Disease with many faces

Double vision as a migraine aura

Double vision as a migraine aura

Until 1988, every doctor could practically create his or her own definition of a headache. This only changed when the International Headache Society (IHS) published a catalog of the numerous diagnostic criteria. This can now also be found in the so-called ICD-10, the International Classification of Diseases, 10th edition, which is published by the World Health Organization (WHO). In 2004, a first revision, the second edition, was published by the International Headache Society.

If we look at the general categories of this classification alone, we can count 13 different main groups of headaches. A level deeper we come to 36 subcategories and with a very precise diagnosis we count over 250 different types of headaches.

Double vision as a migraine aura (photo Dr. Angelika Demel)

Of course, if all of these types of headaches were treated in the same way, such a nuanced classification would be nothing more than a toy for medical bean counters. But that's not how it is. It is obvious that the headache caused by high blood pressure can be treated by lowering the blood pressure, or the headache caused by bacterial meningitis can be treated with an antibiotic.

However, many people find it difficult not only to differentiate between these very specific types of headaches, but also to correctly diagnose the two large groups “tension-type headaches” and “migraines”, which together account for a good ninety percent of all headaches.

Tension-type headache or migraine?

The doctor must of course rule out so-called symptomatic headaches based on a thorough examination. These are headaches as a symptom of another illness. After all, it could be that the pain is the result of a flu-like infection, a toxic substance or even a brain tumor. If these types of headaches are excluded and the patient can state in detail - for example using a headache diary - when and how often the pain occurs and what accompanying symptoms it has, then the distinction between tension-type headaches and migraines is basically very simple.

The distinction between migraine headaches and tension-type headaches is, on the one hand, the duration: a migraine attack is usually over after a maximum of 72 hours, while tension-type headaches can last from 30 minutes to seven days if left untreated. The nature of the pain is also different: While migraines cause throbbing, pulsating or hammering pain, tension-type headaches tend to be dull, pressing or pulling. The intensity also varies: While a migraine attack usually extremely restricts normal activity, this is not necessarily the case with tension-type headaches. Migraine sufferers seek bed rest, but tension headaches get better with exercise in the fresh air.

A very important criterion is the occurrence of nausea and vomiting, as well as sensitivity to light and noise. Nausea and vomiting are not common in tension-type headaches, while sensitivity to light or noise is possible but not typical.

Of course, this can only be found out when the headache has already occurred at least five times and the patient can provide very precise information about the course of the pain. And of course there are people who suffer from both migraines and tension-type headaches. It is then important to recognize both types of headache and treat them specifically.

A special case and a complication, so to speak, is chronic migraine. This has occurred on 15 or more days per month for at least 3 months. Medication overuse was ruled out. Chronic migraines usually only occur as a result of years of headaches.

If you are affected yourself, you should keep a diagnostic headache calendar. If you do this diligently, you can continually determine your headache type and discuss it with your doctor. You can retroactively enter your experiences in the diagnostic headache questionnaire. It will help you find out whether you are suffering from migraines or tension-type headaches.

Harbingers of migraines

Sensory overload before the attack

Sensory overload before the attack

Almost a third of migraine sufferers have symptoms up to two days before the migraine attack that herald the coming attack. These harbingers can be very different: severe irritability, craving for sweets, frequent yawning, excitement, tiredness and much more.

When the migraine attack begins, it is of course obvious to the patient to see the precursor symptoms as the trigger or even the cause of the migraine - for example, stress in the case of the previous symptom of irritability, chocolate in the case of the symptom of "an appetite for sweets" or lack of sleep in the case of previously occurring tiredness. But that would be a false conclusion. These are not the triggers of the migraine attack and certainly not the causes. Rather, these are the first non-specific symptoms of migraines.

Aura: When your nerves go crazy

In one in ten migraine sufferers, the attack begins with disturbances in the central nervous system, which are known as “aura” . These disorders develop within a few minutes and usually last a maximum of an hour. If several faults occur one after the other, the time periods add up and can then last more than an hour. Even with a special form of migraine – “migraine with prolonged aura” – the disorders last longer: between 60 minutes and seven days.

But what is an aura? The phenomenon was named after the Greek goddess of the dawn, Aurora. Before the headache attack, neurological disorders slowly become more severe within 15 to 30 minutes, like at sunrise. Most of the time - in around 90 percent of cases - it is a case of visual impairment. At the edge of the field of vision, flickering dots or zigzag lines, streaks or veils suddenly appear and gradually spread out. However, the aura can also manifest itself in the form of dizziness, speech problems, tingling in certain parts of the body or even symptoms of paralysis.

The migraine aura takes its name from the Greek goddess of dawn, Aurora: You can find out more about the aurora and the visual phenomena associated with it using this link. It is similar to the visual phenomena that migraine sufferers experience during the aura phase.

After the aura symptoms, the headache usually sets in. But it can also be missing entirely. Some patients complain of one or more aura symptoms for years without even remotely suspecting that they have migraines. Because the symptoms usually last no longer than ten to 30 minutes, patients often do not consider it necessary to contact a doctor.

You may now think that the aura is also a harbinger of migraines, as I described in the last section. But that's not exactly what they are. As you will learn in more detail, migraine is a disease of the nervous system. This neurological disorder usually manifests itself in the form of the typical pulsating headaches, but also in the aura symptoms. They are therefore the migraine itself, not a harbinger. And they are so typical, they only occur in this form with migraines, so that they are an absolutely clear sign that the headaches that usually follow are actually headaches associated with a migraine.

The headache phase and its characteristics

The migraine attack

The migraine attack

There are two possible explanations for the word “migraine.” One says that it comes from the Greek “hemikrania” (hemi = half, kranion = skull) because migraine pain only occurs on one side of the head in about every second person affected. The other explanation sees the origin of the word in the Latin “migrare”, which means “to wander”, “to move around”. This theory is obvious because in all phases of migraine there is a phenomenon that we have already encountered with the aura: that of a gradual spread or migration. In the aura phase, for example, the tingling sensation starts in the fingertips and slowly spreads like the dawn in the sky from there over the entire arm to the tongue.

Pain is a restless wanderer

The same phenomenon occurs in the headache phase. Because the pain can also migrate: at the beginning of the attack, for example, it can be diffusely distributed from the neck over the entire skull, and then over the course of the attack it can sometimes be in this, sometimes in that part of the head - also, for example, in the lower part of the head. and upper jaw – to express. At the climax of the attack, however, it can be felt at its individually different main location, only to retreat back to the starting point with various intermediate stations as the attack continues.

During its migration, the character of the pain is often subject to change. At the beginning and towards the end of the attack it can be dull, pulling or pressing - very similar to a tension-type headache. At the apex of the attack, however, when the pain has taken on its main location, it almost always corresponds to the typical migraine pain with its pulsating character and reaches an intensity that is far above that usual for tension-type headaches.

The migraine attack (painting by Dr. Angelika Demel)

Every movement increases the pain

It is also very typical of migraines that the pain gets worse with every movement. Those who suffer from tension-type headaches may find relief with a walk in the park or a little exercise. Not so for the migraine sufferer: any physical exertion, even if it's just going to the toilet, makes the pain even more unbearable. The same goes for sneezing, coughing or vomiting. This characteristic of migraine pain is so typical that it can also be used to differentiate it from other types of headaches.

Duration and frequency of attacks

The actual pain phase of a migraine can last from four to 72 hours. However, in most cases the pain goes away after about a day. “Only” about ten percent of patients actually suffer from excruciating pain for up to three days. If the attack lasts longer than three days, it is referred to as “status migraenosus” (permanent migraine-like condition). However, this is not the norm, but rather a complication of “normal” migraines.

On average, migraine sufferers suffer from one to two attacks per month. Only around eight percent of those affected have more than three attacks per month. However, the frequency of seizures in the same person can vary greatly over time. There can certainly be phases in which the frequency of attacks decreases significantly, others in which it increases.

Accompanying symptoms are an additional burden

One of the particularly characteristic accompanying symptoms of a migraine attack is nausea, which - depending on the study - affects 65 to 95 percent of those affected. Vomiting occurs in almost 50 to 60 percent of attacks. The remaining patients – those who do not suffer from nausea or vomiting – at least have no appetite. It should be noted that patients understand “nausea” to mean very different things. Some, for example, equate nausea with vomiting, others understand it as a reluctance to eat or pressure in the stomach area. These different terms alone result in the range of typical accompanying symptoms from loss of appetite to vomiting, which also includes heartburn, flatulence and abdominal pain. What is certain is that no migraine patient experiences cravings for certain foods during an attack. This only occurs during the pre-symptom phase.

When caressing becomes torture

A general hypersensitivity of the senses is also very typical for a migraine attack. It usually manifests itself in hypersensitivity to light and/or noise. 61 to 98 percent of patients complain about a strong aversion to loud noises alone. But the aversion can also relate to smells, so that they feel nauseated even when perfumes are applied subtly. An aversion to touching is also common. Even if the partner's compassionate caressing is meant in a nice way, the migraine sufferer can find it to be terrible torture.

It is interesting that the severity of the accompanying symptoms is directly related to the intensity of the pain. In other words: the worse the accompanying symptoms, the worse the pain and vice versa.

Other possible accompanying symptoms

In addition to these typical accompanying symptoms, other symptoms can also occur:

  • The facial skin appears extremely dull and pale during the attack. The cheeks are sunken, the skin looks dry, tired and withered.
  • The eyes may lose their shine and begin to water. Overall they appear lifeless and sunken.
  • The throbbing, pulsating pain can also occur in the sinus area or nasopharynx. Some patients experience excessive production of nasal secretions, which can lead to nasal congestion. The opposite can also occur: a dry nose and burning nose.
  • During attacks, the whole person suffers - not just physically, but also psychologically. Negative moods such as depression, anxiety, anger and others gain the upper hand, pushing positive moods such as self-confidence and forbearance into the background.
  • Some patients experience weight changes because fluid intake and excretion are altered.
  • Some patients begin to shiver, freeze, tremble, or sweat during attacks. It is unclear whether this is accompanied by an actual change in body temperature or whether it is “just” a subjective perception of those affected.

After the pain, the migraine is not over

Once the migraine headache subsides, the attack is not yet over. Almost all patients subsequently suffer from severe exhaustion, tiredness and fatigue for up to a day or two, as well as the desire to be alone with themselves.

In addition, there is often increased sensitivity to pain. For example, combing your hair can be extremely painful or you can experience stabbing pain in the head area (so-called “ice pick headache”). All in all, most patients need a period of rest with plenty of sleep after an attack.

The images on this page were created by the doctor Dr.med. Angelika Demel, Günzburg, kindly provided. She uses this to illustrate her own migraines.