One of the occupational hazards of being a physician, moreover, one who is trained in internal medicine and neurology, is the dinner table. This is the traditional “non-doctor place” where we physicians are hit-up by guests for medical advice. I am often asked by family, and friends, “What is a migraine headache, and are my headaches migraines?” This is sometimes difficult to answer when brought up as dinner conversation. Why? Because many things can cause headaches, from brain tumors to lack of sleep, any condition can present with severe to mild headaches. Besides, this subject gets so deep, unless you’re postured for a long conversation, you don’t dare get started, because it gets long, and many questions come up. So, this is the discussion which usually ensues, and it always gets interesting.
Barring serious conditions such as brain tumors, severe head and neck pathology, trauma, eye and vision disorders, serious metabolic conditions and infectious diseases, this article is meant to discuss non-pathogenically and non traumatic induced headaches, moreover, the difference between muscle tension headaches and migraines.
Generally, the lay person thinks of a migraine as a very severe headache. So, when they get a “bad” headache, they usually refer to it as a “migraine”, but this is not the case at all. There are many types of benign headaches which are severe enough to ruin one’s day or even their week. The classification of headaches, and more importantly, migraines, has been written and rewritten by doctors for centuries. It wasn’t until the 20th century that the specialty of neurology was born and a way to evaluate headaches scientifically was put into place. Interestingly, even during the 20th century, the classification of the different types of migraines has changed substantially. For the sake of this article, we will differentiate between 2 common benign headaches, those which are muscle tension induced and those which we in medicine refer to as migraine type. Keep in mind that there is no purity in these classifications, and that most headaches are mixed.
We live in a fast paced society. We run around dehydrated, drinking coffee, stare at LCD screens whether tiny or large, and on top of that, process more information in a day than our great grandparents did in their lifetime. That’s right! No wonder we run around stressed out. Most of us manifest our stress physically, so we either get upset stomachs, aching necks, or we get headaches, and for some, all three. In America, particularly, two types of headaches are generally seen in this regard, muscle tension types, and vascular migraine types. Here’s “the quick and dirty” on both.
Muscle tension headaches tend to come on as the day progresses, while the stressors one is dealing with are ongoing and building. So by the end of the day, your headache progressively worsens, your neck and scalp muscles increase their tone and now you have a full blown “knocker” at the end of the day. Migraines on the other hand are vascular in nature, are brought on by chemical changes reacting to stress loads and dietary triggers. You generally awaken with the headache as they come on after the stress is gone. You guessed it, the following day, after the stressful event or events are over, you’re in pain. It is the classic euphoric phase of “the general alarm reaction to stress”. So you wake up with a “banger” which is hugely painful and stays with you all day. This is also why a migrainer (pronounced, “mi-gren-urr”) tends to have his headache on Saturday mornings, or say, the day after that big speech he had been preparing for weeks.
Muscle tension headaches, also known as “tension” headaches or “contraction” headaches are direct results of increased tone and muscular irritation in the back, shoulders, neck, and scalp. As a result, they usually respond to anti-inflammatory drugs like ibuprofen or aspirin; massage; muscle relaxants; or just laying down for a while. Migraines are more brittle. Since they involve vascular changes in the coverings of the brain, anti-inflammatory drugs and muscle relaxation are usually ineffective treatments; moreover, they can even make a headache worse. Increased blood vessel caliber is generally the problem and needs to be controlled and re-set. This is why caffeine, decongestants, and other vasoconstricting agents help.
A test I have many patients, as well as friends and family try, is the “Beer Test”. It’s not one hundred percent, but if you want to know if that headache you’ve had all day is a migraine or tension headache, when you get home, drink a beer. If the headache goes away, it’s a tension headache, if it gets worse, it’s a migraine.
So, tension headaches are a direct result of stress insult, like someone turning up the volume on your neck muscles throughout the day. This type of headache is obviously exacerbated by posture, compensatory changes after an injury, arthritis, chronic musculoskeletal conditions, and of course stress load, and the amount of rest a person gets.
Migrainers suffer as they do because the headache waits, then sneaks up on them when they’re resting. The other important thing to remember is that in all these headache types, physical examination, metabolic workups, and imaging, are always negative for “lesion” or organic pathology. What I’m saying is that, “migraine”, is a diagnosis of exclusion.
Let’s discuss this phenomenon we call migraines. “Migraine” is a very old term derived from the Greek, meaning “semi-cranium” or “half skull”. Yes, generally a migraine headache is usually, but not always, unilateral, affecting one side of the head. The problem is they come in so many different manifestations that it has been difficult to classify them, even in modern medicine. Several versions have been published since the early 1920s, however, after World War II, neurologists in America started to find some consistencies which allowed at least for neurologists, an ability to observe, diagnose, and treat with a standard of care. It also allowed doctors to communicate the type of headache a patient was experiencing.
This so-called classification remained in place for nearly sixty years, but in 1995, The National Headache Foundation along with The American Academy of Neurology, published straight forward guidelines that have allowed all physicians to more easily navigate the presentation of headache patients, diagnosis them accurately, and treat them appropriately and effectively. The older “traditional classification” which is still used by many older doctors, uses excellent descriptors and relies on 5 major presentations, and thus, the patient is labeled as such. They are: Classical Migraine; Common Migraine; Complex Migraine; Mixed Headache; and Migraine Equivalent (also known as Retinal Migraine). I don’t need to remind you that there are many variations on each one of these.
Classical Migraines are the brittle ones you hear about, and the type that causes a great many to present to the emergency department of their local hospital. Here’s a typical presentation. Usually a woman, as 75% of migrainers are women, she awoke with a one sided throbbing headache that wouldn’t respond to any medication. It started with a visual aura of sparkles in the upper left visual field (what we in medicine call a stratified visual scotoma). She can’t stand to have any light in the room, noises make the pain worse, and she’s nauseous and vomiting, in addition, just moving around makes it much worse. The patient generally requires narcotic pain management and neurovascular control with a triptan drug (see below). It is this sufferer, who insurance statistical experts and the U.S. Department of Labor have stated, “costs our nation nearly 95 billion dollars in lost man hours a year! That’s not including the tab to her health insurance company, or if she’s on Medicaid, your tax dollars. Wow!
Common Migraines, are much less intense and disabling, they still throb, are usually one sided, the patient can have nausea, but generally no vomiting. The lights and sounds are still bothersome but not as overwhelming. Most apparent in their history, is no aura or scotoma. These are self limited, usually responding to aspirin, Tylenol and caffeine in combination, and of course, rest.
Complex Migraines can be terrifying. Also referred to as Hemiplegic Migraines, they will generally have features of either a classical or common type, but in addition, present with neurologic deficit. Many are mistaken for Cerebral Vascular Accidents (stroke), or Transient Ischemic Attack, and require hospital observation and treatment. Ancillary studies are usually negative, and the event resolves spontaneously. Obviously, this patient requires an exhaustive evaluation before being given this diagnosis.
Mixed Type is just that. Usually a common migraine with muscle tension overlay or muscle tension headache with migraine overlay. Again, aspirin, Tylenol, and caffeine are helpful; also mild muscle relaxants are effective. Usually if one component is treated, the other falls away.
Migraine Equivalent types are very interesting. Generally seen in college aged “type A” personalities, their hallmark is the scintillating visual scotoma, but there is no pain. That’s right! There is no headache. These patients are obviously afraid they have something serious when they first see their doctors, but after a negative work up and reassurance they do fine. Also interesting is the phenomenon of “dissipation with this migraine. The scotoma starts generally as a “dot”, slowly enlarges, becomes a crescent with a large visual field cut known as a superior quadrantanopsia, (say that 3 times, real fast), sweeps laterally, then vanishes. These types of migraines usually resolve as a condition by the time the individual reaches their thirties.
The newer guidelines have made diagnosis more accurate and streamlined for therapy using two sets: “Migraine with Aura”, and “Migraine without Aura”. Both have their specific subsets, criteria, and recommended therapies. Understand that The National Headache Foundation also endorses guidelines for other types of headaches that are not classified as “migraine”.
What we really know about migraines now, started in the 1980s, subsequently producing new knowledge and new therapies. When sumatriptan hit the medicine cabinet as migraine weaponry in 1991, much changed in the approach to headaches, including migraine classing. Since its introduction, our understanding of the migraine condition and the migrainer’s display of symptoms has been revolutionary, and produced a paradigm shift in treatment. We now know that the “migraine” is actually a cascade of events.
We always knew that there was an underlying driver and that migraines were vascular, hence, the pre-triptan therapies, which were designed to do two things, lyse an acute headache with narcotics and get the patient to sleep so as to break the vascular pain cycle and throbbing. The other, was to approach chronically, preventing the migraine from evolving. We assumed that they were vascular from the beginning of migraine research history and therapies, because they generally throb and respond in kind to vasoconstricting agents. Subsequent research revealed that they occurred in 2 phases. First the blood vessels of the brain would constrict during stress or dietary trigger attack. Then, rather than come back to their original caliber, the vessels would overshoot, engorge, ultimately causing the painful phase.
So, our therapies in the 1980s and 1990s were designed to keep the constricting phase from manifesting, and therefore there would be no overshoot and no pain. This is why to this day we continue to see migrainers treated with blood pressure lowering medications like verapamil and propranolol, which prevent tightening of vessels. In addition to these agents, antidepressants with chronic neurovascular down-gain activity like amitriptyline are added which help control chronic pain. For many patients these drugs work. That’s why they are still used in many migrainers who suffer severe and ongoing disabling attacks.
Sumatriptan lead to more compounds in the “triptan class”, and a host of “me too drugs” which are the mainstay of therapy today. Why? Because the research which produced these drugs revealed that deep inside the brain of a migrainer is a “migraine motor”. It is tied to an area in the midbrain called the Trigeminal Nucleus Caudalis. When stimulated by neurotransmitters from stress loads, lack of sleep, too much sleep, medications, or food triggers, it sends pain signals along the Trigeminal Nerve (The Fifth Cranial Nerve), and the vascular bed which surrounds it.
The two Trigeminal Nerves (left and right) are sensory nerves innervating the scalp, forehead, face and periosteal bone of the skull. When the migraine motor is stimulated, blood vessels are irritated, inflamed, and dilate, causing severe painful migraines. This should not be confused with its very famous cousin, Trigeminal Neuralgia which is also extremely painful and responds to similar medical treatments. Sumatriptan counters this directly. It is structurally similar to serotonin (5HT), and is a 5-HT_agonist. The specific receptor subtypes it activates are present on the cranial arteries and veins. Acting as an agonist at these receptors, sumatriptan reduces the vascular inflammation and dilatation associated with migraine at its source. Even in a disabling attack, sumatriptan injection can lyse the pain of migraine within minutes, without the side effects and sedation of narcotics and anti-emetics.
So now we know more about migraines and tension headaches. We know what causes them, how they are different, and how we can treat them. But you’ve probably been asking yourselves, what are these food triggers and how do they stimulate the “migraine motor”? Migraine triggers are all over the web. A good place to start for a thorough list is at The National Headache Foundation website: http//www.headaches.org.
The real mechanism of migraine motor stimulation is not fully understood, but may involve the neurotransmitter levels of dopamine, serotonin, and nor-epinephrine, in addition, the hormones 2-hydroxy-estradiol, progesterone, and thyroxin, as well as IgG antibodies from different food antigens. However, the triggers are well known and they themselves give us a clue.
Certainly there are known direct vasodilator foods such as Monosodium Glutamate (MSG), caffeine, kava based, and ephedra based herbs, and chocolate. Of course MSG is in all of our salted snacks and most of our “prepared” foods in the freezer section. Not surprisingly, many of my migraine patients when asked to keep a food diary, find they consumed large amounts of MSG the night before an attack, usually a potato chip, Doritos, or Frito binge. Citrus such as orange juice; wine, particularly the reds; hard aged cheeses; meats cured in nitrates; pickles; peanuts; and mint, to name only a few, are well known culprits.
The non-food triggers are classic: too much or not enough sleep; the computer screen you’re looking at right now; stressful life styles; drugs of all kinds; and lastly, medicinal hormones such as progesterone, yeah, your birth control pills. This is one of the reasons why women are more prone to migraine.
Because headaches are so prevalent, they can become a huge topic in conversation with any doctor. Perhaps one needs to write a book on the subject to produce a concise literary treatment which the chronic headache sufferer can utilize. Or should I say, “Another book”. That’s right. There have been many, written by doctors and non-doctors alike. Hopefully this article will help you choose the right one. In the mean time, watch those foods, try some way to lower your stress, don’t forget to drink plenty of water, and if you are a true migrainer, or a chronic headache sufferer, you should see your doctor right away and don’t forget to check out The National Headache Foundation.