Is this my usual migraine?

January 15, 2018

Living with migraine involves many situations that are difficult to deal with.  One of the common difficulties is to decide if the current headache that you are experiencing is migraine or not.  While migraine is very common, tension headache is even more common.  Further, sometimes very severe headaches may be due to neurological emergencies, such as a hemorrhage.  Basically, people who suffer from migraine often have other headache types that are treated differently.  So, when you start experiencing pain, it is important to first decide if this is one of your typical migraine headaches or if it is a different type of headache.

What else could it be?

As mentioned, the most common type of headache is known as tension headache.  It is often associated with stress and accompanied by muscle tension.  It is not usually accompanied by migraine symptoms, such as the aversion to bright lights or loud noise, even though those may also occur.  Tension headache is generally bilateral, with a feeling of pressure over the entire head or a large portion of it.  It is generally shorter-lasting than migraine.  Most importantly, tension headache is effectively treated by over-the-counter non-steroidal anti-inflammatory drugs such as ibuprofen.

On the other end of the spectrum, there are certain headaches that are symptoms of relatively rare but serious neurological conditions that demand urgent evaluation and should be treated in the hospital.  Migraine sufferers usually have little doubt, but sometimes unusually severe pain may be misleading.  Keep in mind that conditions such as bleeds (examples are subarachnoid hemorrhage and intracerebral hemorrhage) and tumors are much less common than migraine, and their characteristics are different than those of migraine. When I was a resident in a busy New York hospital, I was often called to consult on patients in the emergency room who complained of “the worst headache of my life”.  Since this complaint rightfully demands immediate attention since it may signify a life-threatening emergency due to the rupture of an aneurysm in the brain, otherwise known as a subarachnoid hemorrhage, most often the situation would be diagnosed as a much more common and less dangerous condition – that of a severe migraine.  By asking a few focused questions, a neurologist or other skilled clinician is able to determine that the quality of the patient’s headache conforms to his/her typical migraine pattern, only more severe in intensity.  As such, the management becomes focused on treating a severe migraine and not on a subarachnoid hemorrhage.  As a caveat, keep in mind that even skilled clinicians may not be certain of the diagnosis and will justifiably take a conservative approach by considering that the patient may have the more serious condition until proven otherwise by appropriate tests.  The point is that it is critical to determine if the current headache is a migraine, even in the context of a patient who suffers from frequent migraines.

How can I tell?

The most important step in deciding if your headache is a migraine is to determine if it fits a pattern of your migraines, more or less.  The qualities or characteristics of your migraine should be well known to you.  They may not be the same all the time, but they generally follow one or more patterns.  For example, if your migraines are usually on the right side of your head, have a pulsating quality, build up over 30 minutes to an intensity of 8 out of 10, are accompanied by nausea and aversion to bright lights, you can pretty much be certain that the current headache is one of your migraines if it has a number of these characteristics, even if it does not fit the complete pattern.  However, if the current headache does not really follow your typical pattern, and rather is more of dull pressure of the top of your whole head, then it is most likely not your migraine.

Does it matter?

Deciding that you are having a migraine determines the course of how you should treat your headache at home.  Since you are a migraine sufferer, you most likely have been prescribed one or more medications to treat an acute migraine episode, and you most likely have other over-the-counter and alternative remedies that you have tried for your migraines.  Therefore, you must decide whether to take your migraine treatments, whether to take a treatment that is better for tension headache, or whether to be concerned about more serious but less likely conditions.  For example, your migraine medications, such as Imitrex (sumatriptan), is not appropriate for a tension headache.  Rather, an over-the-counter medication such as ibuprofen may be the best treatment, as it is the best treatment for tension and may also work for migraine.

Empowering patients to make better decisions at home

There is now a strong movement in healthcare towards patients taking control over their management at home.  In chronic conditions such as diabetes, asthma, and heart disease, successful management at home may result in better health outcomes for the patient, more effective care by the physician and other healthcare providers, and less resource utilization resulting in decreased costs for the payers.  Through a new smartphone app called Rewire Migraine, I aim to apply this approach to migraine headache, as well.  Key aspects of this approach include education and personalized data, with benefits focused on empowering patients to make more informed decisions about their own care and effective sharing of patient data with healthcare providers to empower better professional care decisions.


The first step in effective migraine treatment is determining if the current pain episode is actually a migraine.  The most important factor is to “know your migraine”.  If the current headache has the characteristics of your migraine, then it is most likely a migraine and will respond to your migraine treatments.  If, however, the characteristics are sufficiently different, then the headache may not be your migraine – it may require different treatment, or may even require immediate medical attention in some cases.  Simply by focusing on the intensity of the headache can be misleading.  It is important to know the characteristics of your own migraine.  The best way to do this is by logging your migraine characteristics in a diary, most conveniently with a smartphone migraine aid.



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