What Are Chronic Migraines? Neurologists Describe the Causes and Treatments
Pulsing pain? Light sensitivity? Here's what you can do to manage these frequent headaches.
Everything is loud, bright, and your head is pulsating with pain. You might even feel as though a vice grip is clenching your skull. Migraine sufferers know what it's like to have an entire day sidelined because of an irresistible urge to hide in a cool, dark room.
But one migraine is bad enough. Imagine having several every month. Chronic migraines differ from typical migraines in part by how often they happen but also because most chronic migraine sufferers have several non-migraine headaches the rest of the month.
"Very often I'll ask a patient, how many migraines do you have a month? And they'll say, 'oh, maybe two a week,'" says Robert Cowan, MD, professor of neurology and chief of the division of headache medicine at Stanford University. But when he asks if they're headache-free the other 22 days of the month, they're quick to correct themselves. "They say, 'No, no, I have my regular headaches, those are every day—but I only seem to have migraines about twice a week."
Chronic migraine is defined as "a patient that has headache more than 15 days per month, of which eight or more have migrainous features," Dr. Cowan explains. That's based on the International Classification of Headache Disorders.
What are chronic migraine symptoms?
For migraine sufferers, their migraines often feature "a mostly one-sided headache with either nausea or a combination of light and sound sensitivity, worsened by exercise, and is moderate to severe," Dr. Cowan explains.
Per the American Migraine Foundation, symptoms for a typical migraine include:
Moderate to severe pain on one side of the head, although it sometimes happens on both sides
Throbbing or pulsing pain
Sensitivity to light
Sensitivity to sound
Sensitivity to smell
Sensitivity to touch
Nausea and vomiting
Dizziness
Pain that gets worse with exercise
But, as mentioned, chronic migraines also feature general "headache" days. Headaches come in different forms, according to the Cleveland Clinic, but generally, their symptoms include:
Consistent, mild-to-moderate pain without throbbing
Pain on both sides of the head
Pain that decreases or subsides with over-the-counter treatments
What causes chronic migraines? "The main cause is poor parental selection," says Dr. Cowan—that is, your genetics play a big role in how susceptible you'll be to migraines. If a family member has migraines, you're much more likely to experience them.
Migraines are more common in women and tend to start in adolescents, though they can begin at any age. They're usually the worst in your 30s and begin to lessen as time goes on, according to the Mayo Clinic.
As far as the exact mechanism that causes migraines, it's not entirely clear. It may have to do with changes in the brainstem, or possibly an imbalance in brain chemicals, as the Mayo Clinic explains.
Risk factors that make chronic migraines more likely include obesity, overusing medications, asthma, and poor sleep habits, Dr. Cowan says. A doctor should be looking at health conditions you have, because managing other illnesses may help reduce the frequency of migraines, he explains.
Certain things can trigger migraines. Dr. Cowan says the biggest triggers are a change in sleep, particularly not sleeping well, a change in eating routine or amount, and a big increase in physical activity relative to how active you usually are.
Other triggers include hormonal changes (like those around menstruation), drinking alcohol or caffeine, bright lights, strong smells, and loud sounds, along with certain foods, according to the Mayo Clinic.
But the important thing to understand about triggers is that they build on each other, which can make them hard to identify. For example, a patient who gets a migraine after eating blueberries they may blame the berries, Dr. Cowan explains. But often that person got a poor night's sleep and had a stressful day, and then had blueberry pie. The migraine wasn't triggered by blueberries alone.
Actively managing your migraines may make your triggers less impactful, says Mason Dyess, DO, a general neurology and headache medicine physician at Ochsner Medical Center in New Orleans. "People tend to have more triggers and are more susceptible to their triggers when their migraines are uncontrolled," he explained. But until you've found a regimen that works for you, "if you know something's going to give you a migraine, avoid it," he says.
How are chronic migraines diagnosed?
You're unlikely to have any imaging done with a migraine. "Ninety-five percent of your diagnosis in headache patients comes from the history," Dr. Cowan explains. The more information you have about your experience with headache and migraine, the better your doctor will be able to diagnose you. Try making a note each day you have a headache or migraine before your appointment.
That's important, explains the American Migraine Foundation, because chronic migraine is diagnosed based on the number of headache days you have, not on how disabling the condition may be.
Your doctor may also do a physical exam to check your neck range of motion and touch the back of the head and around your temples and eyes to check on certain nerves. "That can tell me a lot about how to treat the patient," Dr. Cowan says.
If you're having frequent headaches, your doctor will want to rule out other potential causes, such as an underlying health condition or a different type of headache, notes the American Migraine Foundation.
How do you get rid of chronic migraines?
Treatments for chronic migraines can be broken into two categories: preventive medications that help reduce the number of migraines every month and acute medications for when you actively sense a migraine coming on.
"Most patients take both if they have chronic migraine," Dr. Dyess says.
But it's important to know when to take them. "The acute medications are supposed to be employed at the very first sign of migraine," Dr. Dyess explains. That means as soon as you feel any pain. Acute medicines include over-the-counter medications like ibuprofen or aspirin and headache-specific medicines called triptans, such as sumatriptan and rizatriptan.
Preventive medications include oral medications, like beta blockers, antidepressants, and seizure medications. They might also include injectables, like Botox or calcitonin gene-related peptide (CGRP) inhibitors.
There are also newer CGRP blockers in pill form, which are approved as both acute and preventive medicine. This category includes Nurtec (rimegepant) and Ubrelvy (ubrogepant). "We probably get the most questions about them right now," says Dr. Dyess, because they've been popularized by several celebrities. "Those work to fundamentally help the inflammatory pathway, to stop the inflammation that leads up to a migraine."
You may also take other medications that help with migraine side effects, such as Zofran (ondansetron) for nausea.
The important point is this: if you're struggling with migraines, talk to your doctor—especially if your headaches or migraines have been increasing. "I'm more concerned about a patient who's gone from two headache days a month to six or eight headache days a month. That person is still going to be defined as episodic, but that's a patient that's in trouble or headed for trouble," says Dr. Cowan. "That patient's on their way to being disabled by their headaches if you don't intervene."
The 14 Different Kinds Of Headaches You Can Get—And How To Treat Each One
1. Tension headaches: Tension headaches are the most common type of headache, and feel like a constant ache or pressure around the head, or a headache in the back of the head or neck. They're not as severe as migraines, and aren't usually accompanied by nausea and vomiting, which means they rarely stop someone from continuing their regular activities (so they're just a huge nuisance).
Over-the-counter treatments, such as aspirin, ibuprofen, or acetaminophen (Tylenol), are usually sufficient to treat tension headaches, which experts believe may be caused by contraction of neck and scalp muscles (including in response to stress), and possibly changes in brain chemicals.
2. Cluster headaches: Cluster headaches, which affect men more often than women, are headaches that occur in groups or cycles. Cluster headaches recur regularly, even multiple times daily, over a certain period of time and then may be followed by a headache-free period of months or even years. The headaches appear suddenly and are characterized by severe, debilitating pain on either the right or the left side of the head, and are often accompanied by a watery eye, nasal congestion, or a runny nose on the same side of the face. During an attack, sufferers are often restless and unable to get comfortable and not likely to lay down the way someone with a migraine usually does.
The cause of cluster headaches is unknown, but they may have some genetic component. Triggers can include alcohol, cigarettes, high altitudes, and certain foods. There is no cure, but medications can reduce the frequency and duration of attacks.
3. Sinus headaches
When a sinus becomes inflamed, usually through an infection, it can cause pain. Sinus infections are typically accompanied by a fever, and can (if necessary) be diagnosed by MRI or CT scan (which can both detect changes in fluid levels), or by the presence of pus viewed through a fiber-optic scope.
These types of headaches are typically the most over-diagnosed, according to Peter Goadsby, MD, director of the Headache Center at the University of California, San Francisco. Migraines, for example, can often be mistaken for sinus headaches, since symptoms like sinus pressure, nasal congestion, and watery eyes can happen in both types.
A true sinus headache is related to an infection and comes with nasal discharge that is green or tinged with red, says Dr. Goadsby. Sinus infections often resolve with time or antibiotics, if necessary, and shouldn't cause nausea or light sensitivity, which are migraine symptoms. Headaches due to sinus infections can also be treated with antihistamines or decongestants.
4. Rebound headaches: Overuse of painkillers for headaches—like aspirin, acetaminophen (Tylenol), ibuprofen (Motrin, Advil), or prescription drugsc—can, ironically, lead to rebound headaches. "Most of the patients we see in a headache center with daily headaches have medication-overuse—or rebound—headaches," says Stewart Tepper, MD, director of research at the Center for Headache and Pain at the Cleveland Clinic Neurological Institute.
"They are on a merry-go-round and they can't get off," says Dr. Tepper. "They keep taking more medicine, they keep having more headaches, and so the patient becomes more and more desperate. That's when they end up coming to headache specialists to kind of reset the whole system."
One theory is that too much medication can cause the brain to shift into an excited state, triggering more headaches. Another is that the headaches are a symptom of withdrawal as the level of medicine drops in the bloodstream.
So how much medication is too much, and too often? Regularly taking any pain reliever more than twice a week or taking triptans (migraine drugs) for more than 10 days a month, can put you at risk for rebound headaches in just a few months.
5. Migraine headaches
Migraine headaches are severe headaches that are three times as common in women as men. The cause isn't clear, but genes appear to play a role, and brain cell activity may affect blood vessel and nerve cell function. Migraine headaches are defined by certain criteria:
At least five previous episodes of the same type of headaches
Headaches that last between four hours and 72 hours
Having at least two out of four of these features: one-sided pain, throbbing pain, moderate-to-severe pain, and pain that interferes with, is worsened by, or prohibits routine activity
Having at least one associated feature: nausea and/or vomiting, or, if those are not present, then sensitivity to light and sound
An oncoming migraine attack may, for some, be foreshadowed by an aura, which can include visual distortions (like wavy lines or blind spots) or numbness of a hand. It's estimated, though, that only 15% to 20% of migraineurs experience auras.
One common migraine trigger is change in your body, including hormones, stress, and sleeping or eating patterns. "If you know skipping meals is a trigger, don’t skip meals while menstruating and having a late night," says Dr. Goadsby. Treatment can include acetaminophen, ibuprofen, or triptans (such as Imitrex or Zomig), which are drugs that specficially help treat or prevent migraines.
6. Dental headaches: There are dental-related conditions that can trigger headaches or face pain, such as bruxism (a.k.a., teeth-grinding) and temporomandibular joint disorder (TMJ), which affects the joints in your face, located just in front of your ear, which connect the jaw to the skull.
TMJ can be caused by bad jaw alignment, stress, poor posture (like sitting at a computer all day), or arthritis, which affect the cartilage, muscles, or ligaments in the jaw.
Your dentist can help diagnose these types of headaches. Treatment includes stretching the jaw, hot or cold packs, stress reduction, and bite guards.
7. Caffeine headaches
You love your coffee, but it can be a cruel companion. For example, if you have two cups of coffee every day at 9 a.m., and then miss those cups when you oversleep on Saturday—boom—you can end up with a caffeine withdrawal headache.
You will be more likely have them, though, if you drink a lot (say, five cups of coffee a day), then go cold turkey. Your only real options? “You can take caffeine when you normally do and feed the addiction, or quit altogether" and suffer temporarily, says Dr. Goadsby.
8. Orgasm headaches: Orgasm-induced headaches are caused by uh, having an orgasm. Luckily, they're relatively rare and are more common in younger people, particularly men, Dr. Flippen says. They usually start shortly after intercourse begins and end in a “thunderclap” headache at climax.
A dull headache can often linger for hours or a day. Dr. Flippen says that there is often no known cause for these headaches, and they usually go away on their own. He does recommend seeing a doctor, however; in rare cases they can be a sign of something more serious. A dose of pain reliever before sex may help ease the pain.
9. Early-morning headaches: If you’re waking up in pain, there are several possible culprits. Migraines are more likely to happen in the morning, or medication may be waning in your body as you sleep, which causes a rebound headache, Dr. Goadsby says. Sleep apnea sufferers may also be more prone to headaches early in the day, as are those with dental headaches. In the absolute worse-case scenario, waking up consistently with a headache could be a symptom of a brain tumor, says Dr. Goadsby.
10. Ice cream headache:These headaches are typically known as brain freezes—a shooting head pain that can occur while enjoying a icy cold drink or treat on a hot day. And while most everyone gets one in their lifetime, people with migraines may be especially prone to them.
Turns out, ice cream headaches have an impressive medical name—sphenopalatine ganglioneuralgia—but they’re not all that serious. Experts think a cold sensation on the roof of the mouth can cause an increase in blood flow to one of the brain’s arteries. The cure? Take a momentary break from the frosty goodness until the pain subsides, or sip warm water to help quell the cold and constrict the brain artery.
11. Chronic daily headaches: If you have a headache at least 15 days per month for more than three months you’re considered to have chronic daily headaches, says Dr. Goadsby. These could be caused by overuse of pain medications (i.e., rebound headaches), head injury, or in rare cases, meningitis or tumors. But if there is no obvious cause, it could be because your body’s pain signals are heightened or not working properly, says Dr. Goadsby.
Chronic daily headaches may respond to antidepressants; beta blockers like atenolol, metoprolol, or propanolol (used to treat high blood pressure and migraines); anti-seizure medications like gabapentin or topiramate; pain relievers like naproxen (Aleve); and even Botox injections.
12. Menstrual headaches: As if PMS wasn’t bad enough, the sudden drop in estrogen right before your period can sometimes trigger migraines, Dr. Flippen says, which usually occur between three days before and two days after your period has started.
Other women, however, may have PMS-related headaches that aren’t migraines. These arrive about six days or so before your period, at the same time as any moodiness, cramping, or other PMS symptoms. Dr. Flippen recommends over-the-counter headache remedies; magnesium supplements may also help PMS-related head pain.
13. Weekend headaches: Some people may experience headaches that mainly show up on the weekend. These are thought to be caused by oversleeping on weekend mornings, going to bed later at night, or caffeine withdrawal. Also, if your stress level is high all week, the weekend relief may trigger a headache. Over-the-counter pain medications can be helpful, as can sticking to your regular sleep-wake schedule.
14. Emergency headaches: Most headaches aren’t an emergency, but there are a few symptoms that warrant rapid attention, says Dr. Flippen. One is a sudden onset headache that is quickly “explosive," which could be indicative of a brain aneurysm. Another is when a headache comes with a fever or extreme rise in blood pressure, or if it occurs after a blow to the head or exertion.
Other problematic symptoms include vision or speech change, neck pain, dizziness, loss of sensation, or muscle weakness on one side of the body. Call 911 if you have these worrisome symptoms in addition to headache.
Until next time, Stay Safe and Stay Healthy
James A Vito, D.M.D.