Differentiating Migraine From Other Headache Disorders


Jessica Ailani, MD, and Bradley Torphy, MD, discern the signs of migraine and comment on the importance of ensuring accurate diagnosis for patients.

Jessica Ailani, MD: Part of the challenge of making a diagnosis of migraine is that it’s not just 1 type of headache. People can have different types of headache. Even if you have migraine, you can have migraine with aura, migraine without aura, tension-type headache, or other types of headache disorders. A person who comes in might describe 1 type of headache and then, on a follow-up, another type of headache. Even as a headache specialist, I’ll struggle with the diagnosis because it turns out the patient has 4 or 5 headache disorders. This will delay or impact treatment options for the patient because I’m treating migraine, but they have cluster and tension type, and they’re trying to treat everything with 1 type of medication. Sometimes have to peel through different types of criteria, which can take a lot of time.

I often tell my colleagues, “It’s OK to understand that this is a relationship you’re starting, so take your time during the visits. If you don’t have the time to set up multiple visits, try to get the history a few times over to ensure nothing new is coming up.” Repeatedly, our epidemiology studies suggest the same thing: those who are most disabled are going into sick care. But the care we’re providing isn’t always the best care. Patients who need help aren’t always getting preventive treatment. This is where all of us are failing, and it can be problematic.

When we’re trying to teach our patients about different headache disorders, Brad, what are some key tips to differentiate migraine? We learned about how to differentiate migraine with different auras and without aura, but what about migraine vs tension-type headache or migraine vs cluster? These are the 2 most common things our health care colleagues wonder about but also patients. How do you differentiate these 2 types of headaches from each other?

Bradley Torphy, MD:This is such an important point. One thing I’ve learned is not to necessarily listen to the diagnosis that the patient has brought into the office because patients will often say they have cluster headache or tension headache. Obviously, we want to listen to our patients, but we have to look at this methodically. When we speak with residents and medical students about this, impact on activity can play a huge role, and what activity does to the headache. With tension headache, activity can sometimes improve the headache in some cases. With migraine, routine activity will typically worsen the symptoms. That’s 1 key way to differentiate.

We all know that tension headache is more common than migraine. But by the time a person comes to speak to a health care provider, if it’s not a secondary headache, it’s overwhelmingly likely to be migraine. When we’re making our diagnosis, we want to make sure we’re looking through that lens as well. With cluster headache, how do we make the distinction? These are top-line approaches. What’s the activity of the patient when they’re having their attacks? Patients with cluster headache are typically going to be the folks who are pacing—they’re restless, they’re doing distracting activities. Patients with migraine are going to tend to lie down in a dark room. A cluster patient can’t sit still. Those are some top-level approaches. Of course, if we think about characteristics typical of cluster patients, they’re more likely to be met. Migraine in adult patients is 3:1 more common in women. Certainly, we’ve all seen cluster patients who are women and men. But as we continue to think about those factors, that helps us make the diagnosis.

Transcript Edited for Clarity

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