Migraines & Headaches

You may have heard someone say, ‘It gives me a migraine’ or ‘Oh! I have a migraine,’ and wondered why they have to name it instead of calling it a headache. In general, migraine is a headache type, but it isn’t like any other headache. Headache is a wide term used to describe a wide variety of nervous system conditions. Headache disorder includes both migraine and other types of headaches. 

What are the other common types of headaches?

It is not always easy for someone to describe a headache as different types of headaches have different clinical presentations. But, in general, the throbbing, squeezing, either constant or intermittent pain, in one part of the face or skull, or generalized to the whole head, is described as a headache. There are several different types of headaches. Headaches are categorized into primary headaches, secondary headaches, and Cranial neuralgias, facial pain, and other headaches. 

Primary headache

Most common primary headaches include:

• Tension headache: They feel like intense and concentrated pressure around the head and can be associated with either an episodic or chronic migraine. 
• Migraine headache: They are severe headaches that are often accompanied by nausea, vomiting, sensitivity to light and sound.
• Cluster headache: They cause severe pain on one side of the head, often behind an eye. They are called cluster headaches as multiple headaches occur at about the same time, every day, for several weeks. They are recurring headaches that are followed by periods of no headache. 
• Hemicrania headache: They are persistent headaches that fluctuate in severity and usually affect the same side of the head.

Primary headaches also include other common types of headaches, and it affects the quality of life. The symptoms of these headaches are often confused with the symptoms of a stroke, which causes a lot of misperception. It must be noted that the amount of pain caused by a headache does not determine the type of headache. Most people diagnose a headache as a migraine without considering the other types of headaches that show similar symptoms. 

Secondary headache

Secondary headaches are caused by underlying infectious or structural problem in the head or neck. It comprises a broad group of medical conditions that include pain from infected sinus, pain from infected tooth or teeth, or life-threatening brain infections like meningitis. It also includes headaches caused by substance abuse, medication overuse, and headache caused by alcohol and dehydration- called a hangover. 

Cranial neuralgias, facial pain, and other headaches

Neuralgia refers to nerve pain. Cranial neuralgia refers to the inflammation caused by one of the twelve cranial nerves that come from the brain and send sensory signals such as pain from the head and neck. Most commonly recognized neuralgia is a trigeminal neuralgia that presents with severe sharp pain affecting either side of one’s face and worse with chewing, shaving or brushing teeth. 

What is migraine?

Migraine is an extremely painful type of primary headache with not always identifiable etiology. It is often accompanied by nausea, vomiting, sensitivity to light, and sensitivity to sound. Migraine is a headache that affects more women than men and usually starts in young adults. It is not uncommon to have migraine headache in kids that at times can present in kids as young as 4-5 years old. The headache generally lasts between four to seventy-two hours. 

What are the different types of migraine headaches?

Migraine headaches are divided into:

• Migraine with aura 
• Migraine without aura
• Other rare migraine headaches

Aura refers to a sensation that a person feels or experiences before the onset of a migraine headache. The sensation can be visual aura or motor aura, and include:

• Having trouble thinking
• Seeing unusual lines or flashes of light
• Numbness or tingling in the face or hands that radiates to the face
• Unusual sense of smell, touch, or taste
• Blind spots that expand over time
• Jumbled or slurred speech
• Difficulty writing
• Difficulty understanding others

They are just sensations or migraine aura, and not symptoms of a migraine headache. 

Other rare migraine headaches include:

• Hemiplegic migraine is a very rare type of migraine headache that causes temporary paralysis before or during the headache. Some of the symptoms include vertigo, vision problems, stabbing sensation in the head, difficulty swallowing or speaking, and trouble moving one side of the body.
• Ophthalmic Migraine is a short-lived, complete or partial loss of vision in one eye, accompanied by a dull headache behind the eye that may spread to the rest of the head.
• Migraine with brainstem aura is strongly linked to hormonal changes. You will experience a sudden onset of symptoms or aura such as dizziness, loss of balance, confusion, moments before the headache.
• Status migrainosus is a severe type of migraine that lasts more than 72 hours, sometimes caused by medicines or medicinal withdrawal.

What is the pathophysiology of a migraine?

Migraine is thought to be a neurovascular pain syndrome with complex mechanism including altered central neuronal processing and involvement of the trigeminovascular system (triggering neuropeptide release, which causes painful inflammation in cranial vessels and connective tissue that surrounds brain) as well as occipital nerves. 

What triggers a migraine headache?

Unfortunately, there is no exact cause of migraine headaches. It is triggered by the following triggers that change from one person to another: 

• Stress: As mentioned before, migraine is a result of a change in blood flow. Stress releases a chemical that can cause the blood vessels to change and trigger a stress migraine headache.
• Caffeine: A Migraine headache can be a result of abrupt changes in caffeine intake, especially caffeine withdrawal. If your blood vessels are used to caffeine, a sudden drop in caffeine can trigger a migraine headache.
• Food: Food such as monosodium glutamate, alcohol, and food additives cause almost 30% of migraine headache. 
• Other reasons: Change in weather, feeling tired, acidity, skipping meals, change in sleep timings, and lack of sleep are some of the other triggers of a migraine headache. 

Phases of migraine headache

There are four distinct phases of migraine headache:

• The Premonitory Phase is also called the preheadache phase or the prodrome phase and includes non-painful symptoms that may occur several hours or even days before the headache. Some of the symptoms include mood swings, food cravings, neck stiffness, sensitivity to light, sound and/or smell, and constipation or diarrhea.
• Aura Phase, as mentioned before, refer to sensory disturbances that can affect a person’s vision, touch, or speech.
• The Headache Phase is when a person experiences the migraine pain that caries from mild to severe. Exposure to light, excessive sound, smell, physical activities can worsen the pain.
• The Postdrome Phase is a feeling of exhaustion that a person feels after the headache subsides. People who experience the postdrome phase feel exhausted, unwell, confused for a few hours, or even several days.

Treatment of migraine headache

Most people make a mistake by self-diagnosing headaches as migraines. There might be other underlying problems that may be causing a headache. Identifying underlying cause is an important task as it guides your healthcare provider with making appropriate treatment options. 

The treatment of migraine is divided into the treatment of individual attacks and the prevention of future attacks. Treatment with dihydroergotamine or triptans is a usual choice for abortive therapy. Some natural remedies like herbal supplements as well as some vitamin supplements can be considered as well. 

Preventive treatments are indicated for individuals with frequent migraine, which is generally agreed to be more than four headache days per month. Many preventive treatment options have been discovered accidentally, and include antihypertensive drugs, anti-epileptic drugs and antidepressants. Botulinum toxin was FDA approved for patients with chronic migraine headaches that were identified as at least fourteen headache days per month with each headache lasting for four or more hours. Recently FDA approved a new class for episodic migraine headache prevention – CGRP inhibitors that include Aimovig, Ajovy and Emgality. They all were approved for a self-administrated subcutaneous shot monthly. 

Besides pills there are more invasive options including occipital nerve block, supra-orbital nerve block and spheno-palatine block that can benefit specific type of patients who are refractory to other options. 

Discussing your options with trained physician is a key. Ignoring headaches unfortunately will not eliminate the problem but instead can lead to more frequent and debilitating headaches.

Author

Dr. Lenny Cohen