The Empowered Patient's Guide to Migraine and Headache

Knowing what type headache you are experiencing – whether from stress, cluster attacks, or inherited migraine – can make all the difference in finding relief faster. Inside symptoms, triggers, and treatments.

All headaches are bullies. But while some are short-lived hindrances (a “normal” headache), others are relentless and soul-crushing in their taunts (and so we meet again, migraine).

In fact, if we put together a lineup of these bullies, it would be half-a-dozen-headaches long. Here’s the thing, though: No matter what kind you get, you are in control. Many people don’t realize this and never seek diagnosis or treatment. In fact, many headache attacks can be prevented with a few simple changes. But since you’re here, we realize you’re not one of those people, so let’s get you some relief.  

 

How Common Are Migraine and Chronic Headache Disorders?

All headaches—be they stress-induced, clusters, or migraine – are neurological illnesses (aka: disorders of the nervous system). The headaches occur when nerves send messages to blood vessels in the brain (or to layers of tissue around the brain) that result in painful inflammation. This inflammation can feel like throbbing pain or present as other symptoms.1

According to the World Health Organization, headache disorders are the most common disorders of the nervous system. Up to 4% of adults experience a headache on 15 or more days per month – yes, that’s a full half a month!2 This type of impact (15 or more headache days) means the person has chronic daily headaches or chronic migraine.3 If you get a headache less than 15 days a month, it means you experience episodic headaches or episodic migraine.

Migraine, in particular, is the third most prevalent illness in the world, notes the Migraine Research Foundation. In the United States alone, it affects 39 million people, including 18% of women, 6% of men, and 19% of children. Nearly 1 in 4 households include someone with recurring migraine, and 90% of people with migraine have a family history of migraine (yay for genetics!).4

Along with the toll headache pain takes on daily living, the frequency of attacks and other symptoms can have a significant impact on a person’s livelihood. Another survey, by The Novartis and European Migraine and Headache Alliance, found that, on average, 60% of employed survey respondents missed almost a full week (4 to 6 days) of the month due to migraine.5

If this all sounds debilitating, it’s because it is. But what’s really mystifying is that an estimated 50% or more of all people who experience migraine attacks are never diagnosed and most never seek medical help for their pain. This means people who may benefit from interventions (such as medication or injections, discussed below) to prevent attacks from occurring are not tapping into that care. Migraine and chronic headache disorders are real medical conditions and there are treatments to help.4

The tricky part is that there are distinct types of headache disorders, including migraine, tension and cluster headaches. Some even get “medication overuse headaches” caused by the meds themselves (more on this later). They each differ in presentation, how they are triggered, and how you can prevent or reduce their occurrence. The good news is that knowing the type you have can help you and your doctor make the best decisions for managing them.

 

SO, WHAT ARE THE TYPES OF MIGRAINE AND CHRONIC HEADACHE DISORDERS?

When seeking a diagnosis, your doctor will first try to determine if the type of headache you are experiencing is itself a disease (called a primary condition) or a symptom of another disease (called a secondary condition).

A primary headache is caused by overactivity of – or structural issues with – the brain’s processing and sensitivity centers. Various structures may play a role including your brain’s chemical activity, the nerves or blood vessels around your skull, your head and neck muscles, or a combination of all of these. Genetics can also play a role.3

Common primary headaches include:4

  • Tension/stress headache: occurs in 75% of the US population. Also known as muscle contraction headache, psychomyogenic headache, ordinary headache, essential headache, idiopathic (meaning no known cause) headache, and psychogenic headache
  • Migraine with aura: occurs in 25% of people who experience migraine
  • Traditional migraine: occurs in 12% of US population
  • Cluster headache: occurs in 0.1% of the US population.

If you are told you have a secondary headache, that means there is an underlying condition that may be causing your headaches. Several conditions may be responsible for secondary headaches as described below.

One important and perhaps unexpected type of secondary headache is known as Medication Overuse Headache (MOH), meaning your use of medication to treat a headache is actually causing your headache to recur. Also known as “rebound headache,” “drug-induced headache,” or “medication-misuse headache,” MOH is most often seen in people using certain medications, such as opioids.6 While MOH is commonly diagnosed, many patients simply have chronic migraine, and the medications are not, in fact, inducing more headaches.

But what do headache attacks feel like? Well, it depends on the type of headache you have. Many people who live with migraine disorder describe the attacks as the most painful thing they’ve experienced. In a survey conducted by Eli Lilly in 2018, migraineurs reported the pain of migraine as worse than that of kidney stones, broken bones, and even childbirth.7  The severity of migraine ranges from more moderate pain to very severe.

Read more about what each headache type feels like below.

 

Headaches and Migraine Symptoms

Traditional Migraine: These moderate to severe headaches occur one side of the head with pain described as “pulsating,” “throbbing,” or “pounding.” You may also experience nausea, vomiting, or sensitivity to light and noise. Physical activity and movement can make symptoms worse – such as feeling shooting headache pain or nausea. Up to 80% of people may experience the sensation pain from a non-painful stimulation, such as a light touch to the shoulder. Others experience vertigo – called a vestibular migraine. Treatment is critical as symptoms can last for a few hours—to a few days—depending on how quickly the migraine is addressed. Traditional migraine does not have aura symptoms, described below.

Migraine with Aura: This type of migraine, which is sometimes categorized as an ocular or visual migraine, comes with pain like that of a traditional migraine, plus sensory disturbances such as seeing bright dots or zigzag lines, having tunnel vision, experiencing speech problems or tingling on one side of the body. These disturbances usually last between 20 to 60 minutes prior to a migraine attack. See how one migraineur has used her aura experience to create works of art based on what she sees during the attacks. 

Tension Headache / Stress Headache: This mild to moderate headache is usually felt behind the eyes or in the forehead area, and can last from 30 minutes to several days. Many people describe it as a “vice-like” pain on both sides of the head. The pain may be accompanied by increased sensitivity to light or sound, as well as tender head and neck muscles. For those with migraine, these “tension headaches” are milder migraine attacks.

Cluster Headache: Often called “the suicide headache” because it is the pain is so severe and relentless, a cluster headache causes severe headaches on one side of the head, red or teary eyes, runny or stuffy nose, face flushing or sweating, and/or restlessness or agitation. Episodes usually occur at the same time of day and tend to follow the seasons of the year – making them very predictable. Headaches recur in a series (cluster periods) lasting for weeks or months, separated by periods when they go away for months or years. Some patients suffer from chronic clusters, where they don’t have a break in attacks for several months. Read how they manage.

Medication Overuse Headache: To get an MOH diagnosis, you must have headachesymptoms for 15 or more days each month for at least three months, and symptoms that develop or worsen with overuse of headache medications. Getting a diagnosis takes time as other headache types must be ruled out first. Diagnosing MOH is difficult, as the offending medication(s) have to first be withdrawn. Then, an evaluation may be possible as to whether the medication itself was increasing the headaches. MOH tends to be somewhat over-diagnosed.

Of note, sinus headaches are caused by inflammation and congestion around the nasal passage and usually accompany or follow a cold or allergies. You may feel pain in your face, such as behind your eyes, in your ears, jawline, or cheekbones. Sinusitis, or chronic sinus infections, can be over-diagnosed as a cause of headache. Sinus infections are caused by bacteria and not considered a neurological disorder as are the other headaches described here. You’ll want to see an ear, nose, and throat doctor for a proper diagnosis and treatment.

Still unsure of what type of headache you may be experiencing? Take our headache quiz.

WHAT ELSE TO EXPECT WHEN LIVING WITH HEADACHES AND MIGRAINE  

If you are diagnosed with migraine, you may experience symptoms BEFORE and AFTER the attack. But there are warning signs that can clue you in when a bad headache is on the way.

According to the American Migraine Foundation, this time before the onset of a headache is referred to as the prodrome period, “preheadache” or “premonitory” phase.8 Not everyone who experiences migraine will have these warning signs, but knowing what these signs are if you do experience them is important so you can seek out treatments to help prevent the attack. These early warning signs can occur between several hours to up to several days before an attack and include:

  • subtle changes to your day-to-day life, including constipation, mood swings, food cravings, neck stiffness, increased thirst and urination, and frequent yawning
  • difficulties concentrating
  • fatigue
  • movement or speech disturbances
  • muscle or limb weakness
  • nausea
  • sensitivities to light or sound
  • sleep problems
  • visual changes (seeing flashes of light, zigzag lines, blurry vision)

And then there are the after-effects of a migraine attack or headache. This is called the postdrome phase or “migraine hangover” and can include:

  • body aches
  • dizziness and sensitivity to light
  • fatigue
  • trouble concentrating

In addition, some people with migraine may be more likely to have chronic dry eye disease.9

 

Migraine and Headache Causes

Migraine and tension headaches usually have a genetic link – just as some inherit asthma or another illness, you likely inherited a tendency to get these headaches from your family. Once inherited, several factors can trigger an attack.

The top FOUR migraine triggers are:

  1. stress
  2. weather changes – such as when there is a drop in barometric pressure from a front coming in, high heat, high humidity, or other weather changes
  3. hormone changes (usually related to menstruation or, occasionally, use of birth control pills)
  4. undersleeping, lack of sleep

Less common migraine triggers are alcohol and MSG.

Tension Headache – Common Triggers

  • alcohol
  • caffeine, or withdrawal symptoms from lack of caffeine
  • eye strain (for example, looking too long at a computer screen or reading very small text)
  • head injury
  • illness, such as a sinus infection
  • grinding your teeth or clenching your jaw frequently
  • intense physical activity, such as a workout
  • poor posture, with pain starting in the neck and back of the head
  • sleeping with your neck in an abnormal position
  • smoking
  • tiredness

Cluster Headache – Common Triggers

Unlike migraine and tension headaches, cluster headaches tend to occur because of abnormalities in a region of the brain (hypothalamus) that connects the nervous system to the endocrine system (the system that regulates your hormones). Once a person has clusters, alcohol or MSG may trigger an attack.

 

HOW TO TREAT MIGRAINE AND HEADACHES

There are a variety of ways to help reduce or prevent headache symptoms. The first step is to find a doctor who can diagnose what type of headache you have – just seeing your primary doctor is not likely to get you the diagnosis or treatment you need. Instead seek out a neurologist or headache specialist. The Migraine Research Foundation provides a list of headache doctors by state and city.

To diagnose your headache, you will probably be asked to fill out a detailed medical history and undergo a physical exam that will include testing your motor skills, senses, and reflexes. To rule out any possible serious conditions that may be causing your headaches, you also may be asked to undergo blood tests and imaging such as an MRI or CAT scan.

Once the diagnosis is made, your doctor will recommend a treatment approach based on the type of headache you have and the severity of your symptoms. The most common approaches include medications and making lifestyle changes, such as avoiding your known triggers and reducing stress.

Managing Migraine

Treatment will depend on how often migraine attacks occur and how severe they are. Medications that are used “as needed” to stop a migraine in its tracks, and also to prevent migraine, include:

  • Anti-inflammatory drugs: For mild symptoms, you can take over-the-counter drugs such as aspirin, ibuprofen, and acetaminophen. For more severe symptoms, you may be prescribed a drug in a class of drugs known triptans – such as sumatriptan or rizatriptan.
  • Anti-nausea drugs:To reduce any nausea that you may experience, you may be prescribed a drug in a class of drugs known as antiemetics – such as ondansentron (the only one that does not cause tiredness), chlorpromazine, metoclopramide, or prochlorperazine, often in combination.
  • Steroids/Opioids: If other drugs have not worked, you may be prescribed an opioid or steroid such as prednisone or dexamethasone as a last resort. These should be used in low doses, for limited periods of time.
  • Botox: onabotulinumtoxinA injections have been used for many years to prevent migraine, sometimes in combination with other regular medications.
  • Preventive medications (sometimes called prophylactics) such as beta blockers (propranolol, metoprolol, etc), certain anticonvulsants (topiramate, valproate), and some anti-depressants (amitriptyline, duloxetine). Petadolex can be an effective “natural-herbal” medication as well.

Some migraineurs may benefit from taking a new class of drugs that work to slow or stop the onset of migraine by blocking a peptide called calcitonin gene-related peptide (CGRP) that is released during migraine attacks and may play a role in causing the onset of an attack.10,11 There are currently four drugs in this class approved for the prevention of migraine:

  • Erenumab-aooe (Aimovig) – given by injection every month
  • Fremanezumab-vfrm (Ajovy) – given by injection every month or every 4 months
  • Galcanezumab-gnlm (Emgality) – given by injection every month
  • Eptinezumab (VYEPTI) – given by infusion every 3 months

Talk to your doctor or consult with a neurologist or headache specialist to learn more about whether the CGRP meds may work for you – some trial-and-error may be necessary. CGRP preventives have many possible side effects (unlike Botox, which has few side effects). What you need to know about CGRPs.

Managing Tension Headaches

Symptoms of tension headaches are usually milder than those of migraine and can be treated with the following:

  • Anti-inflammatory drugs: over-the-counter medications such as ibuprofen or aspirin
  • Antidepressants: for more frequent headaches, you may be prescribed a drug called amitriptyline for prevention; others are used as well, such as duloxetine.
  • Complementary or Alternative Treatments: biofeedback, meditation, relaxation, cognitive behavioral therapy, acupuncture, massage therapy, yoga, exercise, and physical therapy are all non-pharmacological options that may help

Managing Cluster Headaches

Treatments for cluster headache include medications to treat the attack while you are having it (acute treatment) or to prevent future attacks (preventive treatment).

  • Acute treatments: these may include oxygen(high flow rate, 12 to 15 liters per minute),  triptans (particularly the nasal sprays or injections), ergots (such as dihydroergotamine), and lidocaine nasal spray
  • Preventive treatments: these may include verapamil (heart medication), lithium carbonate, corticosteroids, topiramate or valproate (drugs used to control seizures).
  • Occipital nerve blocks may also help. One of the newer CGRP monoclonal antibodies, Emgality, is also approved for episodic cluster headache.

 

WHY YOUR MENTAL HEALTH MATTERS WITH MIGRAINE AND HEADACHES

Missed days at work. So fatigued you’re in bed all day. Blinded by the dimmest of lights. Is it any wonder that those battling chronic headaches also experience a blow to their mental health?

About 20% of people who experience migraine on 14 days or fewer each month (episodic) may have depression and/or anxiety, according to the American Migraine Foundation. For people who experience migraine more days a month (chronic), depression and/or anxiety is even higher – between 30% and 50% for anxiety.12 The same inherited brain chemistry that causes migraine may also be involved in anxiety and depression. Depression increases headaches, and headaches increase depression, so they both must be treated.

For some, depression and anxiety may appear months or years after living with the often-debilitating pain of migraine and headaches. It is not uncommon for migraineurs to say they spend several days a month in bed because of their migraine or headache attacks. For others, depression and anxiety, just like migraine, may run in the family.12

If you find yourself lying in bed day after day, even after your migraine or headache passes, you may be experiencing a residual mental health issue. Talk to your doctor or headache clinic about a referral to a psychologist for talk therapy and home-based strategies.

PPM recently held a video chat House Call on migraine and mental health. Check it out to get some common questions answered as well as a few self-help tips.

SELF-CARE

There are many things you can do to help relieve the physical and mental challenges that come with having a chronic condition like migraine and headaches. According to the Mayo Clinic, choosing a healthy lifestyle that promotes good overall health can help reduce how often you get headaches and their severity:13

  • Pay attention to your sleep habits. Try to maintain regular sleep hours, going to bed and waking around the same time every day (this includes the weekends!); if you nap, try not to nap longer than 20 to 30 minutes. Relax before bed, and avoid intense exercise and food/drinks that can interfere with sleep (such as heavy meals, coffee, and alcohol).
  • Watch what you eat. Plan your meals for the same time every day, don’t skip meals, keep a food journal to track any foods that may trigger your headache, and avoid foods that do (remember food is low on the list as a migraine trigger). According to a study by Physicians Committee for Responsible Medicine14, a plant-based diet may reduce pain symptoms linked to migraine – this diet includes cooked vegetables such as broccoli, spinach, carrots, sweet potatoes and summer squash, cooked or dried fruits such as berries, pears, and prunes, brown rice, and water. Ginger and turmeric have reported benefits as well as though more research is needed. Read more about potential supplements and food triggers.
  • Manage your stress. We get it – easier said than done. But even if you do just one of these things, you’ll cut your risk – simplify your life by not taking on too many tasks at work or home; taking 10- or 15-minute breaks when overwhelmed; finding daily activities that are enjoyable; and practicing deep breathing exercises to relax (here’s a step-by-step guide). Some migraineurs have found temporary relief with lavender oil during a migraine attack or after a Botox injection aimed at relieving the headache.
  • Keep moving.  Regular physical activity can help you maintain mental health and a healthy weight. It is thought that the risk of migraine may increase as the more overweight a person due to inflammation. For people with episodic headaches, being overweight or obese can increase the risk of developing chronic headaches.15-18 (Read more about the links between weight loss and migraine.)

 

WHAT CAN I DO RIGHT NOW?

1.     Start a migraine or headache diary. Keeping track of your headaches can help you recognize what triggers them. The American Migraine Foundation recommends that you include: the time and day of your migraine (or headache) attack, any symptoms other than pain that started before the head pain; any possible triggers, how the headache progressed, whether treatment helped and what kind, how long the attack lasted, and any effects after it was over.19

2.     Make changes to your work life.  If you experience frequent attacks, talk to your employer about creating some flexibility in your schedule, either remote hours or weekend catchups if you miss time in the office because of a migraine attack. (Get more tips in our workplace guide for chronic pain.)

3.     Get help for related anxiety and/or depression.– There are many resources available to help you manage mental health challenges, including from the National Alliance on Mental Illness (NAMI), Anxiety and Depression Association of America, or Depression and Bipolar Support Alliance.

4.     Reach out to a Support Group. Many people experience migraine and headaches and can offer both emotional support and practical help with finding resources. One example is Move Against Migraine, an online Facebook support group maintained by the American Migraine Foundation.

5.     Consider being an advocate. Raise awareness of migraine and headache disorders through educational and advocacy events, such as the annual Headache on the Hill. Our patient advocate and migraineur Jaime Sanders found the experience of sharing her story and fighting for increased migraine research to be quite inspiring.

 

CRUSH THE STIGMA

People who do not experience migraine or other headaches may not understand how debilitating these conditions can be. Just Google “stigma of migraine” and you will see posts about how to “fake” a migraine to get out of work. Clearly, people with migraine and headaches are often misunderstood and their symptoms minimized.

According to the American Headache Society, social stigma against people with migraine is the same as it is for people with epilepsy or panic disorder – those without such disorders simply don’t understand the life-encapsulating experience that comes with chronic, relentless pain and the years of trying to find something, anything, that relieves that pain.20 Because mild headaches affect most people at some time in their life, many put migraine or more severe headaches in the same category – but it is totally different.

And you understand the difference, putting you in a good position to talk to others about the real emotional and physical difficulties you experience. Share what it’s really like on social media, join an advocacy group, speak up.

 

FAQs

 

How does migraine differ from a cluster headache or tension headache?

A migraine differs from a cluster headache in several ways. A main difference is their duration. Cluster headaches usually last for 30 to 90 minutes, can happen many times in one day (hence: cluster), and then not return for many weeks or months. Migraine headaches are longer, often a full day or several days if not treated, and can return often during the same month. Cluster pain is centered around the eye, and is sharp. With clusters, there often is tearing of the eye, redness in the white area of the eye, or stuffiness of the nose (on the side of the headache).

The onset of both migraine and tension headaches often is “triggered” by something in one’s environment, such as stress, lack of sleep, or change in hormones. Cluster headaches are caused by changes in the brain not in the environment, and therefore onset is not “triggered” by something around you. Clusters often run in “clusters or cycles” of time, for a number of weeks or months. They often occur about the same time of year.

What other symptoms may you feel when you have a migraine?

A person with a migraine may experience a range of symptoms, including nausea, vomiting, and sensitivity to light and noise. Some may notice vision changes, such as seeing zigzags, or feeling tingling in the body. Over time, people with chronic migraine may develop depression or anxiety.

What does a vestibular migraine feel like?

Someone experiencing a vestibular migraine – that is, vertigo – may not have head pain but may have symptoms affecting their ears, vision, and balance. Symptoms can include dizziness, imbalance, pressure in their head and ear, neck pain, and pain with certain movements like bending down or turning their head. Some people may also have headaches with hazy, blurry, or blotchy vision.

What is an ocular or optical migraine?

Ocular or optical means connected to the eyes or vision, so people with these migraine attacks may experience temporary visual loss, blind spots, zigzag lines, or seeing stars. Migraine with aura (sometimes called a visual migraine) is one subtype of this type of migraine, the other subtype is called retinal migraine.

What causes migraine aura?

Migraine aura comes about because of “cortical spreading depression.” This implies that part of the brain (often the back of the brain, where the vision center is located) is shutting down for a brief period of time.

 

Updated on: 08/12/20
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A Closer Look at Migraine and Headache Treatment
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