Advocating for—and providing health care to—migraine patients.
Amaal Starling knew at a young age that she wanted to be a doctor. As part of a 6th grade project, she shadowed a neurologist for a day at the prestigious Mayo Clinic in her hometown of Scottsdale, AZ. This sparked her interest in the study of the brain.
While attending undergrad at UCLA, she experienced her first migraine attack. Both sides of her family had members with migraine disease, so Amaal knew the warning signs. Within six months of her first attack, she had her diagnosis and began taking over-the-counter anti-inflammatory medications that helped to a degree.
By the time she reached medical school at Drexel University in Philadelphia, Amaal learned about triptans. On average, students in medical school receive only about four hours of education in headache medicine. Medication overuse headache (MOH) was never discussed and Amaal soon developed this secondary type of headache after using triptans too often.
Amaal chose neurology as her specialty. She returned to Scottsdale, where she completed her residency at the Mayo Clinic. To her delight, the same neurologist she shadowed over a decade prior was still at Mayo, and she works side by side with him today.
During her residency, Amaal became very interested in neuropathic pain, especially a condition known as complex regional pain syndrome (CRPS). This chronic, painful illness is caused by damage to the peripheral or central nervous systems and includes changes in skin color, temperature, or swelling in the affected area.
Still, though a specialty in this area was extremely promising, Amaal says she “gravitated towards patients with migraine and other headache disorders because I could easily empathize with their pain and wanted to relieve their pain and associated symptoms.” She adds that it was the most gratifying group of patients to work with.
Dr. Starling, the Headache Specialist
After completing her neurology residency, Amaal chose to spend another year studying headache medicine in order to focus her practice on the underserved population of patients with headache disorders.
“My personal history of migraine strongly influenced my desire to become a headache specialist,” says Amaal. “However, as I learned more about the underlying pathophysiology of headache disorders and the various treatment options, my passion for headache medicine was ignited.”
Dr. Amaal Starling is now one of about 520 physicians in the country who have earned the designation of headache specialist. Unlike fellow neurologists who treat patients with migraine as well as Parkinson’s, amyotrophic lateral sclerosis (ALS), multiple sclerosis, or sleep disorders, Amaal treats only patients who have varying degrees of almost 300 separate headache disorders.
Headache specialists are in high demand. There are 36 million Americans who have migraine disease, meaning there is one headache specialist for about every 70,000 migraine patients. Waiting lists for new patients are long and access can be difficult, especially for those in rural areas. However, these highly skilled doctors are the most qualified to treat patients with the most debilitating forms of migraine disease.
Just because Amaal helps hundreds of patients navigate their way through the many obstacles of living with migraine doesn’t mean she doesn’t still have her own struggles. She was able to pinpoint her triggers early on: stress, sleep deprivation, and caffeine—three things that are almost unavoidable during medical school and residency. Over the years, she found physical therapy, exercise, yoga, and massage to be integral in managing her migraine disease. Other keys to maintaining her health are “sleep, lots of love, and happiness.” Currently, Amaal has two to three migraine attacks a week. She explains that there are varying degrees of severity and intensity that each person with migraine experiences. In her practice, she sees patients who have the same number of attacks that she does, but much more debilitating symptoms. Amaal uses a regimen of nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, biofeedback, and occasional nerve blocks to manage her migraine attacks. Amaal’s household understands her disease well. Her husband, whom she met in college at UCLA, also has migraine. She describes his attacks as high frequency, teetering between episodic and chronic. He also has migraine with and without aura. Amaal was in residency while pregnant with their son. Roughly 80 percent of women with migraine report reduced attacks during pregnancy, but Amaal was in the unlucky minority who experience worsening migraine symptoms. She says it was the only time her attacks were so disabling she had to miss work. Once, she had to get fluids in the hospital for her migraine when she was originally scheduled to be on call. Their seven-year-old son also has migraine—not surprising since a child who has two parents with migraine is 75 percent more likely to inherit the disease. Amaal says her son is very aware of his triggers. He recently remarked that he probably didn’t drink enough water that day, which caused an attack. “Medical school, residency, and life as a neurologist and working mom of an energetic and lovable seven-year-old is as wonderful as it is stressful,” she says. “Sleep deprivation, stress, and caffeine are strong triggers for my migraine attacks. I do my very best to avoid my triggers, but it is hard work every day.”
The Value of Advocacy
“People don’t feel guilty about having diabetes. People don’t feel guilty about having multiple sclerosis. So people shouldn’t feel guilty about having migraine. It’s in our DNA,” says Amaal—strong words spoken like a true advocate for migraine disease.
Amaal stresses to her patients that their migraine attacks are not their fault. It’s nothing that they did wrong. Guilt shouldn’t be part of their struggle.
Migraine is “a neurobiological disorder or a brain state that results in attacks of neurologic symptoms caused by abnormal sensory processing,” she explains. “Pain, light, sound, motion, and much more is processed abnormally during a migraine attack.” This definition doesn’t leave any room for people to question what they did to cause this disease. It also doesn’t allow for someone to feel guilty about having this disease.
For Amaal, getting over the guilt began to lift the stigma of migraine disease. She believes that her son will be part of the first generation to not have to face the same stigma.
Amaal recently completed her first 5K during the 2017 Miles for Migraine race in Phoenix, another step in fighting the stigma of migraine. She’s not only proud of herself for running the entire course and finishing, she was excited by the larger-than-expected turnout.
Amaal also participates in Headache on the Hill, an advocacy event on Capitol Hill that brings awareness and asks lawmakers to fund research for migraine disease. She is the physician co-chair of the American Headache and Migraine Association, the patient arm of the American Headache Society. The mission of this patient-led group is to advance awareness and education about headache disorders, provide resources for those affected, and support research efforts for effective treatments.
For Amaal, advocating for those with migraine serves not only herself, but her patients, her husband, and her son. She is excited about being in the field of headache medicine now because of so many new, promising developments. As a doctor, she has a unique viewpoint to understand each patient’s struggles. Through her migraine journey she has learned that “pain is humbling. It has taught me to love life whether it hurts or not.”
American Migraine Foundation: americanmigrainefoundation.org
American Headache and Migraine Association: ahmaishope.net
Directory of Headache Specialists: migraineresearchfoundation.org/resources/find-a-doctor/doctors-certified-in-headache-medicine