What are the characteristic differences and treatment approaches for migraines versus headaches?

Characteristics and Treatment Approaches for Migraines vs. Headaches

Migraines are characterized by recurrent moderate to severe throbbing headaches, typically unilateral, exacerbated by physical activity, and associated with phonophobia, photophobia, nausea, and vomiting, while other headache types lack these specific features. 1

Diagnostic Characteristics

Migraine Characteristics

• Pain pattern: Typically unilateral, throbbing/pulsating quality
• Severity: Moderate to severe intensity
• Duration: 4-72 hours if untreated
• Associated symptoms:
  • Nausea and/or vomiting
  • Photophobia (light sensitivity)
  • Phonophobia (sound sensitivity)
• Aggravating factors: Physical activity often worsens pain
• Frequency: Chronic migraine is defined as ≥15 headache days per month for >3 months, with ≥8 days meeting migraine criteria 2

Tension-Type Headache Characteristics

• Pain pattern: Bilateral, pressing/tightening (non-pulsating)
• Severity: Mild to moderate intensity
• Duration: 30 minutes to 7 days
• Associated symptoms: Generally lacks nausea, vomiting, photophobia, and phonophobia
• Aggravating factors: Not typically worsened by routine physical activity

Diagnostic Approach

1. Rule out secondary causes by evaluating "red flags" 2, 1:

   • Headache worsened with Valsalva maneuver
   • Headache that awakens patient from sleep
   • New-onset headache in older patients
   • Progressively worsening headache pattern
   • Neurological symptoms or abnormal neurologic examination
   • Headache during sexual activity

2. Use headache diary to track:

   • Frequency and duration of headaches
   • Pain intensity and characteristics
   • Associated symptoms
   • Triggers
   • Medication use and response 2, 1

3. Ask about headache days: "Do you feel like you have a headache of some type on 15 or more days per month?" to help identify chronic migraine 2

Treatment Approaches

Acute Migraine Treatment

1. First-line for mild to moderate migraine 1, 3:

   • Simple analgesics: Acetaminophen
   • NSAIDs: Ibuprofen, naproxen
   • Combination of NSAID + acetaminophen

2. First-line for moderate to severe migraine 1, 3:

   • Triptans (sumatriptan 50mg)
   • Combination of triptan + NSAID (e.g., sumatriptan + naproxen)

3. Second-line options 1, 3:

   • CGRP antagonists (gepants): Rimegepant, ubrogepant, zavegepant
   • Antiemetics when nausea is prominent
   • Ergot alkaloids

4. Important considerations:

   • Begin treatment as early as possible after migraine onset
   • Avoid opioids and butalbital-containing medications
   • Limit acute medication use to prevent medication overuse headache:
     • NSAIDs ≤15 days/month
     • Triptans ≤10 days/month 1

Preventive Migraine Treatment

Consider preventive therapy if 1:

• Migraines occur ≥2 times per month
• Attacks are prolonged and disabling
• Quality of life is reduced between attacks

Recommended preventive medications 2, 1:

Medication	Dosage
Propranolol	80-240 mg/day
Timolol	20-30 mg/day
Amitriptyline	30-150 mg/day
Divalproex sodium	500-1500 mg/day
Sodium valproate	800-1500 mg/day
Topiramate	100 mg/day
OnabotulinumtoxinA (Botox)	FDA-approved specifically for chronic migraine

Note: Only topiramate has been shown to be efficacious in randomized, placebo-controlled clinical trials specifically for chronic migraine 2

Tension-Type Headache Treatment

1. Acute treatment:

   • Simple analgesics: Acetaminophen
   • NSAIDs: Ibuprofen, naproxen

2. Preventive treatment (for chronic tension-type headache):

   • Amitriptyline (first-line)
   • Stress management techniques
   • Physical therapy

Lifestyle and Complementary Approaches

• Lifestyle modifications 1:

  • Regular sleep schedule
  • Consistent meal times
  • Adequate hydration
  • Regular physical activity
  • Stress management

• Complementary approaches 1:

  • Magnesium supplements (400-600mg daily)
  • Riboflavin supplements (400mg daily)
  • Coenzyme Q10 supplements
  • Cognitive behavioral therapy
  • Relaxation techniques
  • Biofeedback

Special Considerations

• Pregnancy: Acetaminophen is the safest acute option 1
• Cardiovascular risk: Use caution with triptans 1
• Women of childbearing age: Avoid valproate derivatives due to teratogenic potential 1
• Elderly patients: Use caution with triptans; consider lower initial doses 1

Common Pitfalls to Avoid

1. Misdiagnosis: Only 20% of patients who fulfill criteria for chronic migraine are correctly diagnosed 2
2. Medication overuse: Can lead to medication overuse headache and chronification of migraine
3. Inadequate dosing: Subtherapeutic doses (e.g., amitriptyline at 10mg) are ineffective for prevention 1
4. Premature discontinuation: Allow 6-8 weeks at therapeutic dose to assess effectiveness of preventive therapy 1
5. Ignoring comorbidities: Conditions like depression, anxiety, and sleep disorders can exacerbate headaches

By understanding the distinct characteristics and appropriate treatment approaches for migraines versus other headache types, clinicians can provide more effective management strategies and improve patient outcomes.