Migraine Myth of the Month: It’s migraine only if you have an aura, etc.
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Amongst healthcare providers, headache patients and the general population there is a common misunderstanding that migraine requires the presence of aura. Or that a migraine headache is always severe. Or throbbing. Or accompanied by nausea and vomiting.
As has been emphasized in previous issues of this magazine, however, migraine is rarely so stereotyped. Instead, migraine is the “Baskin Robbins of Headache”; it comes in all flavors, and it’s unusual for the disorder we refer to as “migraine” to always occur in the same flavor.
For example, only 20 to 25% of migraineurs ever experience aura, and very few of these individuals experience aura with every migraine episode. Those individuals who occasionally do have migraine with aura may not regard their “other” headaches as migraine if aura is not present. This unfortunately can lead to lost opportunities for appropriate treatment.
As for the intensity of headache, an individual migraine episode can span the spectrum from no headache whatsoever (aura only) to the severe, functionally incapacitating headache of “classical” migraine. Along that spectrum of headache intensity, migraineurs - especially those with chronic migraine - often experience individual episodes that are symptomatically identical to tension-type headache. Interestingly, when migraineurs administer an oral triptan for their acute “tension type” headaches, the positive response rate to the triptan is similar to what was reported from clinical trials involving acute treatment of migraine headache. On the other hand, if an individual with “pure” tension-type headache and no history of migraine administers an oral triptan, the response rate is no greater than that observed with placebo. Looked at another way, if a patient with chronic migraine responds positively to treatment with Botox or an anti-CGRP monoclonal antibody, there is a reduction not only in monthly “migraine days” but in monthly “headache days” taken as a whole.
According to the International Classification of Headache Disorders, a diagnosis of migraine requires only that an individual experience at least 5 episodes of unprovoked headache severe enough to significantly inhibit or prohibit routine activity, with those episodes lasting 4 to 72 hours and with the headache accompanied by nausea or light/sound sensitivity. “At least 5” is not synonymous with “all”; just because one headache slows you down while another knocks you off your feet does not mean only the latter is a migraine headache. And for the record, neither lateralization of headache to one side of the head, a pulsatile (throbbing) quality to the head pain nor an increase in head pain with routine physical activity is absolutely required for diagnosis of migraine.
So in working with your health care provider to assess your migraine burden, worry less about labeling your individual headaches (“migraine”, “not migraine”, “tension”, etc.) and more about determining the frequency and severity of the headaches you are experiencing along with the degree of functional disability they are conveying.
