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BackTable / ENT / Article
Headache Management: Medicine, Supplements & Botox
Iman Iqbal • Updated Sep 27, 2025 • 36 hits
Managing sinus headaches and migraines requires a layered approach, combining lifestyle changes, supplements, medications, and non-pharmacologic therapies. While many patients begin with basic lifestyle modifications like sleep, hydration, and diet, these measures are not always enough to fully control symptoms.
When symptoms persist a variety of additional options can be explored, from targeted supplements and lab testing to prescription therapies and advanced interventions. Adjunctive approaches such as acupuncture, cold therapy, and stress reduction techniques may also play a role. Ultimately, the key lies in building an individualized care plan that balances effectiveness with quality of life.
This article features excerpts from the BackTable ENT Podcast with otolaryngologist, Dr. Jessica Lee. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Supplements such as riboflavin and magnesium are common recommendations for migraine management; some forms of magnesium are also useful for improving sleep quality.
• Supplements containing CoQ10, omega-3s, alpha-lipoic acid, or probiotics may help, but patients are typically encouraged to introduce only one or two at a time.
• Lab testing for thyroid function, vitamin D, B12, ferritin, and iron can uncover metabolic deficiencies that worsen fatigue, brain fog, or headache symptoms.
• Triptans are frequently used as acute “rescue medications,” helping to end disabling episodes while also confirming whether headaches are truly migraine-related.
• Preventive treatments such as tricyclic antidepressants, topiramate, beta-blockers, or CGRP therapies may be considered for patients with frequent or severe symptoms.
• Botox is an option for patients who prefer to avoid daily medication or who have not responded to other treatments, with benefits for both chronic migraines and conditions like TMJ-related pain.
• Non-pharmacologic therapies – including acupuncture, acupressure, cold therapy, and herbal remedies – can complement treatment and empower patients to build a personalized migraine toolkit.
Table of Contents
(1) Supplements & Nutrients in Managing Chronic Headaches
(2) Headache Management
(3) Botox for Migraine & Sinus Headaches
(4) Non-Pharmacologic Approaches for Headache
Supplements & Nutrients in Managing Chronic Headaches
Supplements play an important role in supporting patients with chronic headache and migraine symptoms, especially when lifestyle changes alone are not enough. Among the most studied and commonly recommended are riboflavin (vitamin B2) and magnesium, both of which have evidence for improving neurological and gut-brain health. Magnesium glycinate and threonate are often preferred due to added benefits for sleep. CoQ10, omega-3 fatty acids, alpha-lipoic acid, and probiotics are additional options, though the focus is usually on introducing one or two supplements at a time rather than overwhelming patients with multiple regimens. While benefits can take two to three months to appear, some patients notice improvement much sooner.
Beyond supplements, lab testing can help uncover hidden contributors to persistent symptoms. Common checks include thyroid levels, vitamin D, B12, ferritin, and iron studies, as deficiencies in these areas may worsen fatigue, brain fog, or nerve sensitivity. For iron replacement, dietary adjustments are emphasized first, but supplements may be considered when necessary. Pairing iron with vitamin C improves absorption, and certain formulations help avoid common side effects like constipation. This holistic approach, balancing targeted supplementation with lifestyle and dietary strategies, aims to provide safe, sustainable relief while minimizing unnecessary medications or invasive interventions.
[Dr. Ashley Agan]
Can we talk about some of the supplements that you will recommend for patients?
[Dr. Jessica Lee]
Yes. The two that have the most research are vitamin B2, which is riboflavin, and magnesium, and there's a thousand varieties of magnesium. Some will say that even your citrate, which is going to be one that doesn't really cross the blood-brain barrier, it stays in the gut, even that can be helpful. I think that's realistic to say because, maybe all, I say all, maybe most of us have heard that there's a gut-brain connection. If we're thinking of this as a brain issue and we improve maybe some gut health issues, then that can also make their symptoms better.
Also, I tend to choose magnesium glycinate for these patients. Magnesium threonate is another version that's very good, but essentially, some version of magnesium and riboflavin are usually the first two I will recommend. Then CoQ10 would be a third that comes right behind it potentially. I try not to overload people. I don't want to be the person that is like, "Here's your 10 supplements. Go start all of them and then come back and see me." I don't like to do that, and so I tell people, "We're going to start with one or two at a time, pause, see how you feel, and then we can move forward if we need to."
There's other evidence for things like omega-3 fatty acid, alpha-lipoic acid, probiotics, again, back to gut health issues. Definitely lots to explore there.
[Dr. Ashley Agan]
Yes. What's the dosing? Do you know off the top of your head what you dose for the magnesium and the riboflavin?
[Dr. Jessica Lee]
The magnesium depends on the type a little bit, but it's somewhere usually between 250 and 500 milligrams a day. Then the riboflavin is 400 milligrams a day. Again, sometimes I'll titrate people up, too. There's not a whole lot of side effect with these. Usually, it's going to be some kind of GI complaint, but I'll have them start 200 of riboflavin once a day. Then we can either bump it up to 400 once a day, or they can do it in divided doses. The magnesium, I'll usually tell them to take before bed, especially if they're taking something like glycinate or threonate, because those do potentially also have some benefits when it comes to sleep.
[Dr. Ashley Agan]
How quickly do you tell people that they can expect to maybe see some benefit when they start these?
[Dr. Jessica Lee]
I usually will say, "Give it a few months." The patients I'm starting these on, these are usually chronic, more chronic symptom patients. This is not someone, who three or four times a year has an episode. I will tell you, I had a woman come in, this was probably a year or two ago, and had been through the wringer, like we talked about at the beginning of the episode. Essentially, I said, "Look, let's just start--" Her lifestyle stuff was pretty in tune. She was pretty like clean eater, went to the gym regularly, felt like she slept pretty well, didn't drink a lot of alcohol, didn't smoke, things like that.
I was like, "Okay. Well, let's just start with some supplements." I was like, "I can't guarantee this is going to fix it by itself, but let's at least get this on board." The woman came back a month later, and she was like, "I have not felt this good in years." Just by adding two little supplements. She was thrilled and I was thrilled. It can happen really fast for some patients, but I certainly usually will say, "It's probably going to take two to three months to feel a difference."
[Dr. Gopi Shah]
Do you worry about any toxicities or interactions with other medications? I know you said they were pretty safe, but if they're on anything else, are there any red flags, where you're like, "Ooh, we can't do the--"
[Dr. Jessica Lee]
Not for those. They're pretty safe from a side effect and interaction standpoint, yes.
[Dr. Ashley Agan]
Do you check any labs? I think about vitamin D deficiency is super common. Is that part of this at all?
[Dr. Jessica Lee]
I will sometimes check labs. Usually, patients have had a basic panel from their PCP in the past year, so we'll gather up that. Sometimes, usually, hopefully, that involves some thyroid testing, so I can check that box, but I do. I think about thyroid hormone. I think about vitamin D. I'll check B12, a serum B12, because, again, from a neuro support standpoint, that's very important. I will also check iron labs, so a ferritin and an iron panel. Like I said, usually, they've already had a CBC. They're usually not clinically anemic, but I definitely have seen a lot of people, especially women, again, who have non-anemia iron deficiency. Replacement can be helpful in those cases.
[Dr. Ashley Agan]
How do you like to replace that? Because I feel like iron is hard to take.
[Dr. Jessica Lee]
Again, back to the lifestyle medicine training, and I will fully admit that this is my bias. If it's me trying to treat something, I, typically, my first question for my doctor is, "What can I change about my daily habits that would prevent me from having to take a pill?" That's the way I approach life, with my family, too. I admit that I have that bias, and I will declare that to patients. Point being, usually with iron, I'm like, "Well, look, what can we adjust in your dietary intake? If you eat meat, let's look at your sources of iron in your diet, and maybe we increase that slightly."
Maybe, for a woman, if it's more like a menstrual connection, maybe just during your menstrual cycle, you could supplement with iron, and then you don't have to do it every day. If that's not possible, let's say I have someone who's a vegetarian, certainly, there are vegetarian sources of iron, beans and greens and things, but I think there is enough to say it's probably not as well absorbed as heme iron from meat, but we have that conversation. If their choice is, "I don't want to eat meat," okay, then let's talk about supplements. You definitely want a supplement that has vitamin C with it because it does help with absorption.
There is a brand of supplement that I tend to use that's a pretty well-regarded brand called Pure Encapsulation, and they have a ferrous sulfate with vitamin C that I, personally, actually, I have been on this train and I have taken it and it didn't have any constipation side effects for me, which is the main issue people complain about. I think that's usually the one I start with if we're going to go that road. I'm not an affiliate. I don't get any kickback from that.
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Headache Management
Pharmacologic management is often introduced when lifestyle changes and supplements alone are not enough to control recurrent migraine or headache symptoms. Triptans are one of the most common types of medications used in this setting – serving both as an acute treatment and diagnostic aid. Patients are instructed to take the medication at the first sign of symptoms, with the option of a second dose two hours later if the headache does not resolve. Triptans are typically used as “rescue medications,” useful for patients with occasional but disabling episodes, while also helping to clarify whether the underlying condition is migraine rather than sinus-related pain. However, their use requires careful consideration of cardiovascular history, as these drugs can pose risks for patients with heart disease or arrhythmias.
When symptoms are more frequent or severe, preventive options may be considered. Tricyclic antidepressants like amitriptyline are sometimes used, particularly in younger patients, though potential side effects such as dry mouth or drowsiness are discussed. In cases where first-line strategies fail, more advanced treatments like topiramate, beta-blockers, or newer therapies targeting CGRP pathways may be appropriate. At that stage, collaboration with neurology specialists is often recommended to ensure comprehensive care and access to the full range of therapies.
[Dr. Gopi Shah]
We talked about supplements. Do you do much medication management? Are you putting patients on amitriptyline or topiramate, or even just triptans to have for acute episodes?
[Dr. Jessica Lee]
Yes, perfect, because I would say that, triptans, I've become much more comfortable prescribing, and upfront, you do have to ask about their heart health and talk about concern for arrhythmia and things like that. I always tell them, if you have any symptoms or if they have a history of things, we're not going to do that. Yes, in fact, I will often use triptans as a diagnostic trial. Again, if someone's coming in and having these recurrent episodes and they're going to urgent care and getting an antibiotic, I'm going to say, "Instead of doing that next time, as soon as you feel it coming on, I want you to take this medication."
Then, "The way it works is you take one, and if it is able to halt that progress, if it is able to halt the release of all the mediators like CGRP and substance P and all these things, then your symptoms should immediately start to get better. If after two hours, it hasn't halted that progress, if things are continuing to progressively worsen, you can take a second dose two hours later, but then you don't take any more for the next 24 hours." That's the instructions I give. These are rescue meds, I tell them. This is not someone who has daily symptoms that I'm giving this to.
I tell them that I can only prescribe eight a month because if you're using more than eight a month, then we need to switch and think about something preventative. I love that as a diagnostic test because number one, you're sending them out the door with something that you're telling them, "I believe this is going to help you not feel miserable for 24 or 48 hours when you feel this way," and that's all some people need. Again, some people are getting this a few times a year and they just need that really good rescue med, maybe while they work on some of these other lifestyle things.
As far as things like Elavil, Topamax, things like that, I haven't found that I've needed to get into that too much. I feel comfortable with Elavil because we do a lot with the chronic cough pathways. I feel like a lot of us are comfortable with that one. I do talk about some of the TCAs as an option, typically. Of course, with those, you have to warn them about-- especially, you don't want to use it on older patients. Again, migraine being very commonly a young person problem, that's usually not an issue, but we do talk about dry mouth, feeling a little groggy, things like that. We can always change it if they have that.
Again, you start low, you titrate up. Again, I haven't gotten too far into Topamax or the beta blockers or even gepants and CGRP antibodies. If we are not getting success with everything else we've tried to this point, usually, that's where I have started to refer to neurology. I actually have a colleague, he's not in our practice, but he's at the medical university. He runs like a dizzy clinic, so he does a ton of vestibular migraine. I've asked him. I was like, "What do you do when you get to that point? Are you prescribing gepants, or are you sending those out to neurology?"
He said, he was like, "Sometimes, I will." He's like, "But most of the time, I'm setting them up with neurology at that point." I think that's very reasonable. In fact, I would love if there's any neurologists out here who would love to collaborate, I think it would be great to put minds together and come up with a really good algorithm for people.
Botox for Migraine & Sinus Headaches
Botox is generally considered for patients who either prefer not to take daily medications or who have not responded well to other treatments such as supplements or triptans. While only a small fraction of patients with chronic headaches or migraines ultimately require botox, it remains a valuable option when necessary. Specialists skilled in administering these injections can target specific muscle groups to help reduce pain, particularly in cases involving chronic headache patterns. Although not the most common route, botox offers an alternative for patients seeking a non-daily therapy that can still provide significant relief.
In addition to migraine treatment, botox is sometimes used for patients with temporomandibular joint (TMJ) pain or neck-related symptoms, both of which can overlap with migraine-like conditions. Because jaw muscles and neck muscles share nerve pathways with the pain pathways related to headache symptoms, distinguishing between true TMJ, neck strain, and migraine can be difficult. Providers often emphasize education, using nerve pathway explanations to show patients how pain in the neck or jaw can radiate to the head or ear. For some, the solution may be botox, but for others, physical therapy, massage, or strengthening exercises may be more appropriate.
[Dr. Gopi Shah]
Then who are the patients that you consider Botox for, that you're like, "Okay, we've tried the supplements. You've tried the tryptans, maybe," or is it, "Let's try tryptans or Botox," or who are the Botox patients and how does that work?
[Dr. Jessica Lee]
I typically present it as an option in the tablescape of options. Some people are comfortable with that thought. Some people just do not want to take a medication every day. That is just the last thing they want to do. Then we bring up things like Botox injections. Again, there's several providers where I work who are really skilled at this, and so I often will send them out. Again, I honestly think if you say you start with a hundred patients that walk in your office with sinus headache, you're going to end up with single digits of people that need to be referred on is what I've seen, at least in the past few years of paying attention to this.
It's just not all that common that people have to go that route. The great news is if they do have to go that route, there are specialists who love to do that and are very skilled at that. It is an option.
[Dr. Gopi Shah]
Is it within other ENTs doing this, or I always think of neck pain or TMJ, but I don't really know where else people are injecting and what headaches and who and how long it lasts. Do any of that stuff?
[Dr. Jessica Lee]
Yes. I don't do the injections. I know there's-- he's actually a facial plastic surgeon in town who's really good at it. He does a lot of the corrugators and stuff up here. We do have a provider who will do more for TMJ spasm stuff. He'll do more masticator Botox, but that brings up a good point, too, because a lot of patients have jaw pain as part of their symptomatology. I think we forget that the masticators are innervated by the trigeminal nerve. Again, is it TMJ or is it actually migraine? I think in the neurology world, from some of the things I've read, it seems like a lot of TMJ is probably migraine. You mentioned it could be neck pain. It's another symptom falls--
[Dr. Gopi Shah]
I'm asking for a friend. [laughter] There's so much of this conversation, I'm like--
[Dr. Jessica Lee]
I know. When you start paying attention to it, you're like, "Hang on a minute, was my headache last month a headache or was it a migraine?" With neck pain, that's a symptom that falls into-- it could be that you have a tight muscle. It could be that you tweaked your neck at the gym, or it could be a migraine. It could be part of that symptomatology. I am super nerdy about bringing out pictures of the nerve pathways in clinic to just explain why would I tell someone that their ear pain is from their neck? Because you've got C2 and C3 innervation.
Then you say that, and they go, "Oh, well, my neck is super tight on that side." I'm like, "Great. You need a massage, and maybe you need to go see a PT, or we need to do some strengthening. Again, I may not be the one to guide you through that, but there are excellent, skilled professionals in our town who will help, but your ear is normal. It's not an ear infection."
Non-Pharmacologic Approaches for Headache
For patients who have already explored lifestyle changes and supplements, non-pharmacologic therapies can provide additional avenues of relief. Options such as acupuncture, acupressure, cold therapy, and herbal remedies may not have large-scale randomized controlled trial data behind them, but they are often low-risk and can be tailored to a patient’s needs. The approach is less about finding a single cure and more about building a “migraine toolkit”, a set of supportive strategies like cold packs, eucalyptus inhalers, or guided acupressure techniques that patients can use during episodes. Herbal options such as nettle for congestion or chamomile for sleep can also complement treatment, provided safety considerations are taken into account.
Beyond specific remedies, there is an emphasis on cultivating self-awareness and learning to recognize the body’s early warning signals before symptoms escalate. Too often, patients, especially women, are told their pain is “just stress” or the result of fatigue, leading to dismissal rather than treatment. Since migraines disproportionately affect young women, the lack of validation in clinical settings compounds frustration.
[Dr. Gopi Shah]
Very well said. As we round this out, I would love a few more non-pharmacologic options for patients. If you've got your patient that's checking all their boxes, as far as lifestyle modifications, and they're trying their supplements, and they're like, "What else can I be doing?" I'm thinking things like acupuncture and cold plunge and light therapies and things like that. Do you ever have a list of things that maybe there's less evidence for, but in your practice, you've seen it help, or maybe there is evidence for it that is just not as robust? It's hard to find good evidence.
By the nature of it, we're never going to have great randomized controlled trials that show-- Some of these things are just never going to be funded, but you've got to go work with what you got.
[Dr. Ashley Agan]
Some of these things, it's cost, but like, "Okay, you want to try a cold plunge? Try a cold plunge."
[Dr. Jessica Lee]
Also, what's the danger to you, right? If there's a new, we'll say, complimentary treatment that someone wants to try, it's like, "Okay. Well, what's the personal financial cost to you? What are potentially dangerous side effects?" If those are both low and you want to try it, and there's some mechanistic study out there in a mouse that says it might work, cool. Let's try it. Let's partner together with that. As far as other options, acupuncture, for sure, and even acupressure. Again, there are case studies and there are small studies that show that even just acupressure points can be helpful.
I would never tell someone that this is the only treatment they need, but I often tell patients like, "You want to build a migraine toolkit or a sinus headache toolkit if we want to speak this language, and if migraine is off-putting." In that, might be a cold pack. One of those cold packs that you can break and you can just put over your face, or it might be a eucalyptus inhaler. It might be a little diagram. I have a-- It's not a little one, but I have like an 8x10 normal piece of paper that I print off for patients that shows them the acupressure points and how to do it. There's several in your face, obviously, up here. There's some in the back of the head.
Again, you can do that while you're sitting in your car at the red light. Those types of things, I think, are helpful. I do look at herbal medication options with patients. There are some herbs. Classically, there are some that were used that there's some concern about liver toxicity, so I'm cautious with those, but even trying to use things like nettle, which, again, has a benefit from an allergy congestion standpoint. Even chamomile is great, especially if they're having trouble falling asleep. Chamomile is great at night. There are definitely herbals, whether it's a tea and an infusion, or a tincture or something.
[Dr. Gopi Shah]
It's funny, we talk about self-awareness and a lot of that, I think of emotional EQ mindset, but I think there's a lot of physical health self-awareness that you also have to take time. Like you said, you can run, run, run, run, run, go, go, go, and your body's trying to give you these little signs, until there's, "I just feel like crap," or until, "I'm so sick. I can't get out of bed." Yet, along the way, there were little yellow lights and signs. It's just why don't we pay attention to it enough? I think my gender bias is that, especially as women, we don't pay attention to it enough, yet we probably take the brunt of a lot of these physical things because of physiological changes and things like that.
[Dr. Jessica Lee]
As women, we do know that migraine impacts young women more predominantly, or it's more prevalent in young women. Again, a lot of what I hear from patients when they see me is they told me it was just stress. They told me it's just because I'm a busy mom and I'm tired. I think young women do get written off. You're healthy, you're young, you're fine. Go take an ibuprofen and don't come back. That's frustrating, right?
Podcast Contributors
Dr. Jessica Lee
Dr. Jessica Lee is a practicing otolaryngologist and lifestyle medicine specialist in Charleston, South Carolina.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2025, June 24). Ep. 228 – Sinus Headaches vs. Migraines: Diagnosis & Treatment [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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