What differentiates a migraine from a headache?

Differentiating Migraine from Headache

Migraine is a disabling primary headache disorder characterized by recurrent attacks with specific features including unilateral location, pulsating quality, moderate to severe intensity, aggravation by physical activity, and associated symptoms like photophobia, phonophobia, nausea, and vomiting, while general headaches lack these distinctive patterns and associated symptoms. 1

Key Diagnostic Features of Migraine

Migraine Without Aura

• Recurrent headache attacks lasting 4-72 hours when untreated 1
• At least two of the following pain characteristics:
  • Unilateral location (although bilateral pain occurs in ~40% of cases) 1
  • Pulsating quality 1
  • Moderate to severe intensity 1
  • Aggravation by or causing avoidance of routine physical activity 1
• At least one of the following during headache:
  • Nausea and/or vomiting 1
  • Photophobia and phonophobia (sensitivity to light and sound) 1

Migraine With Aura

• Transient focal neurological symptoms that usually precede or sometimes accompany the headache phase 1
• Visual aura occurs in >90% of affected individuals (classically as fortification spectra) 1
• Sensory symptoms occur in ~31% of cases (unilateral paresthesia that spreads gradually) 1
• Aura symptoms typically spread gradually (≥5 min) and occur in succession, unlike TIA symptoms which have sudden, simultaneous onset 1
• Each aura symptom typically lasts 5-60 minutes 1

Distinguishing Features from Other Headache Types

Tension Headache Differences

• Tension headaches have pressing/tightening (non-pulsatile) quality 1
• Typically mild to moderate intensity (vs. moderate to severe in migraine) 1
• Usually bilateral location 1
• No aggravation with routine physical activity 1
• No nausea or vomiting (though anorexia may occur) 1
• May have either photophobia OR phonophobia, but not both 1

Cluster Headache Differences

• Cluster headaches are characterized by severe unilateral pain lasting 15-180 minutes 1
• Accompanied by ipsilateral autonomic features (lacrimation, nasal congestion, rhinorrhea, sweating, ptosis, miosis, eyelid edema) 1
• Occur in clusters with frequency of 1-8 attacks daily 1

Additional Migraine Characteristics

Prodromal and Postdromal Symptoms

• Prodromal symptoms before pain onset may include:
  • Depressed mood 1
  • Yawning 1
  • Fatigue 1
  • Food cravings 1
• Postdromal symptoms after headache resolution can last up to 48 hours:
  • Tiredness 1
  • Concentration difficulties 1
  • Neck stiffness 1

Chronic Migraine

• Defined as ≥15 headache days per month for >3 months 1
• Must fulfill migraine criteria on ≥8 days per month 1
• Often fluctuates between chronic and episodic forms 1

Special Considerations in Children

• Migraine attacks in children are typically shorter (2-72 hours vs. 4-72 hours in adults) 2
• Headache is more frequently bilateral and less pulsatile than in adults 2
• Gastrointestinal symptoms like nausea and vomiting are often more prominent than the pain itself 2
• Diagnosis in children requires modified criteria to account for these differences 2

Impact and Burden

• Migraine affects more than one billion people worldwide 1
• It is the second most prevalent neurological disorder globally 1, 3
• Responsible for more disability than all other neurological disorders combined 1
• Affects approximately 22.3% of women and 10.8% of men in the US 4
• Often has a strong genetic component with positive family history 1

Common Pitfalls in Diagnosis

• Failing to recognize that migraine can present with bilateral pain (occurs in ~40% of cases) 1
• Confusing migraine aura with transient ischemic attack (TIA) - migraine aura symptoms spread gradually over ≥5 minutes and occur in succession, while TIA symptoms have sudden, simultaneous onset 1
• Missing the diagnosis in children due to different presentation patterns 2
• Not recognizing medication overuse headache in chronic migraine patients 1
• Overlooking the need to rule out secondary causes of headache when red flags are present 1

By understanding these distinctive features, clinicians can more accurately differentiate migraine from other headache types, leading to more appropriate treatment strategies and improved patient outcomes.