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The stereotypical image of a migraine sufferer is someone lying in a dark, quiet room for hours with an ice pack on their head. 

And while that is still true in some cases, new effective medications specifically designed for migraine have changed the outlook for many patients of this often misunderstood neurological disorder, experts say. 

"The problem with migraine is that a lot of people endure a lot, and they're not treated properly," Elizabeth Leroux, a neurologist in Montreal specializing in headaches and migraine, told Dr. Brian Goldman, host of CBC's The Dose.  

"I see a lot of patients who know more than their doctors sometimes." 

What is a migraine? 

Unlike a regular headache that only involves head pain, a migraine is a neurological event that usually comes with other symptoms — nausea, vomiting, sensitivity to light and noise, neck pain and visual auras are all possible. 

Frequency can vary, and chronic migraine is defined as having a headache at least 15 days per month, with at least half of them having migraine symptoms. 

Compared to a tension headache, a migraine is often disabling, said Dr. Lara Cooke, a professor of neurology at the University of Calgary's Cumming School of Medicine. 

"If you wish you could turn down the volume on the world or you could turn down the brightness of the sun … likely, it's a migraine," said Cooke, who has a specialty in headache medicine. 

What causes migraine? 

Though the exact science behind migraine isn't fully understood, researchers now understand more about the nature of the pain, according to Leroux. 

Migraine pain comes from an interaction between the trigeminal nerves and certain systems in the brain, said Cooke. 

The two trigeminal nerves run down each side of the face and send touch and pain sensations from the face to the brain.

When something triggers a migraine, those nerves get fired up and release calcitonin gene-related peptide (CGRP), a brain chemical that interacts with blood vessels in the head, causing throbbing pain. 

Migraines can start in childhood and affect all genders. Research shows that after puberty, more women than men experience migraine. 

Some migraines are tied to the menstrual cycle and often improve post-menopause. 

"It's very clear that ups and downs with estrogen play a very important role in migraines in women," said Cooke. 

Some hormones, including progesterone and oxytocin, make the female brain more prone to chronic pain diseases in general, including migraine, said Leroux.

Migraine triggers 

Experts say there are a few common migraine triggers, such as alcohol, lack of sleep and weather changes. They differ for everyone, so it's worth figuring out your individual triggers.

A common theory around migraine is that everyone has a threshold for their triggers, and if several triggers coincide and the threshold is surpassed, a migraine will follow. 

"You had a bad sleep, you're stressed, and then you had a glass of red wine … the sort of perfect storm," said Cooke. 

Managing your triggers can help with migraine, but it can only go so far, said Leroux. 

"Sometimes, your threshold is so low that just living and going to work and doing things with your family is unbearable," she said. 

"And that's where I think medical care comes in."

New medications for migraine

There are two general categories of medication to treat migraine: those that treat a migraine attack and those that can prevent attacks. 

Medications used to treat acute migraine attacks usually include a category of prescription drugs called triptans, which act on serotonin and block some pain signals. Over-the-counter medications, including anti-inflammatories such as ibuprofen and naproxen, can help treat some of the milder symptoms.  

Doctors have, for many years, also been prescribing various medications originally designed to treat other conditions, such as epilepsy, depression or high blood pressure, to try and prevent migraine attacks or at least reduce their frequency and/or intensity. 

But for some with frequent migraine, a new category of preventive medication called CGRP blockers, or anti-CGRP monoclonal antibodies — designed specifically to treat migraine — has made a huge difference, said Leroux. 

"[Patients] come to me after decades of migraine — their life has changed … they don't fear the next attack," she said. 

These medications — which came onto the market in 2018 — block CGRP, the protein in the brain that causes the pain of a migraine attack, and can reduce the intensity and frequency of migraine attacks over time. 

There are four such medications approved in Canada: erenumab, fremanezumab, galcanezumab and eptinezumab — sold under the brand names Aimovig, Ajovy, Emgality and Vyepti. Patients self-inject them, usually once a month.

Another class of CGRP antagonists, known as gepants, come in pill form and can be used to treat acute migraine attacks or preventatively. Three are approved in Canada: ubrogepant, rimegepant and atogepant — sold under the brand names Ubrelvy, Nurtec and Qulipta.

CGRP medications are expensive, costing more than $600 per injection and around $20 per tablet, and not all provincial drug plans fully cover them. Coverage by private insurance plans varies. 

Relief from new drug

Christina Sall has been taking the anti-CGRP antibody Aimovig (erenumab) since 2019 and said it has been "the best experience." 

Sall, a registered nurse from Surrey, B.C., started getting migraines when she was five years old. 

As a teen, the attacks intensified. They became so bad in her early 20s that she had more than 15 days a month with a migraine. 

Sall tried preventive medications, but they didn't work and gave her terrible side effects, even landing her in the emergency room. 

"Being dismissed at the ER that these aren't even real symptoms and that I'm just having anxiety is really frustrating," Sall said. 

"It was a really, really dark time in my life."

Sall's migraines were so bad that she was forced to drop out of school during her nursing degree, but after taking anti-CGRP antibodies was able to return.

CGRP blockers aren't effective for everyone, cautioned Leroux, but she said that if they work for you, they can vastly improve your quality of life. 

Botox injections were approved as a preventive for chronic migraine in Canada in 2011 and have been shown to be effective for some patients, say experts. 

The toxin in Botox gets taken up in the nerve endings and prevents the nerve from releasing the neurochemicals believed to cause migraine pain, said Cooke. 

In order to be approved for Botox, patients often need to confirm that they tried other preventive medications that didn't work. 

Sall is grateful for the advances in migraine treatment in the past few years but cautioned it can be challenging for each individual to find medication that works. 

"It does take time to make sure that you're on the right track," she said.  

"Changes to your lifestyle can help to an extent, but it isn't going to miraculously get rid of migraine. It is a neurological disorder."

Nearly 200 Palestinians have managed to escape Gaza and obtain approval to travel to Canada — but they had to pay thousands of dollars to smuggle themselves into Egypt.

That avenue is now closed off, due to the Israeli military campaign underway in Rafah in the southern Gaza Strip.

On Monday, Hamas announced that it had agreed to a ceasefire deal brokered by Egypt and Qatar. Israel rejected the deal — which it said contained elements it could not accept — and began its incursion into Rafah, where more than a million Gazans have sought shelter from the war.

Among them are the members of Hazim Almasri's family, who have been travelling from Gaza City to Deir el Balah, a town neighbouring Khan Younis, since October.

"We were always stressed and very sad and always worried," said Almasri, a resident of Kitchener, Ont. He is still waiting on word from the Canadian government on whether he'll be allowed to bring his siblings and their families to Canada.

Prior to the war, Almasri had plans to fly to Gaza this month for a family reunion. The eruption of hostilities on Oct. 7 put an end to those plans and started him thinking about getting his loved ones out instead.

In January, the Canadian government announced a new program — the Special Measures for Extended Families of Palestinian Canadians in Gaza — meant to allow relations of Palestinian-Canadians in the war zone to move here temporarily to escape the conflict.

"The day they announced the program, it was a celebration in my house and the kids in Gaza. They were crying from happiness," Almasri said.

But the program depends on the governments of Israel and Egypt approving individuals for travel through the Rafah crossing into the latter country, once they are placed on a list by Canada.

Canada has submitted multiple lists of approved candidates for the program to Israel and Egypt, but — for reasons that have not been disclosed — all of those names have been rejected to date. Now, the incursion launched by Israel this week into Rafah has made any further movement into Cairo impossible.

Almasri said he has raised enough money to get some of his family members out, but others, like his brother Nael, are still stuck on the Gaza side.

Nael Almasri recently met with a freelancer working for CBC News in Deir El Balah. He said he and his family finally found a small apartment to rent after being constantly on the move since October. Now they're waiting for their applications to come to Canada to be approved.

"They bombed the house beside us and 18 people were martyred," he said. "It was terrifying for the entire family."

In January, Hazim Almasri filed applications for his three siblings and their families to get them out of Gaza through the program. Two of the three have received codes from the Canadian government — the first step in the application process, which allows them to apply for a visa. But Nael and his family have yet to receive anything from Canada.

"The purpose of applying to this program is to save our souls from death," said Nael. "We were hopeful and happy and the kids were happy, but then … the process is slow."

He said he's lost all hope of escaping the war.

"Right now, I feel like it doesn't really matter to me… Open the border, close the border, either way I'm stuck in the Gaza Strip," he said.

Hope isn't the only thing the Almasri family has lost. About a week ago, their uncle, who had made it across the border to Cairo, died after undergoing surgery to amputate an infected leg.

Mike Morrice, Green Party member of Parliament for Kitchener Centre, said he knows Immigration Minister Marc Miller is in a "difficult" position — but he needs to maintain diplomatic channels to get as many people out of Gaza as possible. 

"Everything about this program, as you know, has been broken from the start," said Morrice. "So, we want to see him continue to prioritize all diplomatic channels to do better by families like Hazim's and so many others across the country."

In a statement, Immigration, Refugees and Citizenship Canada (IRCC) said the department is very concerned about the plight of people in Gaza and is aware that some are exiting Gaza "on their own."

The department says it does not recommend the use of such people-smuggling services and continues to call for Egypt and Israel to approve applicants for exit.

IRCC said that as of April 29, 179 people have completed the process and have been approved to come to Canada. None were evacuated from Gaza through official channels.