Am I Having a Headache or a Migraine? with Dr. Susan Broner

Faith: Welcome to Health Matters – your weekly dose of the latest in health and wellness from NewYork-Presbyterian. I’m Faith Salie.

Headaches are a common symptom that many of us feel when we’re sick or stressed, but what’s the difference between a headache and a migraine? Migraines are not defined by severity as much as they are by a specific set of symptoms. As the second most debilitating condition globally, and the first for women under fifty, knowing how to spot a migraine is the first step to getting help.

To better understand headaches, migraines, and what causes them, we talked to Dr. Susan Broner, a neurologist and headache specialist at NewYork-Presbyterian and Weill Cornell Medicine. Dr. Broner explained migraine triggers, and what our options are to treat them.

Dr. Susan Broner, thank you so much for joining us.

Dr. Broner: Oh, my pleasure. Thank you so much for inviting me to speak. 

Faith: So we’ve all likely experienced headaches at one time or another. I think a lot of us are curious: what is the difference between a headache and a migraine? 

Dr. Broner: That’s a great question. So, headache is just a symptom, right? It’s like stomach ache. It doesn’t tell you whether or not you have reflux or stomach cancer or any other host of pain causes in the stomach. Headache just describes pain above the neck. And so there isn’t really a diagnosis of headache.

Headache instead is categorized into over 150 headache disorders that are classified by the International Headache Society. So really the question is where is your pain? What does it feel like? How strong does it get? What associated features are with it? Like, do you have light and sound sensitivity or nausea, or do you have any neurological symptoms like getting numb or weak on the side or getting stroke-like symptoms? And is it a new headache or something that’s been going on for a while? 

So there’s so many different questions that as a headache specialist, I ask to find out what type of headache a person has. So there’s actually diagnostic criteria for migraine which are recurrent episodes, meaning you’ve had at least five episodes of headaches that have the following two out of four characteristics. One sided, throbbing. Worse with moving around. So like you’d avoid activities. You may not do your usual routine. And the last is moderate to severe pain. 

And then they need to be associated with light and sound sensitivity or nausea or vomiting. And some people have all of those features. The symptom range can be anything from like a four out of ten to a ten out of ten. It could be on both sides of the head or one sided and not everybody has all of the features. So it’s important to recognize that migraines aren’t always what we think of the worst headache of a person’s life. And the importance for realizing that is because whether it’s moderate or severe, migraine impacts the quality of people’s lives and their productivity in such a way that migraine is the second most disabling condition globally in years lost to disability and first in women under 50.

Faith: This is …This is a huge problem then.  

Dr. Broner: Yes, it’s the elephant in the room.

Faith: The American Migraine Foundation reports that migraines affect 39 million people in the United States.

Dr. Broner: Yes

Faith: And that an estimated more than 10 percent of people worldwide. So if you haven’t had a migraine, you know or love someone or work with someone who has.

Dr. Broner: Exactly. One in four households has someone who has migraine.

Faith: What’s exactly going on in our brains, in our heads, in our bodies when we have a migraine?

Dr. Broner: Deep inside the brain is a nerve ending called the trigeminal nerve. And when someone gets a migraine, that for some reason gets activated. And then that sends signals to different parts of the brain to create pain. Um, on a more detailed level, it actually sends signals to blood vessels around the outside of the, not the skull, but around the outside of the brain within the skull. It activates nerve endings around blood vessels. Those blood vessels get sort of swollen, and irritated, and inflamed, and then that then sends signals back to that migraine generator, which then sends signals through other pathways in the brain that create the pain symptoms and other migraine symptoms. So it’s an actual loop of pain.

Faith: Are there common warning signs of an oncoming migraine?

Dr. Broner: Yeah, there are several phases to migraine. And so before the actual pain starts, some people get something called an aura, which are these reversible neurological symptoms. The most common one is called a visual aura where they, people can experience a small blind spot in their eye, in both eyes that gradually builds and obscures their vision such that, for example, if you’re reading something, you might be missing text on the page.

So you can’t read everything on the page, or if you’re looking at somebody, they might be missing half of their face and that gradually expands and then tapers away after 5 to 60 minutes. And around that, or separate from that, people can also get this shimmering sparkly lights in their vision that also gradually fade away.

That’s the most common visual aura, but people can also get speech problems where they sound like they’re babbling and not making any sense, or they can get numbness sort of marching up in their hand and around their face, or some people even get hemiplegia where half of their body gets stroke like symptoms where they can’t move their arm or their leg.

Faith: That’s scary. 

Dr. Broner: It is scary.

Faith: I do have to say that applying the word aura to a migraine makes it sound so spiritual and transcendent, which is not the case at all. 

Dr. Broner: [laughs] No, it’s not. 

Faith: A lot of people associate migraines with stress. So when you were talking about, you know, things that might clue you in that you’re about to have a migraine, is stress one of those things?

Dr. Broner: So if we think about this analogy of brakes being on a pain pathway, there’s a threshold below which those brakes will come off. There’s just too much strain on the system, off they’ll come, and you’ll get a migraine. And for different people, different triggers are what can cause those brakes to come off. For example, weather changes are a really common trigger for people with migraine, barometric weather shifts. And the reason for that isn’t clear. There’s a debate about, um, chocolate being a trigger. And for  some people, it is a trigger. For some people, it’s a prodrome where their body’s craving chocolates or salty before they get a headache as part of the headache syndrome.

Faith: When should someone see a doctor about their migraine?

Dr. Broner: Yeah, so, um, if your, if your migraines are getting more frequent, If they’re becoming stronger, if they’re not responding to their usual medication, or if they’re changing in how they feel, those are all indications to see a doctor. And generally, if you’re having four to six migraines a month or more, you should probably be seeing a health care practitioner to try to work on ways to reduce your frequency because we know that more than that can lead to, and is a risk factor for, developing more and more migraines. You use the term chronic migraine, ultimately people can end up in chronic migraine, which is having 15 headache days per month or more.

Faith: Oh my goodness. 

Dr. Broner: There’s also something that we call red flags, which are really warning signs that you need to see someone sooner rather than later, which is new onset migraine that you’ve never had before.

Sudden onset, explosive worst headache of your life. A headache that comes with a fever, a stiff neck, in case you have something like meningitis or stroke-like symptoms for the first time where you’re thinking, well, maybe this is an aura. Well, if you’ve never had it before, you should be evaluated.

Faith: All right, somebody is diagnosed with migraines. What is the typical course of treatment for a patient who comes to you suffering from migraines?

Dr. Broner: Yeah, so there are two main goals. One is to reduce the frequency to keep that frequency low. The other is to make sure that the episode is short in duration. So we look at the migraine specific medications, which were developed specifically to treat migraine. And there’s two classes on the market. 

Those are the older medications that were developed a number of years ago that were revolutionary, and they’re called triptans. They’re very effective. And then if those aren’t effective, or people have contraindications to those, we use the newer class of as needed medications called gepants.

Faith: So, I, you know, you’ve mentioned that there are certain demographics and groups who are more likely to be affected by migraines. It’s folks under 50 and more women than men, is that right?

Dr. Broner: Correct. So, migraine can start in childhood and then it’s sort of, its peak is sort of in our most productive years in teen times through 40 and 50. Um, people still, I have patients as old as 80 and 90 in my practice who still experience migraines, but have them under control. But that’s the lion’s share of people. So it’s affecting people at the prime of their life, which is another reason for its great disability. So women have a higher incidence of migraines than men. 

Faith: Are migraines associated with hormonal fluctuations?

Dr. Broner: Yes, they are. That’s probably one of the aspects affecting higher prevalence in women than men. Depending on the studies you look at about 60 percent of women with migraine experience stronger, longer lasting headaches, uh, around their menstrual cycle and sometimes out of ovulation, but menstrual migraine definitely lasts longer, harder to treat, more associated nausea and vomiting.

Faith: Dr. Broner, in a perfect world, what would happen when someone is suffering from a migraine?

Dr. Broner: They would see their healthcare practitioner and their healthcare practitioner would be knowledgeable about the basics of headache medicine. What’s a migraine, what’s a tension type headache? And they would be armed with the simple treatments that can help people get better, even with a fact sheet about lifestyle factors that they can integrate, supplements they can integrate, when to refer if their headaches aren’t responsive, and a good as needed medicine.

We would have a workplace that allows a dark space for people to rest for an hour while they take their medicine and that it’s not stigmatized. And that there’s education done on the broader range in terms of support groups for people who have headache disorders and funding for migraine research. If we could get more and more research where we can ultimately have a bespoke medication that really targets even more specifically what we can target now that can help turn off migraine, we can really transform lives.

Faith: You have painted a very hopeful picture that we are really living in a golden age of migraine and headache treatment. So, what I’m taking away is no one needs to live in pain.

Dr. Broner: Absolutely. Absolutely. There’s great hope out there, but it’s better, it’s better than hope. There are tools out there to help people get better. And I, it’s an exciting time to be a headache specialist.

Faith: Dr. Susan Broner, this was fascinating. Thank you so much for joining us.

Dr. Broner: Oh, it’s my pleasure. Thank you for the conversation. 

Faith: Our many thanks to Dr. Susan Broner. I’m Faith Salie. Health Matters is a production of New York Presbyterian.

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