Rest, ice, relaxation, and minimal interventions are recommended ways to treat the typical muscle-tension headaches.
Treatment of a migraine—a specific type of headache—is much more complex.
“They're more of what I would describe as a phenomenon, and they can be debilitating,” says Neurologist Keith J. McAvoy, MD, from Dartmouth Hitchcock Clinics Specialty Care in Bedford, New Hampshire.
Triggers and treatment differ from person to person, and you may need to set a goal of minimization rather than complete elimination, he says.
The common headache vs. the migraine
“When most people think of the term headache, they're predominantly referring to what we consider muscle-tension type headaches that might come out of the blue and tend to come along if, for example, you're stressed or sleep deprived,” says McAvoy.
This muscle-tension headache is mild to moderate, steady, and usually occurs on both sides of the head, without accompanying neurological symptoms.
In contrast, a migraine is a neurological disease with severe, throbbing pain, often on one side of the head and usually accompanied by symptoms like nausea, vomiting, and sensitivity to light and sound.
It also has distinct phases that can last anywhere from four hours to days and has a stop and start.
“A key feature of migraines is that they're episodic. So if someone comes into my office and says, ‘I have a headache that started a month and a half ago and it's just not going away and it keeps getting worse and worse,’ I’m not thinking migraine,” he says.
Types of migraines
Migraines can be debilitating.
According to the American Migraine Foundation, migraines are the second leading cause of all global disability and 40 million Americans suffer from them.
The most prevalent types of migraines are:
- Migraine with aura (classic migraine)
- Migraine without aura (common migraine).
Other, less prevalent migraines include abdominal migraines, chronic migraines, menstrual migraines, and ocular migraines.
Who gets migraines and why?
The American Migration Foundation also reports that three times more women get migraines than men, and 17.5% of all women have them.
Little is known about why certain people are more prone to migraines, but there is a clear genetic component, says McAvoy.
If you get migraines, there's a greater than 75% chance that a first-degree relative—a parent, sibling, or child—also gets them, he says.
How people experience a migraine
The most prevalent, classic migraine with aura has three distinct phases.
Phase One: Prodrome or Aura
Physiologically, the aura stage involves a widespread disruption of electrical activity in the brain called cortical spreading depression (CSD)
During this phase, people often have a feeling that something's coming on. “Not necessarily a headache, but they feel different in some way,” says McAvoy.
This phase often has an aura, which is usually visual, starts off small, and expands across your visual field.
“Usually patients describe what they see in a visual aura as zigzag lines or patterns. But it's not coming from your eyes, it's coming from your brain. If you were to close your eyes, you’d still see it. There's often a shiny component to the aura as well, and it is unlike a stroke where you usually don’t see lines or colored lights,” says McAvoy.
Your sense of smell could also be heightened or you could have an aura that mimics a stroke with a sensation down one side of your body or speech disturbances. “But classic aura migraines are usually visual at first,” he says.
The typical time frame of an aura is somewhere between five to 30 minutes, though they can be longer or shorter than that.
Phase Two: The Headache
The next phase is usually a migraine headache that lasts between four to 72 hours.
During this phase, specific nerves in your blood vessels send pain signals to your brain and inflammatory substances are released.
“They also think that serotonin is being inhibited,” says McAvoy.
The resulting, usually unilateral headache can occur in different parts of your head. Many times patients will describe the headache as throbbing or having a pounding component, which is different from a muscle-tension type headache that is more of a dull ache.
Another distinguishing element is nausea, often accompanied by vomiting, and sensitivity to light and sound.
Phase Three: Postdrome
In the third stage, the headache resolves either through medication or because it has run its course, says McAvoy.
But the nervous system and the brain are recovering despite ongoing neurological instability and reduced blood flow.
“Most patients will have this kind of washout feeling where they're fatigued, they're not thinking quite right, they're not as sharp mentally, as if they've been through something. This phase can be a 24-hour event. It could be a 12-hour event. It could be a three-or four-day event,” he says.
Factors and triggers
"There are very many internal and external factors that can be involved in triggering a migraine,” McAvoy says.
These include:
- Stress and anxiety
- Hormonal changes, particularly changes in estrogen levels in women
- Certain medications
- Insufficient or erratic sleep
- Barometric pressure
- Lack of food
- Exposure to bright lights, loud noises, or strong odors
- Post concussion syndrome (PCS).
Food triggers include:
- Alcohol
- Caffeine (though in small quantities can be preventative for some)
- Food with additives like nitrates or MSG
- Processed or cured foods, such as hot dogs or pepperoni.
Treatment
When McAvoy begins his consultation, he first establishes whether his patient has been experiencing migraines. He bases that decision largely on the migraines' frequency, duration, and symptoms. The headache needs to be episodic, with a stop and start. An aura before the headache is also usually a distinguishing marker, but does not always occur.
Next, McAvoy considers three possible ways to help patients manage or treat their condition. These are:
Addressing modifiable factors and triggers
Addressing modifiable factors means working with a patient to more closely at their triggers.
“Migraines are very individual. It’s hard to say that they are caused by X, Y, or Z. There are so many variables. So, you have to sit patients down and go over when and what is happening, identify possible triggers, and then work with them to make modifications,” he says.
He has had patients with migraines triggered by pizza, avocados, stress, lack of sleep, fluctuating estrogen levels, caffeine (too much and too little), and so much more.
“I even have had patients who are human barometers. They can predict when a storm is coming because they're starting to feel that migraine process coming on,” he says.
“Many, too, have mood disorders, depression, anxiety, tension headaches, as well as migraine headaches. They might have sleep disorders or bad food habits. It's rare that I get someone who comes in and says, ‘I get ten migraines once a month, but the rest of my life is great.’ Usually, the migraine process is confounded by a lot of things.”
Treatment at this stage is a process of evaluating daily habits and then working with patients to make lifestyle adjustments.
Sometimes, too, McAvoy recommends supplements of Riboflaven (vitamin B2) and forms of magnesium.
Migraine-abortive agents
These are medications and adjustments to help stop or manage migraines at their start. They also work to stop or reduce symptoms like pain, nausea, light and sound sensitivity, and more.
“Once you've got a headache and it’s early, an option might be to take 800 mg of ibuprofen,” he says. Aspirin, acetaminophen, or naproxen also works for some.
If bright light or loud sounds are contributors, changing your environment can help, too.
“The analogy that I always use is the boulder rolling down the hill. Is it easier to stop it at the top or when it's halfway down? It's always easier to stop it at the top. Once it gains momentum, it becomes much more difficult,” McAvoy says. “But if in 30 to 60 minutes it's not going away and it's building, it might be time for prescription medication,” he says. These abortive medicines may include what fall under the classification of triptans and antiemetic (anti-nausea) medications, as well as others.
Prophylactic and preventative medication
“I'm not going to start thinking about a daily preventative medication unless you have more than three to five migraine days per month,” says McAvoy.
Common preventative medications include beta-blockers, like Propranolol. “But the problem with any medication is side effects, so we start out at a low dose and titrate upwards if necessary,” he says.
A calcium channel blocker, like Verapamil, is another class of medication that McAvoy sometimes uses. Anticonvulsants and antidepressants are two more.
But determining which class and type of medication is best depends on a range of factors, including migraine symptoms, frequency, intensity, and other existing conditions and tolerances. Possible contraindications and side effects must be considered. “Everything has a trade-off. So we look at the benefits and the downsides,” he says.
McAvoy also stresses that the science around treatment of migraines is improving all the time.
Newer treatments include wearable neuromodulators that treat the nervous system through electrical pulsations. For chronic migraines, Botox has recently been shown to sometimes be effective.
When to call your doctor
McAvoy recommends you call your doctor if:
- Your migraines are so intense that they're interfering with life activities despite over-the-counter medication.
- You have redness and pain in your eye with your headache.
- Your migraines are so frequent that you feel like “you're dodging a black cloud all the time and asking when the next one’s going to hit.”
- Your headaches are unbearable (call 9-1-1 if you just had a head injury or they are more intense than ever before).
- You have accompanying neurologic symptoms, such as slower or garbled speech or clumsiness (if these are sudden and new, also call 9-1-1).
- Your symptoms are worsening.
- You are having side effects from treatment.
Managing your migraine
To find patterns in your migraines and their triggers, McAvoy says there’s now an app Migraine Buddy
You also can keep a diary to track your migraine frequency and intensity (on a zero-to-ten scale), diet, and behaviors.
Remember, too, that with treatment, you may not be able to eliminate your migraines completely, but you should be able to better control them.
Lastly, when it comes to migraines, there is an advantage to getting old. Research shows you’re likely to get fewer migraines as you age.
