Migraine vs. Headache: Learn the Key Differences and Why They Matter
Is your headache a migraine attack? It isn’t always easy to tell. There is a great deal of confusion, misinformation, and lack of awareness surrounding headaches and migraine. As a headache specialist and migraine warrior for more than half of my life, my mission is to educate as many people as I can about migraine and headache. Let's take a look at some common headache types and learn how they differ from migraine attacks.
Like many fields, headache medicine is rapidly evolving. Currently, there are more than 300 different types of headaches, and more are being recognized over time. Leading headache specialists from around the world have compiled all the different types of headaches and standardized the criteria for diagnosing them in an important tool called the International Classification of Headache Disorders (ICHD). It is currently in its third edition and can be found online.
What Migraine Attacks Feel Like
Migraine is far more than just a headache. Migraine is a neurologic disorder with symptoms that far exceed head pain. In fact, some migraine attacks do not feature head pain at all.
A typical migraine attack is characterized by a headache that lasts 4 to 72 hours, often with nausea or vomiting, and sensitivity to light and sound. The pain of a migraine attack is typically moderate to severe, often one-sided, generally pulsating or throbbing, and is likely made worse with exertion. It doesn’t have to be all of these things at once to be a migraine.
Common Migraine Symptoms and Phases
There are plenty of other common migraine symptoms apart from headache, such as smell sensitivity, motion sickness, sinus symptoms, neck and shoulder pain, GI symptoms, vertigo, brain fog, mood changes, and more.
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A migraine attack consists of four potential phases that can occur over the course of several days.
- The prodrome phase can occur up to two days before the headache starts. Common symptoms include brain fog, fatigue, and sensitivity to light.
- The aura phase is not present in every attack and is short-lived. Common symptoms include visual disturbances like blind spots.
- The headache phase typically begins two or three days after the prodrome phase begins. Common symptoms are pain in the head and neck, sensitivity to light and sound, and nausea.
- The postdrome phase typically occurs for two days following the headache phase. Common symptoms include fatigue and difficulty concentrating.
What Causes Migraine?
Migraine is a disorder caused by inflammation. It is not the same kind of inflammation that is associated with common disorders such as arthritis, but a specific kind of inflammation called neuroinflammation. Large nerves that emanate from the brain called cranial nerves release neuroinflammatory molecules, which lead to all of the symptoms associated with migraine.
We have long thought that migraine attacks are associated with triggers, both internal and external. Certain foods, drinks, smells, lights, sounds, changes in the weather, and stress have been associated with an increase in migraine activity.
However, as we gather more evidence, a more-nuanced picture is beginning to develop. It seems that some things that we thought were triggers may be cravings induced by migraine activity. Instead of triggering migraine attacks, some of these things are likely craved and eaten due to a migraine-in-progress.
It is clear that migraine has a strong genetic component and tends to run in families. This is why a healthcare provider takes a detailed family history regarding the presence of other headache sufferers in the family.
A patient with the complaint of a headache does not initially need to see a headache specialist, as their primary care provider will likely be able to diagnose and treat most cases of migraine.
Treating Migraine Attacks
Acute migraine medicines are treatments that one would take on an as-needed basis to stop a migraine attack in progress. Common classes of acute migraine treatments include:
One thing to consider is that certain classes of acute medication can increase the frequency of headaches over time if taken too often.
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Preventive migraine medicines are treatments that aim to reduce the frequency and intensity of migraine attacks over time.
Common classes of preventive medicines include:
- Certain blood pressure medicines
- Anti-seizure medicines
- Migraine-specific medicines that act on calcitonin gene-related peptides (CGRPs)
Often, patients are hesitant to try certain medicines because they feel that if they don’t have depression or hypertension, they shouldn’t take a drug labeled for such. The reality is that medicines are often categorized under their first indication. Sometimes a medicine becomes more useful for a different medical problem than it does for its initial indication.
Additionally, dosages are critically important. For many preventive medicines, the dosages we use to control headache are often not in the typical ranges that one would use to realistically lower blood pressure or effectively control depression.
A common question that I get is "Do I need to take a preventive medicine?" I would say there aren’t hard-and-fast criteria for who should take preventive medicine. It should always be an open-ended conversation between the patient and their healthcare provider, discussing how their migraine attacks are impacting their lives, the person’s goals, and potential benefits and side effects weighed against the person’s unique medical history.
Nondrug Migraine Treatment
In addition to acute and prevention medicines, there are other useful interventions that can be helpful in the treatment of migraine, like:
Devices exist that people can use both as acute and preventive strategies to treat migraine. Several classes of neuromodulation devices are available, and many patients use ice packs, which can be found readily online.
Sleep is very important for migraine frequency, and patients who work erratic schedules or third shifts often do better when they’re able to transition to a regular work schedule. Similarly, I screen all my patients with the question "Are you known to snore?" Snoring is a risk factor for sleep apnea, and these days sleep studies generally take place in one’s bed. If you are found to have sleep apnea and are treated appropriately, this can have tremendous benefits on headache frequency.
Stress is a well-known migraine trigger. I often see people suffering headache flares during periods of final exams, the illness of a family member, or during times of relationship strain. I talk with all of my patients about making self-care a habit by focusing on stress-relieving activities like going for walks, reading for pleasure, not skipping meals, staying hydrated, eating healthful foods, and communicating with your healthcare provider.
Tension-Type Headache vs. Migraine
In my practice, I help train medical students and residents and my favorite question to ask them is "What is a tension-type headache?" The answer is one that they always find both unexpected and memorable. A tension-type headache is not a migraine!
Most people with migraine will experience headaches that do not meet the full migraine criteria and will seem more tension-like in their features. This is why patients who experience very frequent migraine attacks will often get mistakenly diagnosed with tension-type headache.
Tension-Type Headache Treatment
Tension-type headache is typically treated with over-the-counter pain medicines such as NSAIDs or acetaminophen (Tylenol). Nonmedication treatments such as relaxation, massage, physical therapy, acupuncture, or cognitive behavioral therapy can also be used.
Sinusitis vs. Migraine
One of the most confusing topics in headache medicine is the intersection of sinusitis, sinus headache, and sinus allergies. It is very common for someone to receive a diagnosis of sinusitis or allergies when they are actually experiencing migraine attacks.
It is typical to see a patient in the clinic who comes in every fall or spring with sinus attacks. Once treated with antibiotics and steroids, their headache will get better. They assume their headache must have been related to their sinuses, but that is rarely the case. While sinusitis can cause headache by itself, this is an uncommon situation, usually isolated to advanced cases of bacterial or fungal sinusitis.
However, if a person has underlying migraine, it’s very common that upper respiratory infections (like a sinus infection) can flare one’s migraine attacks. In that case, the headache that came with the infection was not caused by the sinuses but was caused by the underlying migraine condition.
Moreover, it’s very common that migraine patients can experience mild, often bilateral autonomic symptoms that can often be mistaken for allergic rhinitis or sinus infection. These can include red eye, tearing, and stuffy nose.
Overwhelmingly, “sinus headaches” are undiagnosed migraine attacks. If you suspect acute sinusitis, I would encourage you to talk with your primary care provider.
Cluster Headache vs. Migraine
Cluster headache is an uncommon headache disorder that falls under the umbrella of disorders called trigeminal autonomic cephalalgias (TACs). That’s a complicated term for one-sided headaches with autonomic features, which are basically things that your nervous system controls without your having to think about it.
Autonomic features that one may experience with cluster headache include:
- Forehead or facial sweating
- Pale skin or facial flushing
- Stuffy or runny nose
- Excessive tearing
- Red eye
- Muffled feeling in the ear
- Constricted pupil
All of these symptoms tend to be isolated to the same side as the headache, and they tend to be very prominent.
What distinguishes cluster headache from migraine is the duration of each attack, the seasonal pattern of attacks, the severity of the autonomic features, the quality and intensity of the pain, the strict one-sided location of the headache, and the response to cluster-specific treatments.
The most common form of cluster headache, which is called episodic cluster headache, will typically occur in cycles once or twice a year for a period of 2 to 12 weeks. Attacks often begin mild (every other day) and then increase in severity (becoming daily and then multiple times a day), and eventually peak with a frequency of six to eight attacks per day (including at night). Eventually, there is a gradual decrease in attacks, and the cluster cycle ends.
Cluster headaches are thought to be one of the worst pains that a human can experience. Unfortunately, they often go years being misdiagnosed. There is a form of cluster headache that is chronic, which, thankfully, is much less common than episodic cluster headache. If this type is suspected, you should be referred to a headache specialist.
Cluster Headache Treatment
The treatment of cluster headache comes in three varieties: acute treatment, preventive treatment, and rescue treatment.
Acute treatments for cluster headache include:
It’s important to give acute medicines for cluster headache intranasally or as injectables because each cluster attack tends to have a short duration, and oral medication takes time to become effective. Moreover, given the intensity of the pain, it’s important to try to deliver relief as soon as possible.
Preventive therapy for cluster headache Includes:
Rescue therapies are designed to provide the patient with rapid relief to allow for the prevention agents to take hold. Rescue treatments include:
- Oral steroid tapers
- Occipital nerve block with steroids
- Intranasal lidocaine block (also called a sphenopalatine ganglion block or an SPG block)
Sometimes, cluster headache can be confused with another TAC called paroxysmal hemicrania. It is very similar to cluster headache except the attacks are typically shorter, and there tend to be more attacks per day.
And last, there is an outdated term floating around: “cluster migraine.” This phrase is used to refer to various conditions, from migraine to cluster headache, but it is generally best to avoid it as it creates confusion, and with the clarity of the ICHD, we can promote more accurate diagnoses and more timely interventions.
Hypnic Headache vs. Migraine
Hypnic headache is an uncommon headache and a diagnosis that is often made after very careful consideration of other primary headache disorders.
Hypnic headache is generally a headache in individuals over the age of 50 that tends to be on both sides of the head. It is usually a mild-to-moderate headache that lasts from 15 minutes up to three hours. Often, this is a headache that is daily or near daily.
Hypnic Headache Treatment
Some medications have been reported as successful treatments for hypnic headache, such as:
One interesting fact to consider is that the headache of a migraine attack is most likely to develop in the middle of the night. Migraine is often such a nebulous disorder that it can masquerade as other headache disorders, like hypnic headache, quite easily.
Ice Pick Headache vs. Migraine
The technical name for ice pick headache is primary stabbing headache, and it’s a common headache disorder. Up to 40 percent of people with migraine also experience ice pick headache.
Ice pick headache pain is described as stabbing-like. The pain typically lasts three seconds or less (rarely up to two minutes), and it occurs in random locations around the head.
Attack frequency is typically low; many patients don’t have daily attacks. If attacks repeatedly occur in one area, this should be evaluated to rule out a problem affecting any of the nerves in that location.
Talking to Your Doctor
It can be common when one is suffering a headache to jump to scary thoughts, such as what if I have a tumor or thinking of a family member or a friend who suffered an aneurysm. Thankfully, these conditions are rare, but it is still useful to know about what we as headache specialists would consider to be worrisome symptoms.
When to Worry
- If one is having a headache along with systemic symptoms such as fever and weight loss
- If one is having confusion or an altered level of consciousness with a headache
- A sudden onset, immediately peaking headache, especially in the setting of a fall or injury
- A headache made worse with coughing, laughing, sneezing, going to the bathroom, lifting weights, or having sex
Other symptoms would require urgent referral:
- A progressive headache in the setting of an immunodeficiency, such as HIV or cancer
- A new-onset headache in a person over the age of 50
- A headache that dramatically gets worse or is resolved based on whether one is lying down or standing up (note that it is common for migraine to briefly increase in intensity with movements such as bending over and improve marginally with lying down).
- A first headache, a new type of headache, or a change in the pattern of a long-standing headache
For any individual experiencing a headache, it is overwhelmingly likely to be either a tension-type headache or a migraine. If the headache and headache-related symptoms are debilitating to the point where one is driven to discuss it with their healthcare provider, the diagnosis of migraine should at least be considered.
Outdated terminology still exists in the headache space. With the advent of the ICHD, accurate and prompt diagnosis benefits both providers and patients everywhere.
It's critical to get the correct diagnosis for your headache disorder so you receive the proper treatment that works. We have entered a golden age of headache treatment, when many acute and preventive treatments are available to release the grip of headache, no matter which kind.