Migraine or Just a Bad Headache? How to Tell the Difference

Migraine Is More Than “Just a Headache”

Interviewer: A lot of times migraines get labeled as just a bad headache, but if you've ever had one, you know it's more like, as one Redditor on r/headache says, "A freight train slamming into a wall inside your skull." Now, migraines can bring nausea, light and sound sensitivity, and some symptoms that don't even feel like a headache at all.

To help us make more sense of what a migraine is, we are joined by Dr. Karly Pippitt, who sees patients in the Headache Clinic at University of Utah Health. Hopefully, we can kind of figure out what migraines are and maybe when it's time to go see a specialist about them.

Common Migraine Symptoms and How Doctors Diagnose Them

So Dr. Pippitt, let's start with kind of the big question. What counts as a migraine?

Dr. Pippitt: That's a really good question, Mitch, and something that we talk about a lot. And it's important to make sure that we are getting the right diagnosis, so then we get the right treatment.

So there was actually a really great tool that was developed many years ago that was intended for primary care to help differentiate "What is this headache?" It's called ID Migraine. It's a three-item questionnaire.

We ask, "In the past three months, have your headaches had any of the following symptoms? Nausea, light sensitivity bothering you more like when you have a headache versus when you don't, and then disability. So did the headache limit your ability to work, study, or do whatever you needed to do for one day?" And if you answer yes to two of those questions, or perhaps even all three, that's really suggestive and really indicative of a migraine.

And I want to really call attention to that last part, because you actually brought up the nausea and the light sensitivity. In addition, we often have sound sensitivity as well. But I think that disability is really key.

Many people have a perception that to have a migraine, it needs to be debilitating pain. I will often tease, "You don't have to be curled up in a dark room in the fetal position for it to be a migraine," because I think that's the perception. It just needs to be, "Hey, I can get this done perhaps, what I need to do today. I'm just not really at 100% of where I should be."

Interviewer: Yeah. And it's funny you mentioned that, because on our other show, "Who Cares About Men's Health," I was one of those who curled up in a dark room and didn't realize I had migraines.

Dr. Pippitt: I was going to say, and yet you still thought it wasn't migraine.

Why Migraines Happen and What Can Trigger Them

Interviewer: No. I mean, if anyone's listening right now, it's not just you.

I guess my next question is, why do migraines happen? I mean, what is it that causes them? Is it something neurological, or is it just something in the environment?

Why Women Experience More Migraines

Dr. Pippitt: This is probably one of the most common questions that I get asked about migraine. And I would say for the most part, we know that this is something that is genetic. So, typically, other people in your family will have this: parents, siblings, aunts, uncles.

It is primarily a disease of women. Much more common in women in the ages of puberty to menopause, although after menopause, rates of men and women with migraine are fairly similar to each other. So, definitely, genetics play a component.

Migraine Triggers Often Work Together

And then you're absolutely right about the environment. The best description I heard of for, "How do we get to a migraine?" . . . Because I think a lot of people try to think of specific triggers. And we're logical people, so we want to think, "I did X, and then Y happened."

It was thinking about if you're going to light a campfire or a fire in a fireplace, you build your little kindling, you put your newspaper in it, and you might have one match that you light in a corner. That's that you didn't sleep very well last night.

And then you might light another match, that's you're just about to start your period. And then you light another match, and that's that you had a glass of wine with dinner. All of those come together to be the inferno that is migraine.

I thought that was such a good description because sometimes you might be able to have that glass of wine and you don't have any problems at all. It's hard to always pinpoint a single trigger.

And that is the case for some people. There might be a very discrete trigger, but often it's this conflagration of a bunch of things at once that really makes it happen.

Interviewer: Got you. So it's not like we're trying to do a scavenger hunt, trying to find all the different triggers. It might be a lot of things.

Dr. Pippitt: Exactly. I mean, it's always a helpful exercise to go back and sort of look, but I think with the caveat that you don't make yourself crazy trying to identify a single thing.

I think people get frustrated. They're like, "Well, you told me to do this diary and you told me to look for triggers, and everything is a trigger." And it's like, "Well, yeah, sometimes things are really bad. So you're right, everything is a trigger right now."

Understanding Migraine Aura and Neurologic Symptoms

Interviewer: One of the things that was most common in my research was people sharing weird symptoms they didn't expect. A migraine aura was one of them that they mentioned. What are some of these symptoms that may also help us decide, rather than just triggers, that you might have a migraine?

What Is a Migraine Aura?

Dr. Pippitt: So you brought up this word "aura." That gets thrown around a lot. And what does that technically mean? So there are two types of migraine. There's migraine without aura and migraine headache with aura. Aura is most technically defined . . .

And I will say, too, all migraines are a clinical diagnosis. We get this based on the history. There is no blood test, a lab test, or an imaging study that proves that this is a migraine. It is all based on the clinical history.

So an aura is a fully reversible neurologic phenomenon. To say that in more plain English, the most common aura is actually a visual aura. And so when I ask patients this question, I will say, "Do you ever have anything that happens before you get a headache? Could it be you feel like you're looking through a waterfall or a heat wave or a shimmer, a kaleidoscope prism in your vision?"

Now, the real formula is you should have an aura full stop, and then you get a headache after, but there can be a little bit of a bleed-over in that time frame.

Not everybody has aura. In fact, aura is not particularly common. It seems to be a little bit more common at elevation, so I would say we see this a little bit more.

When Aura Symptoms Require Emergency Care

We often see in the Headache Clinic people who've been to the emergency room. Because, like I said, this is a reversible neurologic phenomenon. So that could include things like numbness, weakness, drooping face, difficulty speaking, and difficulty getting words out. And all of those could be a stroke.

So we often see people who have never experienced these before, have this inability to speak and a drooping face, and very appropriately go to the emergency room to get worked up for a stroke.

Now, by their very definition, like I said, they are transient neurologic symptoms, so they go away, they resolve, and that's what makes them differ from a stroke. A stroke would be a sign of permanent damage to the brain because of either a hemorrhage of blood or a blood clot.

Interviewer: And so I guess if someone is experiencing aura, recognizing that not all migraines have aura, does that mean that it's more serious of a migraine or it just runs the gamut?

Dr. Pippitt: You can actually even get a migraine aura, and then not get a headache or a migraine. So migraine aura without headache, to just add one more confusing piece to the puzzle.

Probably the biggest implication of aura versus not aura is that it puts you at a little bit increased risk of a stroke throughout your lifetime. And so there are certain populations in which that matters.

So, people who you might be giving estrogen to, perhaps in birth control, you actually want to avoid estrogen in people who have migraine with aura, because we know that estrogen raises your stroke risk, and we know that migraine with aura raises your stroke risk. Because there are alternative options that do not contain estrogen, that's why it's recommended. That's actually a World Health Organization recommendation. So it's important to differentiate for that.

I would not say that it necessarily means a worse migraine. I will sometimes tell patients who have an aura, "In some ways, you're kind of lucky." I don't mean that as sort of obnoxious as it sounds. But I think for some people who don't have aura, you have this question sometimes of, "Well, is this just a bad headache, or is this a migraine? And how do I actually differentiate between the two?"

That may seem like a silly thing to say out loud, but I would say that's actually a really common question for people, is, "How do I know when I've crossed that threshold?" Most of us with migraine also have just plain old everyday headaches, which makes it a little bit complicated.

Migraine Treatments That Can Help You Feel Better Faster

Interviewer: Sure. So if there is someone out there who might be suffering from migraines, they have finally identified it in themselves, or they've struggled in the past, what kind of treatment is available both during a flare-up and for prevention? What can people do today?

Dr. Pippitt: Well, the first is to talk to your primary care provider. So I am a family physician by training, and part of why I enjoy doing this in the Headache Clinic is that primary care is the front line of treatment for migraine, and I want people to feel better about it. So ask about it. I think people don't want to feel like a wimp or anything like that, so they might not bring it up.

And don't do it as an "oh, by the way," which is healthcare lingo for I'm about to walk out the door and I have my hand on the doorknob, and you're like, "Oh, by the way, Doc, I've been having headaches." Like I said, this is a clinical diagnosis, so you want to make sure you have time to talk about your symptoms, what it is when you go through it.

Rescue and Preventive Medications Explained

Interviewer: And so after we go to the doc, what kind of treatments are available if we are deemed to have a migraine?

Dr. Pippitt: So there are two broad categories that we break medications down into. There is rescue medication or acute treatment for what you do when you're having a migraine, and then there's preventive treatment. So what do we do to try to, just what I said, prevent migraines?

You might ask, "Well, how do I know if I need to go on a preventive medication?" Typically, we would suggest this if you have about four to six migraine days per month.

And this could be a little bit tricky. If you're someone who has migraine with aura, you get your aura symptom, you're able to take your rescue medication, and maybe you actually can treat this so much that you don't even get a headache. Maybe that happens once a week. You kind of fall into that four-migraines-a-month category, but you don't actually experience the symptoms of it.

If you compare that to someone who maybe has two migraines a month, but they last two to three days and they have to miss work, that's a total of four to six "migraine days," that's why we use that terminology, per month. And it might be more impact on your life if we actually start something every day so that you don't have that loss of work, loss of life, all of those sorts of experiences that you lose with migraine.

Interviewer: What are the acute meds doing? What is the rescue medication?

Dr. Pippitt: So the first things to think about with rescue medication . . . Sometimes an over-the-counter medication is enough. So not everyone needs a prescription. And I think it's okay to start with over-the-counter medications.

You can find many variations of fill-in-the-blank generic or brand-name over-the-counter "plus migraine." Most of those medications are Tylenol or acetaminophen plus caffeine. Sometimes they also have aspirin in them. Excedrin is classic for some of that. Those actually work pretty well for a lot of people.

You'll find a lot of people who have their own sort of "cocktail" that is ibuprofen, a can of Coke, or . . . It feels like Coke and Dr. Pepper are the most common ones people use. And that's all they need.

A lot of the migraine-specific over-the-counter meds have that caffeinated component to them.

Interviewer: Oh, interesting.

Dr. Pippitt: That might be an issue. Not an ideal choice before bed, right?

Interviewer: Sure.

Dr. Pippitt: So sometimes something like ibuprofen is enough. When those aren't enough or when you find yourself using them multiple times in a week, this is the time to go in and talk to someone about, "Why isn't this working? What else can I do?"

The first medicines that came out that were very migraine-specific as a class are called the triptans. These have been around for a long time, since the '80s.

They're actually over-the-counter in Europe, which I think is helpful for people to understand. Sometimes people equate prescription with stronger. And I wouldn't really say that's the case. It's just more targeted and specific.

There are quite a few different triptans. Sumatriptan, or Imitrex, is the first one that came out, and that's typically the one that I will start people on.

All rescue medications are better taken early in the migraine cycle. And that's why I will tell people with aura, "You're lucky because you know to take something."

So the suggestion that I will give to people is, "If the question enters your mind, 'Is this a migraine, or should I be taking my triptan?' the answer is usually yes." A lot of us don't jump to medication treatment. You're like, "Oh, is this? Isn't this? I don't know." We hem and haw. Just take it. Typically, no harm, just no benefit if it's not a migraine.

Treating early is key, and with an adequate dose, right? So if you said to me, "Hey, Karly, I had this bad headache, and I took half an ibuprofen, and I don't feel better," I would be like, "Well, duh, that's not going to help you."

Interviewer: Take the whole ibuprofen. Yeah.

Dr. Pippitt: Exactly. So make sure you're treating with an adequate dose. And I would say that even with the prescription medication, there is no increased risk of side effects with the higher doses of triptans. It's just not as good of efficacy. So you're more likely to treat it better and more effectively at the higher doses.

There are some newer medications that are out there for rescue. As a class of drugs, they are called the CGRP antagonist, or calcitonin gene-related peptides. There are apparently a lot of famous people out there with migraines who like to talk about them on TV, so you may have heard about some of those before.

I'm going to nerd out on you here for a second. One of my colleagues taught me this. So CGRP has been around for a long time. You've disclosed that you're someone with migraines. If we gave you an infusion of CGRP, it actually would cause a migraine. And that's what they did in the initial trials for sumatriptan to see if it worked. So they would give you a migraine, and then treat it. They just hadn't really considered it as a drug target until the last couple of decades.

Interviewer: Oh, interesting.

Dr. Pippitt: So these medicines are great. Like I said, they're a little bit more targeted towards migraines. There are two of them that are available right now. Because they're newer, they're a little bit more expensive.

So they're recommended for people who've typically tried and failed three triptans, and those just don't work for you. Or there are some people for whom triptans are contraindicated. People with a history of cardiovascular disease, so someone who's had a heart attack or a stroke, aren't people who can use triptans. These new CGRP antagonists are a better choice for them.

Warning Signs That Need Immediate Medical Attention

Interviewer: Are there any red flags or headache symptoms that definitely mean, "Hey, this is something you need to go get seen for immediately and not something you need to hem and haw and try to decide if it's a migraine or a headache"?

Dr. Pippitt: Yes, absolutely. This is going to sound like a silly thing to say, but this is the classic description that you learn in medical school. "The worst headache of my life." And people will legitimately say that, like, "Oh, this is the worst headache of my life." That's something you want to go get looked into right away. That could be a sign of having bleeding in your brain.

If you've had a fall, some sort of trauma, and then have an associated headache, again, you're worried about structural injury to the brain or bleeding. Those are things you want to get checked out.

We talked a little bit about aura symptoms. So when you have new numbness, tingling, loss of function . . . You can have a stroke at any age. Our risk increases with age, but this is something . . . if you've never had that before and that's new, absolutely, go get that checked out. Make sure that things are okay.

If you're pregnant and you have a sudden new headache, that's something else we want to get checked out more immediately, rather than waiting.

It's really probably the neurologic features, the suddenness, the change of symptoms. Those are the things that are primarily concerning.

People with other underlying illnesses, too. So if you had a fever, a headache, and a stiff neck, we would worry about things like meningitis and other things you just don't want to miss.

When to Talk to Your Doctor About Recurring Headaches

Interviewer: There are maybe some symptoms that need to be seen immediately, but for those who are just maybe struggling with migraines or maybe even having trouble determining if they have a headache or a migraine, and they've been white-knuckling for years, what is the first step that you would want them to take to get relief?

Dr. Pippitt: The first step I want you to do is go see your primary care doc. That's what we're here for. This is a very treatable condition that you should not suffer needlessly.