschel MA, De Jesus O. Migraine Headache.  StatPearls Publishing; August 23, 2023. Accessed April 25, 2024.
  9. Martami F, Ghorbani Z, Abolhasani M, et al. Comorbidity of gastrointestinal disorders, migraine, and tension-type headache: a cross sectional study in Iran. Neurol Sci. 2018;39(1):63-70. doi:10.1007/s10072-017-3141-0
  10.  Lankarani KB, Akbari M, Tabrizi R. Association of gastrointestinal functional disorders and migraine headache: a population base study. Middle East J Dig Dis. 2017;9(3):139-145. doi:10.15171/mejdd.2017.64
  11.  Kim J, Lee S, Rhew K. Association between gastrointestinal diseases and migraine. Int J Environ Res Public Health. 2022;19(7):4018. doi:3390/ijerph19074018
  12.  Slavin M, Li HA, Frankenfeld C, Cheskin LJ. What is needed for evidence-based dietary recommendations for migraine: a call to action for nutrition and microbiome research. Headache. 2019;59(9):1566-1581. doi:10.1111/head.13658
  13.  Arzani M, Jahromi SR, Ghorbani Z, et al. Gut-brain axis and migraine headache: a comprehensive review. J Headache Pain. 2020;21(1):15. doi:10.1186/s10194-020-1078-9
  14.  Fila M, Chojnacki C, Chojnacki J, Blasiak J. Nutrients to improve mitochondrial function to reduce brain energy deficit and oxidative stress in migraine. Nutrients. 2021;13(12):4433. doi:3390/nu13124433
  15.  Neri LCL, Ferraris C, Catalano G, et al. Ketosis and migraine: a systematic review of the literature and meta-analysis. Front Nutr. 2023;10:1204700. doi:3389/fnut.2023.1204700
  16.  Hindiyeh NA, Zhang N, Farrar M, Banerjee P, Lombard L, Aurora SK. The role of diet and nutrition in migraine triggers and treatment: a systematic literature review. Headache. 2020;60(7):1300-1316. doi:1111/head.13836
  17.  Gazerani P. Migraine and diet. Nutrients. 2020;12(6):1658. doi:10.3390/nu12061658
  18.  Chen YS, Lee HF, Tsai CH, et al. Effect of vitamin B2 supplementation on migraine prophylaxis: a systematic review and meta-analysis. Nutr Neurosci. 2022;25(9):1801-1812. doi:1080/1028415X.2021.1904542
  19.  Sazali S, Badrin S, Norhayati MN, Idris NS. Coenzyme Q10 supplementation for prophylaxis in adult patients with migraine-a meta-analysis. BMJ Open. 2021;11(1):e039358. doi:1136/bmjopen-2020-039358
  20.  Veronese N, Demurtas J, Pesolillo G, et al. Magnesium and health outcomes: an umbrella review of systematic reviews and meta-analyses of observational and intervention studies. Eur J Nutr. 2020;59(1):263-272. doi:1007/s00394-019-01905-w
  21.  Tian S, Yu X, Wu L, et al. Vitamin B6and folate intake are associated with lower risk of severe headache or migraine in adults: an analysis based on NHANES 1999-2004. Nutr Res. 2024;121:51-60. doi:1016/j.nutres.2023.11.008

Related Insights