Migraine’s House of Headaches ..and Visiting the Neighbors

By: Robert G. Kaniecki, MD

Key Points

Migraine patients experience a range of different headache types.
• Understanding these different migraine types may lead to better medication decisions.
• Issues with mood, nerves, sleep, bowel function, or pain are common in migraine.
• It is critical to discuss these issues during your appointments—a better understanding of you and your concerns result in a more complete diagnosis and treatment program.

Visualizing Your Migraine House and Neighborhood

Any problem becomes easier to solve when you have more information. The more letters you see when completing a crossword puzzle, the more likely you are to finish the word or phrase. This is also true for playing “Hangman”, or watching Wheel of Fortune—the more pieces in place in the jigsaw puzzle, the easier the others seem to fit. Migraine headaches are no different.

The most skilled headache providers will seek to uncover and understand your various headaches. To do so, you must understand that your “migraine house” is full of a number of headache versions. It is also critical to you and your provider to understand that your “migraine neighborhood” is home to other important headache-related medical issues your provider should know.

Your Migraine House

Typically migraine headache is characterized by episodes of pain, which impact our lives due to the “S” trio: Severity of pain, Sensitivities to light/noise/odor, and Sickness with nausea/vomiting. A full-blown migraine is not difficult to recognize. This would occupy the “great room” of the migraine house, due to its importance. The worst attack is important to address during your office visit, because it generally leads to the greatest impact on life through missed work, school, family or social events. This is the headache that often requires aggressive care, involving prescription acute and preventive medications. Commonly, their severity requires home injection or nasal spray options. Unfortunately, the patient-provider discussion unfortunately often ends here. Although this particular version of migraine pain may be critical to your well-being, the migraine house is so much bigger!

Most migraine sufferers report “other” headaches as well. These make up the smaller but often more numerous rooms of your migraine house. They are milder episodes of head pain, which often lack any of the “S” trio (severity, sensitivity, sickness) and therefore are not considered “migraines.” These “regular headaches” occur so commonly that I would place them in the kitchen and bedroom of the migraine house. These are places where folks tend to spend a great deal of time. These are often labeled “stress” or “tension” when the neck is involved or when the pain is “tight” or “like a vice.”

Many seem to associate these with a stressful day. Some patients will refer to these headaches as “sinus” if the face is involved or if the discomfort is “pressure.” This headache may be more akin to the kitchen, as the kitchen is so often remodeled and this diagnosis so often leads to surgeries. Over time many providers and sufferers have come to think of these as separate rooms outside the migraine house. However, research has shown that such “regular headaches” usually are not different from migraine. They actually are versions of migraine itself. The migraine rooms are not separate. One actually flows into another with each a critical component of the migraine house.

If “sinus” and/or “tension” migraine are occurring more than 5-10 times per month seek expert care. If the treatment applied fails to completely and quickly terminate the episodes the majority of the time, a change in treatment should be sought. Overuse of headache or decongestant medication is one of the most common reasons for difficult migraines. This “rebound effect” is yet another source of milder headaches.

One head pain, which occasionally frightens patients, is the “ice pick headache.” This is like a dark attic or “off limits” basement in the migraine house. This headache gets its name from the sudden onset of severe, sharp, localized head pain. This pain generally last seconds in duration. It is as if someone stuck, and thankfully removed, a knife from the skull. These are now called Primary Stabbing Headache by headache specialists. “Jabs and jolts” or “needle in the eye” are versions you may have read of in the past. Occasional episodes do not warrant medical attention, however, multiple episodes per day probably do. An increase in frequency over days-weeks always darkens the room and is worth a call to your provider.

Although technically non-painful, the drawing of the migraine house would be incomplete without reference to aura. Aura is the experience of brain symptoms lasting generally a few minutes to an hour, usually visual in nature. Although most will describe lights, lines, shaped objects, flashing, or distortions of vision, some patients can experience numbness, tingling, speech disturbances, dizziness, and weakness. Aura is like the highly specialized modern media room. Few have them, but the space is stimulating to the senses. Aura is experienced by the minority, estimated at one in four migraineurs. Usually aura comes before headache. Auras also occur during or even without headache. Most aura patients suffer other headaches without aura.

The Migraine Neighborhood

Headache scientists and clinicians agree that the “migraine brain” is very sensitive by nature. This increased sensitivity can be due to genes, since many patients appear to inherent this tendency. Others begin to suffer from migraines after any trauma to the head or neck. The migraine neighborhood is first and foremost described by a fence of variable height or sensitivity. When the sensitive brain is overwhelmed by excessive internal or external stimuli or “stressors,” a migraine attack may result. In this case, the neighborhood is not controlled by the fence as it is not high enough.

Emotional stress, menstrual cycles, weather fronts, and certain foods may all be reported as triggers. Even between such episodes migraine sufferers may report sensitivity of their senses: light, noise, odor, motion, and temperature sensitivities are all common. In addition to these, migraine patients display other sensitivities which might rise to the level of life impact. These sensitivities include mood, nerves, sleep, bowel/bladder function, and body pain control. There are many factors which destroy the fence protecting the migraine house from the neighborhood.

Mood disorders are among the most common, overlooked, non-headache conditions requiring management in a headache practice. They amount to the recurring severe weather in the neighborhood. Although patients may believe they are depressed because they suffer from migraines, the relationship is not that simple. Like the sensory sensitivities outlined above, the migraine brain possesses the biological tendency towards developing depression. This is so even when the migraines are relatively quiet…or before they’ve even developed at all.

In addition to depression, bipolar disorder (commonly known as manic depression) is more common among migraineurs. We also find that generalized anxiety and panic attacks are more frequently seen in migraineurs. With more headache episodes, the more likely a mood disorder is present. The more frequent the headaches, the more sensitive the brain. This is similar to the more rooms in the house, the taller it is likely to be and the greater the risk of a lightning strike. The sensitive brain spirals out of control with combinations of pain, fear, anxiety and depression. This is not unlike the shorter the fence, the more we worry about potential threats from the neighborhood to our security. Finally, many will describe being a “type A” personality, prone to being hurried or worried.

Beyond these mood and simple personality traits, migraine patients can display sensitivities of sleep, bowel function, and body pain control. Insomnia is often due to the anxiety and vice versa. Many migraine sufferers report being “light sleepers,” and others describe significant concerns with either falling asleep or staying asleep.

Irritable bowel symptoms such as diarrhea and constipation are more common in the migraine population. “Gut sensitivity” sometimes begins early in life as infantile colic. Finally, some report issues with unusual pain in the muscles or joints. In the extreme these may be labeled as fibromyalgia. Indeed, the migraine neighborhood is busy and disturbing.

Conclusions

Describe all these headache types, and discuss with your provider how often they require treatment. Review any concerns you have with mood, nerves, sleep, bowel function, or body pains as well. Review your migraine house and migraine neighbors. Try to explain your condition in 200 words or less. The more concise the information provided, the better a provider can make a full diagnosis. That provider should then share that diagnosis with you and design a program to help you. The better you describe and concisely outline your migraine home and neighborhood, the better the planners design will be to address all your needs, concerns and potential fears.

Robert G. Kaniecki, MD Assistant Professor of Neurology, Director of the University of Pittsburgh Headache Center, University of Pittsburgh, Pittsburgh, PA.

This article is a legacy contribution from the American Headache Society Committee for Headache Education (ACHE) and the Fred Sheftell, MD Education Center.