Migraine vs Headache: Symptoms, Triggers, Treatment and Warning Signs

Headaches are among the most common health problems worldwide. Most are harmless, but some are disabling, such as migraine, and a few signal a serious illness. Learning to recognise the pattern helps you choose the right treatment and spot the warning signs.

Main types of headache

Tension-type headache (most common)

• Dull, pressing or tight band-like pain on both sides of the head
• Mild to moderate, does not worsen with routine activity
• No nausea; sometimes light or sound sensitivity, but not both
• Lasts 30 minutes to several days
• Triggered by stress, poor posture, eye strain, missed meals or lack of sleep

Migraine

• Throbbing or pulsating pain, often on one side (but can be both)
• Moderate to severe and worse with movement
• Nausea or vomiting, and sensitivity to light and sound
• Lasts 4-72 hours if untreated
• Some people have an aura beforehand: visual changes such as zigzag lines, blind spots or flashing lights, tingling or speech difficulty, lasting 5-60 minutes
• Stages: prodrome (mood change, yawning, food cravings), aura, headache, and a "hangover" of tiredness afterwards
• More common in women, often starting in the teens or 20s, and may relate to periods or menopause

Cluster headache

• Very severe, stabbing pain around or behind one eye
• Red watery eye, runny nostril, eyelid drooping on the same side
• Lasts 15-180 minutes, up to several times a day, in "clusters" for weeks
• More common in men

Medication-overuse headache

• Daily or almost daily headache caused by frequent use of painkillers
• Improves after the overused medicine is stopped under medical guidance

Other causes

• Sinusitis (pressure over the face with blocked nose and fever)
• Eye strain or uncorrected vision
• Neck problems
• Dehydration, fever, infections including dengue and flu
• Caffeine withdrawal, hangover, hunger
• Medicines such as nitrates and some blood pressure drugs
• High blood pressure (if very high), sleep apnoea
• Rarely, tumours, bleeding, meningitis or giant cell arteritis

Common migraine triggers

• Stress and relaxation after stress (weekend migraines)
• Irregular sleep (too little or too much)
• Skipped meals and dehydration
• Hormonal changes: periods, pill, pregnancy, menopause
• Alcohol, especially red wine, and caffeine excess or withdrawal
• Strong smells, bright or flickering lights, loud noise, weather changes, travel
• Foods such as aged cheese, processed meat, chocolate and MSG, in some people

Keep a headache diary for 4-8 weeks noting date, duration, severity, possible triggers, medicines taken and menstrual cycle. It helps identify patterns.

Treating an attack

Act early: taking medicine at the start of the headache works best.

• Rest in a quiet, dark room, drink water and apply a cold compress.
• Simple painkillers: paracetamol, ibuprofen, naproxen or aspirin (not for children and teenagers) in adequate doses. Avoid NSAIDs if you could have dengue.
• Anti-nausea medicine such as metoclopramide or domperidone can help absorption and relieve vomiting.
• Triptans (sumatriptan, rizatriptan and others) are prescription migraine-specific medicines taken at the start of the headache. They are not suitable for people with heart disease, stroke or uncontrolled high blood pressure.
• Newer options: gepants and ditans, for those who cannot use triptans.
• Do not use opioids, which are ineffective and risky for migraine.
• Limit use: simple painkillers on up to about 14 days a month, and triptans or combination painkillers on up to about 9-10 days a month.

Preventing migraines

Consider preventive treatment if you have four or more headache days a month, disabling attacks, or poor response to treatment.

• Lifestyle: regular sleep, regular meals, adequate water, regular exercise, stress management and limited caffeine and alcohol
• Preventive medicines: propranolol or other beta-blockers, amitriptyline, topiramate, candesartan, flunarizine and others, chosen by your doctor
• Newer treatments: CGRP monoclonal antibodies by injection, and botulinum toxin for chronic migraine
• Supplements: magnesium, riboflavin (vitamin B2) and coenzyme Q10 may help some people
• Non-drug: relaxation training, biofeedback, cognitive behavioural therapy, acupuncture
• Hormonal migraine: women with aura should avoid oestrogen-containing contraceptives, and discuss options with their doctor

Red flags: seek urgent medical care

Go to the emergency department for:

• Sudden, severe "thunderclap" headache, the worst of your life
• Headache with fever, stiff neck, rash, or confusion (meningitis)
• Headache with weakness, numbness, speech trouble, vision loss, double vision or seizures (see stroke warning signs)
• Headache after a head injury
• New headache after age 50, especially with scalp tenderness, jaw pain or vision problems
• Headache that is progressively worsening over weeks, or wakes you from sleep with vomiting
• Headache with very high blood pressure, see how to check blood pressure at home
• Headache in pregnancy or after childbirth with swelling or visual disturbance (pre-eclampsia)
• Headache in someone with cancer or a weakened immune system

When to see a doctor

See a doctor if your headaches are frequent, change in pattern, interfere with daily life, need painkillers more than twice a week or do not respond to treatment. Also get your eyesight and blood pressure checked.

References

• International Headache Society: International Classification of Headache Disorders (ICHD-3)
• American Headache Society: consensus statement on integrating new migraine treatments
• NICE guideline CG150: headaches in over 12s
• World Health Organization: headache disorders fact sheet