09 Jan 2025
Headache is a symptom, not a disease
Although many people use the term “migraines” and “headaches” interchangeably, it is important to recognize that they are different. Headaches is a symptom, rather than a disease. It describes pain the head which can arise from a number of diseases.
In general, headaches can be divided into two forms – primary and secondary headaches. Primary headaches refer to headaches that do not arise from any underlying diseases. Examples of these include migraines, tension headaches or cluster headaches. In contrast, secondary headaches are headaches which arise from an underlying condition such as an uncontrolled high blood pressure, brain tumour or a brain infection.
Migraines vs Tension-type headache (common headache)
Migraines is a primary headache disorder. The underlying reason for migraines is abnormal brain signaling. Unlike a very common type of headache (known as tension-type headache), migraines can result in very severe headaches and interfere significantly with one’s function. Unlike tension-type headaches, headaches in migraines are throbbing in nature, often one-sided and they are almost always associated with other symptoms such as nausea, vomiting, sensitivity to light, sound and noise.
Unlike tension-type headaches, migraine attacks often occur in 4 distinct phases. These four phases are described as the prodrome, aura, headache and postdrome phases. It is important to understand that it is possible to have migraine with any of these phases in isolation. For example, there are a group of patients who have aura without a headache.
The prodrome is thought to occur because of hypothalamic activation. The hypothalamus is responsible for regulating water balance, food and sleep. Consequently, during this phase which can occur up to 72 hours before the onset of a headache, patients can present with thirst, lethargy or a feeling of satiety.
The aura phase occurs about an hour prior the onset of a headache. During this phase, patients may experience abnormal vision or sensation. In some patients, the aura can manifest as a severe neurological loss of function like weakness – and this can resemble a stroke. But fortunately, this rarely the case.
The headache phase can last between 4 and 72 hours. In some extreme cases, the headache can last for longer than 72 hours. This is termed “status migrainosus”.
And during the last phase or the postdrome phase, patients can experience sleepiness or persistent light sensitivity even after the headaches have resolved.
Why it is important to make a right diagnosis
It is important to understand that the treatment for different types of headaches differ. For example, the medications used to treat migraines are quite different from those used to treat tension-type headaches. (see table 1) It is, therefore, important for one to receive an accurate diagnosis to improve treatment success and to reduce the risk of complications from an untreated headache.
Table 1 – Differences in the treatment of Tension Type Headache (TTH) vs Migraines
|
Tension type headache |
Migraines |
|
|
Medications to abort headaches |
Over the counter medications |
Specific migraine medications eg. Triptans |
|
Medications to prevent headaches |
Rarely needed |
Often used in frequent or chronic cases. They include antihypertensives, antidepressants, anti-seizure and CGRP inhibitors (designer medications for migraines) |
|
Trigger management |
Address stress, posture and eye strain |
Avoid specific food, hormone, sensory or sleep triggers |
|
Interventional management |
BTX has not been shown to be an effective treatment |
BTX is an FDA-approved treatment for episodic migraines. |
Unfortunately, migraines are often misdiagnosed. Close to 50-80% of migraines are misdiagnosed at the first instance. We postulate that the reason for misdiagnosis may be due to both patient and physician factors. Examples of patient factors leading to misdiagnosis include – variable presentation of patients with migraine and lack of diagnostic tests to confirm the diagnosis.
It is therefore beneficial for one to consult a headache specialist to obtain an accurate diagnosis of the headache disorder. Headache specialists are trained to rule out serious underlying conditions and provide a precise, comprehensive diagnosis without resorting to overly narrow classifications.
