Migraine Mimics

  Make sure the headaches you have are migraines- a brief overview of migraine mimics follows:

This writing is about migraine headaches. If you have any doubts about the cause of your headaches it is strongly recommended that a medical opinion is sought to be certain about the etiology of your headaches. 

‘Migraine is defined as severe throbbing usually unilateral headache sometimes associated with nausea, photophobia (light sensitivity), phonophobia (sound sensitivity) and vomiting’ .

The term migraine is of Greek origin and comes from the word hemicrania’s, which means “half of the head”. 

This is a striking feature of the disease, as most individuals feel pain in one half of the head. However, bilateral pain is also common and occurs at the front and back of the head. The nature of the pain is throbbing, which worsens with exertion or movement. Migraine attacks are usually moderate or severe.

‘Migraine is defined as severe throbbing usually unilateral      headache sometimes associated with nausea, photophobia (light      sensitivity), phonophobia (sound sensitivity) and vomiting’ .

A typical uncomplicated migraine attack consists of : rapid or rather progressive onset (within a few minutes ) of head pain usually on one side -temple or back of head, throbbing or pulsating in nature , lasting for 4 hours or more generally or even longer, associated with increased light sensitivity or sound sensitivity or intolerance to bright light or loud sound; some patients may get a warning before headache for eg an aura of flickering light or zig zag pattern in visual field; nausea or even vomiting may be associated with severe migraine attacks.

Types of migraine headaches: 

There are a few ways to classify types of migraine headaches.

Two common types of migraine headaches are migraine without aura and migraine with aura.

Migraine without aura are much more common.

Auras are a sensation of visual patterns in visual field just before onset of a migraine full blown headache. So aura may serve as a warning symptom prior to onset of headaches. 

Another way of classifying migraines is episodic or chronic migraines. 

Episodic migraines are headaches occurring randomly and affecting a person less than 15 days a month.

Migraines are called chronic migraines of they occupy more than 15 days per month.

Hemiplegic migraine is another type of migraine and is a severe and rare condition that affects one side of the body and causes temporary numbness or even temporary paralysis of one side of the body.

Migraine mimics:

There are several conditions which can cause chronic recurrent headaches which may have similar symptoms as migraines. Some of these neurologic conditions are:

1-Muscle Tension headaches

2-Occipital neuralgia, a condition causing pain in the back of head and upper neck

3- Referred pain from cervical spine (neck pain radiating to back of head).

4- Pseudotumor cerebri (also called Idiopathic Intracranial hypertension) seen usually in young women who are overweight, symptoms are persistent dull and whole head pain associated with visual blurring or other visual symptoms.

5-Eye conditions for eg. Glaucoma

6-Sinus related conditions.

7- After a head injury i.e Post-traumatic headaches (ie headaches onset after a head injury)

8-Certain Infections for eg. Viral and bacterial meningitis; generally there is fever, headache , neck pain and symptoms suggesting infection for eg malaise and generalized ill feeling.

9-Temporal arteritis is a condition secondary to affection of a scalp artery on the sides of head/temples , usually seen in older age group, this condition can cause chronic headaches. There may be visual symptoms associated with headaches, neck and shoulder pain may be present.

10- Venous thrombosis a relatively rare condition caused by clotting in the intracranial clotting of veins in the head; may be seen in pregnant women. 

11-Cluster headaches, more common in men, headaches are recurrent and typically around the eye region, shorter lasting than migraine and come in quick succession over several weeks or months and then subside for long duration and then re-appear (a cluster pattern).

As you can see there is overlap of symptoms with migraines in the headache type described above and it may not be sometimes easy to differentiate migraines from non-migraine headaches. Your physician would be able to investigate if necessary and if there are doubts about the real cause of headache.

The importance of knowing the underlying cause of headaches is that treatment strategies are different for many of these varied types of headaches.

More sinister  causes of headache for e.g. Brain tumors, aneurysmal rupture and strokes have a very different pattern and clinical presentation and they are not typically ‘chronic and ‘recurrent’ in nature but are differentiated due to their persistence over  certain time (for e.g. tumors) , acuteness and sudden presentation (ruptured aneurysm or strokes).

So in summary it is helpful to understand ‘pattern’ of headaches to be certain about the likely cause of headaches.

Less often , however, migraine can present as sudden acute explosive headaches also termed ‘Crash migraines’ however majority of these patient will have history of migraines in past. I would however recommend urgent medical evaluation in such situations if this is a new type of headache type even in known person with history of migraines. 

Onset of new headaches in later age group, pregnancy and after starting a new medication should also raise questions and causes other than benign headaches should be considered.

Symptoms such as persistent numbness in face and arms and legs or noticeable weakness associated with new onset headaches should also raise suspicion about the cause of headaches professional medical consultation should be sought.

It should not be ignored that a person who is known to have migraines may develop other types of headaches. Therefore, a noticeable change from your usual headaches pattern may need attention and a discussion with your healthcare provider.

Case study 1:

54 year old woman came to see me stating she has headaches for 2 weeks and does not have prior history of migraines but used to have infrequent headaches in her twenties. The headache started suddenly when she was fishing on a boat with family and pulled a large fish. She took over the counter pills for headaches for 1 week but headaches were not going away so she came to see me.

Her general medical and neurologic exam was normal.

I suspected aneurysm and obtained imaging studies of head urgently which did show partially ruptured cerebral aneurysms. She was urgently referred to neurosurgery.

The key in the above case was the history of sudden onset headaches in 50+ woman whose headache onset was sudden while she had exertion.

This publication is directed towards migraine headaches specifically and I will not go in details about non-migraine headaches.

Case study 2:

41 y/o man was seen for history of headaches which he said occur around his left eye and the pain would occur for 1-2 hours and would be associated with redness and tearing in eye. The episodes of pain would occur for several days and weeks with spontaneous resolution but will recur after several weeks or months.

This picture was suggestive of cluster headaches.

Case study 3:

27 y/o female was seen for chronic headaches involving whole head , head pain was dull in nature, not episodic but rather persistent with fluctuating intensity and visual blurring. She was overweight with body mass index of 35 plus and I suspected Intracranial hypertension (formerly termed Pseudotumor cerebri). A lumbar puncture was done, and diagnosis was confirmed after finding of elevated intracranial pressures.

These cases signify the importance of understanding the pattern of headaches and the need for specific treatment, very different from what is done usually for migraine type headaches.