When Headaches Become Migraines: A Clinical Guide to Diagnosis and Modern Treatment

The woman sitting across from me had been suffering for fifteen years. She'd seen four GPs, two neurologists, tried seventeen different medications, and spent thousands on alternative therapies. Her migraines had cost her a promotion, strained her marriage, and left her feeling hopeless. Within three months of starting a CGRP inhibitor, she had her life back. This isn't unusual. Migraine medicine has transformed in the past five years, yet most sufferers remain unaware that effective treatments exist beyond paracetamol and lying in dark rooms.

Every week in clinic, I meet patients who've accepted debilitating headaches as their lot in life. They've been told it's stress, hormones, or simply bad luck. They've been offered outdated treatments or, worse, dismissed entirely. The truth is that headache medicine has undergone a revolution. We now understand the neurobiology, have targeted treatments, and can offer genuine hope to people who've suffered for decades.

The Architecture of Head Pain

Pain in your head rarely originates from your brain itself, which lacks pain receptors. Instead, the surrounding structures scream for attention: blood vessels, meninges, nerves, muscles, and sinuses all contribute to the symphony of headache. Understanding which structure is complaining helps us target treatment precisely.

Primary headaches, where the headache itself is the condition, account for 90% of cases. These include migraine, tension-type headaches, and cluster headaches. Secondary headaches, symptoms of underlying conditions, make up the remaining 10% but generate 90% of our worry. The art lies in distinguishing between the benign majority and the dangerous few.

Migraine affects one in seven people, though many never receive proper diagnosis. Women suffer three times more frequently than men, thanks largely to hormonal influences. The economic impact is staggering: migraine costs the UK economy £8.8 billion annually in lost productivity. Yet research funding remains pitiful compared to conditions affecting far fewer people.

The migraine brain is fundamentally different, not defective. Hyperexcitable neurons, enhanced sensory processing, and unique vascular responses create a perfect storm of neurological events. Brain imaging shows increased connectivity between pain-processing regions and heightened activity in sensory areas even between attacks. You're not imagining the severity; your brain genuinely processes stimuli differently.

Recognising True Migraine

Migraine is far more than a bad headache. The International Classification of Headache Disorders requires specific criteria, but in clinic, I find patients' descriptions more illuminating than checklists. The throbbing, usually one-sided pain is just the headline act. The supporting cast of nausea, light sensitivity, sound sensitivity, and sometimes visual disturbances tells the full story.

Prodrome symptoms start hours or days before head pain. Patients describe unusual fatigue, food cravings, mood changes, or excessive yawning. One patient knew a migraine was coming when she couldn't stop thinking about salt and vinegar crisps. Another noticed her words getting muddled the day before attacks. These warning signs offer crucial intervention windows.

Aura affects 30% of migraine sufferers, causing temporary neurological symptoms. Visual auras are most common: zigzag lines, blind spots, or shimmering lights spreading across vision over 20-60 minutes. But auras can affect any brain function. I've seen patients with temporary paralysis, speech problems, or even Alice in Wonderland syndrome where objects appear the wrong size.

The headache phase typically lasts 4-72 hours if untreated. The pain isn't just severe; it's disabling. Normal activities become impossible. Light feels like daggers, sounds like hammers, smells like poison. Vomiting is common. Some patients describe wanting to cut their head off, and I believe them.

Postdrome, the migraine hangover, lingers after pain resolves. Patients feel drained, confused, or oddly euphoric. Cognitive function remains impaired for hours or days. This isn't malingering or attention-seeking; functional MRI shows continued abnormal brain activity during postdrome.

Tension-Type Headaches Live Differently

Tension-type headaches, despite the name, aren't simply caused by tension. The bilateral, pressing pain feels like a tight band around the head. Unlike migraine, routine activities don't worsen the pain, and nausea is uncommon. These headaches respond to simple analgesics and lifestyle modifications better than migraines do.

Chronic tension-type headaches, occurring more than 15 days monthly, often coexist with migraine. The overlap confuses diagnosis and treatment. Patients describe background daily headache punctuated by severe migraine attacks. Treating both components is essential for improvement.

The muscle tension component is real but often secondary. Poor posture, especially with modern screen use, contributes significantly. I examine necks and shoulders, finding trigger points that reproduce headache pain when pressed. Physical therapy, posture correction, and stress management often help more than medications.

Cluster Headaches Demand Respect

Cluster headaches are thankfully rare but unutterably severe. Patients pace, rock, or bang their heads against walls during attacks. The pain, always one-sided and centred around the eye, has driven people to suicide, earning the grim nickname 'suicide headaches'.

Attacks last 15 minutes to 3 hours, occurring in clusters lasting weeks or months. The clockwork regularity is remarkable; patients can predict attacks to the minute. Alcohol triggers attacks during cluster periods but not during remission. This isn't psychological; it's neurobiological.

High-flow oxygen aborts 78% of cluster attacks within 15 minutes. Yet most sufferers have never been offered this simple, safe treatment. Subcutaneous sumatriptan works even faster. Preventive treatments including verapamil can break cluster cycles. No one should suffer these attacks without proper treatment.

Medication Overuse Creates Paradox

The cruel irony of headache treatment: the medications that help can eventually cause the problem they're meant to solve. Medication overuse headache affects 2% of the population, though many don't realise their daily painkillers are perpetuating their suffering.

The threshold is lower than most realise. Using simple analgesics more than 15 days monthly or triptans/opioids more than 10 days monthly for three months can trigger medication overuse headache. The brain's pain systems adapt to regular medication, creating withdrawal headaches between doses.

Withdrawal is challenging but necessary. Headaches initially worsen for 2-10 days as the nervous system readjusts. Support, preventive medications, and sometimes bridge therapy with steroids help patients through this difficult period. Success rates approach 70% with proper support, dramatically improving quality of life.

Modern Prevention Changes Everything

The old preventives - beta-blockers, antidepressants, anticonvulsants - help some patients but often disappoint. Side effects frequently outweigh benefits. Patients quit after gaining weight, losing libido, or feeling zombified. We needed better options, and finally, we have them.

CGRP inhibitors represent the first class of drugs designed specifically for migraine prevention. These monoclonal antibodies or receptor antagonists block calcitonin gene-related peptide, a key player in migraine pathophysiology. Monthly injections or daily tablets can reduce migraine days by 50-75% with minimal side effects.

The NHS now funds CGRP inhibitors for chronic migraine after other preventives fail. Private patients can access them sooner. The response can be life-changing. Patients who've suffered for decades suddenly have weeks without headaches. One described it as 'like someone turned off a switch I didn't know existed'.

Botox for chronic migraine isn't cosmetic indulgence but evidence-based treatment. Injections every 12 weeks into specific head and neck muscles reduce migraine days by 50% in responders. The mechanism isn't fully understood but likely involves blocking pain signal transmission and reducing muscle tension.

Neuromodulation devices offer drug-free prevention. Transcranial magnetic stimulation, vagus nerve stimulation, and supraorbital nerve stimulation all show promise. These devices, resembling anything from headbands to mobile phones, alter brain activity to prevent attacks. Perfect for patients who can't tolerate or don't want medications.

Acute Treatment Requires Strategy

Treating migraine attacks isn't just about taking painkillers and hoping. Timing, combination therapy, and route of administration all matter. Early treatment dramatically improves outcomes, yet many patients delay, hoping the headache will resolve spontaneously.

Triptans remain the gold standard for moderate to severe migraine. Seven different triptans exist, each with unique characteristics. Sumatriptan works fastest but recurs frequently. Naratriptan acts slowly but lasts longer. Finding the right triptan for each patient requires systematic trial. One size definitely doesn't fit all.

Anti-emetics deserve equal billing with painkillers. Nausea isn't just unpleasant; it prevents oral medication absorption. Domperidone or metoclopramide, taken early, improve both nausea and headache through dopamine antagonism. Some patients find anti-emetics alone sufficient for mild attacks.

Route of administration matters when vomiting occurs. Nasal sprays, suppositories, or injections bypass the rebellious stomach. I've seen patients suffer unnecessarily because they didn't know alternatives to tablets existed. Every migraine patient needs a non-oral backup plan.

Gepants, the newest acute treatments, work similarly to CGRP inhibitors but faster. Rimegepant and ubrogepant offer alternatives for patients who can't take triptans due to cardiovascular disease. They're also less likely to cause medication overuse headache, though long-term data is still accumulating.

Lifestyle Medicine Isn't Alternative

Identifying triggers empowers patients but can become obsessive. Common triggers include hormonal changes, stress, weather, foods, dehydration, and sleep disruption. But triggers are cumulative, not absolute. Chocolate might trigger migraine when you're premenstrual and stressed but not otherwise.

Sleep hygiene profoundly affects migraine frequency. Both too little and too much sleep trigger attacks. Weekend lie-ins trigger Saturday morning migraines. Shift work wreaks havoc. Maintaining consistent sleep schedules, even weekends, reduces attack frequency by 29% in studies.

Regular meals prevent blood sugar fluctuations that trigger migraines. Skipping meals is a reliable trigger for many. The specific foods matter less than eating regularly. The tyramine-containing foods traditionally blamed (cheese, wine, chocolate) affect fewer people than believed.

Exercise presents a paradox. Sudden intense exercise triggers migraines, but regular moderate exercise prevents them. Starting slowly and building gradually is key. Many patients avoid exercise fearing triggering attacks, missing out on one of the most effective preventive strategies.

Stress management isn't about eliminating stress, which is impossible, but changing responses to it. Cognitive behavioural therapy reduces migraine frequency as effectively as some medications. Mindfulness meditation shows similar benefits. These aren't woolly alternatives but evidence-based treatments.

Red Flags Demand Attention

Certain headache presentations require urgent investigation. Thunderclap headache, reaching maximum intensity within seconds, suggests subarachnoid haemorrhage until proven otherwise. These patients need immediate CT scanning and possible lumbar puncture.

New headache in people over 50, especially with temporal artery tenderness, suggests giant cell arteritis. This ophthalmological emergency can cause blindness within hours. ESR and CRP blood tests guide diagnosis, but treatment shouldn't await results if clinical suspicion is high.

Progressive headaches worsening over weeks or months warrant imaging. Brain tumours are rare but must be excluded. Associated symptoms like personality change, seizures, or focal neurological signs increase concern. Morning headaches with vomiting particularly worry us.

Headache with fever and neck stiffness screams meningitis. Photophobia, confusion, and rash complete the picture. These patients need immediate hospital assessment. Delays cost lives. Better to be overcautious than miss this diagnosis.

Sudden severe headache during pregnancy, especially with visual changes or upper abdominal pain, might indicate preeclampsia. Blood pressure monitoring and urinalysis are essential. This obstetric emergency requires immediate hospital assessment.

The Hormone Connection

Menstrual migraines affect 60% of female migraine sufferers. Oestrogen withdrawal triggers attacks, typically starting two days before menstruation. These migraines tend to be longer, more severe, and less treatment-responsive than non-menstrual attacks.

Prevention strategies include continuous hormonal contraception to avoid oestrogen drops. Oestrogen supplementation during the perimenstrual period helps some women. Prophylactic triptans, taken daily from two days before expected menstruation, prevent 50% of menstrual migraines.

Pregnancy usually improves migraines after the first trimester, with 70% of women experiencing significant reduction. But medication options are limited. Paracetamol is safe throughout pregnancy. Most other medications require risk-benefit discussions. Some women choose to suffer rather than risk any medication, though this isn't always necessary.

Menopause is unpredictable. Some women's migraines disappear, others worsen dramatically. HRT can help or hinder, depending on the formulation and individual response. Continuous transdermal oestrogen with cyclical progesterone often works best, avoiding the peaks and troughs that trigger attacks.

Children Get Migraines Too

Paediatric migraine is underrecognised and undertreated. Children can't always articulate symptoms, instead becoming pale, quiet, and seeking dark rooms. Abdominal migraine, causing recurrent stomach pain without headache, affects 4% of children and often evolves into typical migraine.

Treatment requires weight-based dosing and limited medication options. Ibuprofen works better than paracetamol for children. Triptans are licensed from age 12, though some specialists use them younger. Prevention focuses on lifestyle modifications, though some children require daily medication.

School absence due to migraine averages eight days annually for affected children. Educational impact extends beyond missed days; cognitive effects persist after attacks. Schools need education about migraine's legitimacy and impact. Too many children are accused of faking when they're genuinely suffering.

The Cannabis Question

Patients increasingly ask about cannabis for migraine. The evidence is mixed and complicated by legal issues. Cannabinoids interact with pain pathways and show theoretical promise, but clinical trials disappoint. Individual responses vary enormously.

CBD oil, legally available, helps some patients, particularly with associated anxiety. THC-containing products, requiring specialist prescription, might help selected patients but can worsen headaches in others. The lack of standardisation makes dosing difficult.

I neither encourage nor discourage cannabis trials but insist on honesty about use. Cannabis interacts with several migraine medications and can complicate diagnosis. Patients using cannabis should monitor response systematically, not assume benefit.

Looking Forward

Gene therapy for familial hemiplegic migraine is in early trials. Personalised medicine, selecting treatments based on genetic profiles, approaches reality. Novel targets including PACAP and orexin receptors show promise. The next decade will likely bring transformative treatments.

Digital therapeutics using smartphone apps to deliver behavioural interventions show surprising efficacy. Virtual reality for relaxation training and biofeedback reduces attack frequency. These tools democratise access to non-pharmacological treatments previously requiring specialist referral.

Artificial intelligence increasingly assists diagnosis and treatment selection. Machine learning algorithms predict treatment response better than clinical judgment alone. Wearable devices detecting early attack signs could enable ultra-early intervention.

Frequently Asked Questions

How do I know if my headache is actually a migraine?

Migraine typically involves throbbing, one-sided pain lasting 4-72 hours with nausea and sensitivity to light/sound. Normal activities worsen the pain. If headaches regularly disable you, preventing normal function, consider migraine regardless of exact symptoms. Formal diagnosis requires medical assessment, but tracking symptoms helps.

When should I go to A&E with a headache?

Seek emergency care for sudden severe headache reaching maximum intensity within seconds, headache with fever and neck stiffness, headache with confusion or difficulty speaking, headache after head injury, or progressively worsening headache with vomiting. New severe headache in pregnancy also warrants immediate assessment.

Can children inherit migraines from parents?

Migraine has strong genetic components. If one parent has migraine, children have a 50% chance. If both parents are affected, risk rises to 75%. However, inheritance isn't destiny. Environmental factors and early intervention can modify expression and severity.

Why do triptans sometimes stop working?

Triptans can lose efficacy through tolerance, medication overuse, or migraine pattern evolution. Sometimes the problem is timing - taking triptans too late reduces effectiveness. Switching to a different triptan or adding preventive treatment often helps. Don't assume treatment failure is permanent.

Is migraine considered a disability?

Severe migraine can qualify as a disability under the Equality Act 2010 if it substantially impacts daily activities long-term. This provides workplace protections including reasonable adjustments like flexible working, reduced lighting, or time off for appointments. Documentation from healthcare providers supports claims.

Can diet changes really prevent migraines?

Dietary triggers are individual, not universal. Elimination diets help identify personal triggers but can become restrictive. Regular meal patterns matter more than specific foods for most people. The ketogenic diet shows promise in small studies but requires medical supervision.

Are expensive migraine treatments worth it?

CGRP inhibitors cost £300-500 monthly privately but transform lives for responders. If migraine significantly impacts work, relationships, or quality of life, the investment often proves worthwhile. Many patients regret not accessing effective treatment sooner. Some private insurance covers these medications.

Can hormonal contraception help or worsen migraines?

Combined oral contraceptives can worsen migraine with aura and increase stroke risk. Progesterone-only methods are safer. Continuous combined pills, avoiding hormone-free intervals, help some women with menstrual migraine. Individual response varies; systematic trial under medical supervision is advisable.

Do migraine devices actually work?

Neuromodulation devices have solid evidence for selected patients. Cefaly reduces migraine frequency by 30% in responders. GammaCore helps cluster headaches. Individual response varies, but 30-40% of users experience significant benefit. Most offer trial periods or money-back guarantees.

Should I see my GP or a neurologist?

GPs can manage most migraine cases effectively. Seek specialist referral for diagnostic uncertainty, failed response to multiple treatments, complex medication regimens, or concerning features. Private neurology consultation costs £200-350 but can expedite access to newer treatments.

Living with migraine or chronic headache doesn't mean accepting suffering. Modern medicine offers genuine solutions, from revolutionary preventives to sophisticated acute treatments. The key is finding the right combination for your specific pattern.

Don't let outdated beliefs about 'just headaches' prevent you from seeking help. Your pain is real, your impact valid, and effective treatment exists. Whether through NHS pathways or private consultation, take the first step toward reclaiming your life from headache.

Suffering from chronic headaches or migraine? The Online GP provides comprehensive headache consultations with same-day appointments available seven days a week. Access modern treatments including CGRP inhibitors and receive ongoing support for your headache journey. WhatsApp +44 7399323620 or visit our Marylebone clinic.