Welcome to Ask the Migraine Expert, a column about managing life with migraine from Deena Kuruvilla, MD. Dr. Kuruvilla is a board certified neurologist and Director of the Westport Headache Institute in Fairfield County, Connecticut. Got a question for the migraine expert? Submit your question via this form.
Dear Migraine Expert,
What are the best ways to describe different types of headache pain?
— Hamsterwheelbrain, Migraine Healthline community member
Great question. Providing specific details about your pain and all the circumstances surrounding your pain can lead your doctor to the correct diagnosis and treatment plan.
Most headache disorders are diagnosed while you are sitting with your doctor providing your history and receiving a physical examination.
Before we dive into details that could be helpful for your doctor, I will start out by emphasizing the importance of a headache diary. A headache diary can help you track your symptoms and discover patterns.
When tracking your pain and explaining it to your doctor, here’s what to keep in mind:
Describing the location of your pain can be very helpful.
Is your pain occurring on only one side of your head, is it switching sides, or is the pain always on both sides?
If your headache is only occurring on one side of the head, this could point to a fixed mass, aneurysm, or dissection on that side.
Once these things are ruled out, trigeminal autonomic cephalalgias, a group of primary headache disorders that occur only on one side of the head, could be the cause.
Trigeminal autonomic cephalalgias are treated differently than migraine.
The location of the headache should also be described as occurring within the forehead, within the temples, at the back of the head, in the neck, or upper back.
Pointing out an exact area where the pain occurs could help highlight specific anatomic hotspots that are characteristically involved in migraine.
For example, if you find more pain within the back of the head, your doctor may examine you for occipital neuralgia, which is very often seen with migraine and treated with a nerve block injection to the occipital nerve.
If your pain is more focused within the neck, diagnoses such as cervicogenic headache, in addition to migraine, may be considered.
The quality of your headache can certainly help with narrowing down which headache type you may have.
Alarm bells may go off in your doctor’s head if you describe the worst headache of your life or a headache that came on suddenly.
If your doctor hears this, they may recommend a CT scan or MRI of your brain to make sure that there isn’t something dangerous causing your headaches.
Other ways you may describe your pain include:
These are common terms I hear when people describe migraine or other primary headache disorders, such as cluster headache which is a trigeminal autonomic cephalalgia.
How your headache comes on can also be very helpful.
In addition to reporting any sudden onset headaches, it’s also useful to report if your headache progressively became worse and if that was a slow progression. We tend to worry less about headaches that come on slowly or worsen over time.
Most headache diaries allow reporting of your pain level when you experience a headache.
The pain level may be reported as mild, moderate, or severe on a scale from 1 to 10, with 10 being the worst pain.
In addition to pain levels being reported in individual attacks, it’s helpful for your doctor to have a view of the larger picture.
If you have frequent, continuous, or daily headaches, it’s important to report what your typical baseline level of pain is, your worst pain during exacerbations, and the frequency of exacerbations.
These key points can give your doctor a broader view of how you are doing over the span of a month or several months.
Rather than report how many headache days you’re having a month or a week, it’s more accurate to report how many days each week or month you have no discomfort in your head or neck.
When people with migraine report headache days, I find that they often underreport the number of headache days and only report the severe days.
As a migraine doc, I want to know about all your days with any discomfort in your head and neck. I also want to know if your pain is continuous or how long each attack is lasting.
Of everything you should discuss with your doctor, pregnancy and breastfeeding are the most important.
If you’re planning to become pregnant, your migraine doctor should be one of the first to know so that they can taper you slowly off of any medications that could harm the baby, come up with a pregnancy-safe plan, and offer extra counseling.
People can experience migraine or worsening migraine during the first trimester, so it’s important to have a plan in advance to make you comfortable during your pregnancy.
As doctors, most of the mainstream treatments we recommend are thrown out the window if you’re pregnant or breastfeeding. We have safer treatment options that we reserve for this population.
Be sure to mention your plans at the beginning of your visit so we can make safe recommendations.
Since headaches are often a lot more than just pain, it is imperative to report any associated symptoms you’re experiencing.
Common associated symptoms reported with migraine are:
- light sensitivity (photophobia)
- sensitivity to sounds (phonophobia)
- sensitivity to smells (osmophobia)
- worsening headache when exerting yourself
- need to rest during headache
Common associated symptoms reported with cluster headache are:
- bloodshot eyes
- drooping of the eyelid
- swelling in the face
- fullness in the ear
- runny nose
- ringing in the ears
I should highlight here that we do see some of these cluster headache symptoms in migraine also. However, in contrast to cluster headache, which is on one side of the head, these symptoms affect people with migraine on both sides of the head.
There are some signs that should be considered urgent. Reporting these to your doctor right away can help them make sure something dangerous is not causing the symptoms.
Urgent symptoms include:
- visual changes
- speech changes
- weakness on one side or the other
- any other neurological symptoms
These symptoms can be seen with migraine with aura, but this diagnosis would come after more dangerous things are ruled out.
Migraine triggers are useful to identify for two reasons:
- If the trigger is an obvious one and can be easily eliminated, we may have a quick fix.
- Some triggers are extremely common in those with migraine and reassure us that we have the right diagnosis.
Some common migraine triggers include:
- too much or too little caffeine
- alcohol use
- loss of sleep
- sleeping too much
- certain foods
I want to know if your headache is at all related to your period.
Menstrual migraine is defined as migraine occurring only around the period. The headache can occur 1 to 2 days before the first day of bleeding or during the actual menstruation period.
Having your calendar marked for your period can be helpful to pinpoint if your headaches are related. We may approach treatments differently based on what your headache diary looks like, so it’s important to mark your menstrual cycle.
Just as I am interested in menstruation and migraine, I am also interested in hearing about any symptoms of menopause you may be having.
Migraine can worsen if you’re going through perimenopause and improve after this symptomatic period is over.
It’s helpful to know if you are having any of these symptoms in addition to headaches:
- hot flashes
- night sweats
- changes in your period
- mood changes
The more information we have as migraine docs, the better we’re able to create a treatment plan that will work for you.
Communicating with your neurologist about your migraine symptoms and the circumstances surrounding your attacks is a really important step toward getting the care you need.
Deena Kuruvilla is a neurologist who’s passionate about all things headache. She has made it her life’s mission to treat, educate, and bring awareness to headache conditions such as migraine. She is the director of the Westport Headache Institute and has conducted research on medical devices, complementary and integrative medicine, and procedures for headache treatment. She has been featured in Prevention Magazine, Neurology Today, the Hartford Courant, and the Wall Street Journal. She lives in Fairfield, Connecticut, with her husband and two children and loves watching “The Masked Singer” with her family. Connect with her on Facebook or Instagram.