S2:Ep18 – Differentiating Four Headache Disorders



Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease. This episode is brought to you by our generous sponsor, Teva Pharmaceuticals.


Headache specialist Dr. Shivang Joshi breaks down the differences between migraine, tension headache, new daily persistent headache, and cluster headache. He explains the characteristics, diagnostic criteria, and treatments for each disorder, as well as how to determine if someone is experiencing more than one headache disease.


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Molly O’Brien: Hello, and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. 


The Association of Migraine Disorders focuses primarily on migraine. Today we’re taking a step back from that and looking at headache disorders in general. To help us understand this and much more, I’d like to introduce our guest. He’s a board-certified neurologist and headache specialist. He’s also a pharmacist. I’d like to introduce Dr. Shivang Joshi.


Thanks so much for being with us today.


Dr. Shivang Joshi: It’s a pleasure to be here. 


Molly: Always good to see you, and I’m excited to dive into this topic. So we know that there are two types — broad types — of headache disorders: primary and secondary. Can you tell us a little bit about what the classifications mean?


Dr. Joshi: Absolutely. So this is very useful for neurologists, headache specialists, or even primary care. It’s the first initial approach when a patient walks into your office. You want to figure out is this a primary headache disorder or secondary headache disorder. The reason is a primary headache disorder is going to be treated a little bit differently than secondary headache disorders. Usually secondary headache disorders require further workup. So the term secondary headache disorder is referring to the fact that your headaches are caused by something else, such as a brain tumor or an infection or other systemic illnesses. So those are called secondary headache disorders.


Of the primary headache disorders, the migraine is the most common one. Other primary headache disorders include tension-type headaches, something called trigeminal autonomic cephalalgias, is another type of primary headache disorder. Within that, there’s cluster headache, which I think we’ll talk about later on as well too. 


But there are other primary headache disorders as well. Some of them include headaches that are associated with exertion or sexual activity, or there’s something called new daily persistent headache. So there are many different primary headache disorders, of which migraines are the most common one.


Molly: And you mentioned some other common ones as well, but there are many types of primary headache disorders. Can you tell us a little bit more about the most common primary headache disorders and explain how they differ from migraine?


Dr. Joshi: Absolutely. And this is important to recognize because it affects treatment. So a quick and easy way to differentiate, let’s say, migraines from tension-type headache is that the migraine is going to be a headache that’s usually one-sided, with a throbbing pain, sometimes behind the eyes. It may switch from one side to the other side. And there are other features that may be associated with a migraine, such as nausea or light sensitivity or patients want to lay down and not sort of move. And these headaches can last anywhere from 4 to 72 hours in adults. And there are many triggers for these headaches, including weather changes, hormonal changes, a lot of factors that are involved with migraines.


Now, tension-type headaches — quite often patients, when you tell them, “You have tension-type headaches,” they immediately say, “Oh, do you think it’s related to stress?” So the word tension-type headache is primarily being referred to the quality of pain that the patient is referring to. So a tension-type headache is going to be a pressure-like pain that’s located in the temporal area, sometimes the frontal area, usually both-sided, and patients will describe it as a pressure-like or squeezing-type of pain. It doesn’t necessarily have to have all the other features that I mentioned that migraine patients have, which is the nausea and the light sensitivity. So that’s how you differentiate between those two.


The TACs, which is short for “trigeminal autonomic cephalalgias,” include headaches like cluster headaches. Now, another common misconception is patients will have three or four migraine headaches in a row, and sometimes people will call those “cluster headaches” because they’re clustering migraines together. So patients will come in saying, “Oh, I have a diagnosis of cluster migraines,” which is not really a real diagnosis. 


Quite often, patients will go to the emergency room with migraines, and they may have something called “autonomic features.” So autonomic features is referring to things like tearing of the eyes, redness of the eyes, or droopiness of the eyelids. Those qualities that I just mentioned are more common in the TACs. For example, a cluster headache patient may have those symptoms in addition to the severe pain that they get. But it’s not unusual for migraine patients to also have that. They might go to the emergency room, and they falsely diagnosed with cluster headache when it’s not.


So one important thing to distinguish between cluster headache and, let’s say, migraine headache — one easy trick is that migraine patients — remember, tension want to lay down and not move and rest, whereas cluster patients will be pacing, they’re agitated, and they want to bang their head on the wall. So cluster headaches are unique in that they occur specifically at certain times during the day, certain times during the season. And most times, during the day they occur around one o’clock or two o’clock in the morning. They wake patients up. And more likely, cluster headache suffers are male, versus a migraine patient tends to be more female. So those are some of the differences between cluster headaches, tension headaches, and migraine headaches.


Molly: Can you tell us as well a little bit about those new daily persistent headaches?


Dr. Joshi: Right, that’s a very good question. So I think not a lot of people know about this. So it is what it sounds like. It’s a new headache, and it’s daily, and it’s persistent. So it started on one specific day, and most patients will tell you, “I remember this headache started when I was sitting on the couch, watching TV. I had a headache, and I’ve had a daily headache since then.” 


So the way we look at a new daily persistent headache is, What does it present with? What are the symptoms? So, for example, if a new daily headache presents with tension-type features, we call it a new daily headache with tension-type headache features. So the word phenotype refers to how the headache presents clinically. So let’s say if a new daily headache presents as a migraine and they’ve had a migraine since then, so then it’s a new daily persistent headache but with migrainous features. So that’s what we call it, okay?


The way we treat it is how it presents. The unique thing about new daily persistent headache is that it tends to occur before some kind of either an emotional event, sometimes surgical event, or a stressful life event can be a triggering factor. And there’s not that much we know about new daily persistent headache. It’s still an area there’s a lot of gaps in terms of what causes it, what are the mechanisms. 


So one important thing about a new daily persistent headaches and any persistent headache is that you have to consider getting imaging like an MRI of the brain to figure out if there’s any secondary things that are causing that.


Molly: Thank you for helping us understand all this. It’s a lot of information to break down and fascinating to learn as a migraine patient myself. 


We did have a viewer question for you as well. You talked a little bit about some of those symptoms, like if you go into the ER and you’re presenting with slight drooping or pain. Can you tell us a little bit about the difference between maybe a migraine with that eye pain, pressure, and drooping versus the actual cluster headache? Because for some people, it can be confusing, and that’s what this viewer would like to know.


Dr. Joshi: Absolutely. And one thing to note about a migraine is that the pain is going to be throbbing. It will be behind your eyes. But a cluster headache pain that is behind the eyes, it’s going to be extremely severe and debilitating to the point where a cluster headache pain, they want to gouge their eyes out or take a spike and put it through their eyeball. And you might feel like that’s your severe pain. Certainly, migraine patients can have severe pain. But, in fact, the pain associated with a cluster headache is even more severe. 


Now that you’re not able to gauge that yourself, another thing to look for is that the cluster headache is only going to last about 180 minutes, okay? It’s a strange headache that lasts anywhere from 30 minutes to 180 minutes, and it just stops. There might be several attacks that occur during the day of cluster headaches. The majority of them occur at nighttime. 


So the questions I would ask to differentiate between the migraine pressure pain and the autonomic features versus a cluster headache is how is the severity, what time of the day does it occur, how long does it last for, and what are you doing during the attack? Cluster patients are wanting to pace and not rest. So those are some of the things that you want to look at that clearly differentiate. 


Plus if you’re a male and you’re a smoker, these are the things that are said to go along with cluster headache presentation. One interesting thing is that cluster headache patients also tend to have hazel eyes or light-colored eyes. So it’s one of those things that’s out there in research, and it’s interesting that I have a seen a lot of patients that do have that. But whether or not that holds true in the long run, it’s hard to say. But there is a cluster phenotype of how patients present. Sometimes cluster patients are noted to have a rough-looking face. They tend to be very analytical. So these are some of the other traits that have been studied over time.


Molly: So at the beginning of this, you said that it was very important to know about the different classification because of treatment. So can you talk to us a little bit about how treatment differs from migraine versus other headache disorders?


Dr. Joshi: Absolutely. And the other reason why the classification system is important — actually, the reason why the classification system was created was to facilitate research, right? So if you didn’t have a formalized diagnosis, how can you collect data on those patients and do research? So the main purpose of the classification system is to allow for research to be conducted in specific headache or migraine characteristics.


Now, the interesting thing about the classification system is that in the appendix, they put some things in there that are rare cases of headaches. They want to throw it out there. For example, airplane headache was in there for some time. There’s ice cream headache, headaches associated with travel to space, all these rare sort of headache disorders. But if enough people see it and say, “Wait a minute, I’ve had airplane headaches,” and you collect data on that, then it becomes part of the sort of the main diagnostic criteria. So research is very — purposes of research is why the diagnostic criteria was created.


In terms of treatment, it’s important to recognize the diagnosis first because there are acute treatments, there are preventative treatments, right, and there are acute and preventative treatments that involve medications. So typical medications for acute treatment of migraines include triptans. There are multiple different types of triptans. There are some that are longer acting, shorter acting, and sometimes we can use some of the longer-acting triptans for people who have migraines around their menstruation. There’s ways to do that as well.


There are newer medications call gepants. They target something called calcitonin gene-related peptide receptors, so these are small molecules, and they are very new, and they’re effective. There’s another new class of medications called ditans. So there’s a lot of new buzz with acute treatment available now.


There also have been some advances in preventative medicines, right? So the new monoclonal antibodies, these are highly specific medicines that are developed that are antibodies to bind something called CGRP, and they’re usually once monthly and preventive. So once you’ve identified that this patient has a migraine, the next step is to identify is it an episodic migraine or is it a chronic migraine, right? Because there are some other medications that are available for chronic-migraine patients. For example, onabotulinumtoxin is available and approved for chronic-migraine patients. So differentiating between episodic and chronic is going to be important. 


Also there are other features of a migraine. Sometimes people have aura, which is most commonly flashing lights or zigzag lines or things like that. I find magnesium, which is a natural supplement, to be very effective in patients who have migraine with aura, so that’s something natural.


So you can see that there’s so many things that we can do depending on how your migraines present. Is it with aura? Is it without aura? Do you have autonomic features? Do you have migraines around your period? Migraines in general improve during pregnancy. It’s because estrogen is a protectoral. During perimenopause, they tend to get worse because of just estrogen fluctuation. So sometimes we’ll have a conversation with our patients that are on birth control medications. If they’re on a very high dose of estrogen, this affects their treatment too. We may want to have them decrease their estrogen dose.


So treatment options for prevention and acute treatment are very dependent on the diagnosis, but we also talk about lifestyle modification, right? It’s a comprehensive, holistic approach. So we talk about sleep. Make sure you’re getting good sleep, right? No reading a book from the bed or watching TV from the bed, because that can actually stimulate your brain. We talk about are you clenching your teeth at nighttime. Do you snore at nighttime? Do you have sleep apnea? 


We talk about dietary triggers, including foods that contain nitrates or food that contains monosodium glutamate. Barometric pressure tends to be a trigger for migraine patients. So these things are very unique to migraine patients and not so unique to sometimes something like a tension-type headache patient or a cluster headache patient. 


And there are some unique things to cluster headache patients, which is the seasonality. So whenever there’s daylight savings time is sometimes when we see these cluster headache patients come in, because, remember, there’s an internal biological clock in the brain — the fancy word, it’s called the “suprachiasmatic nucleus,” but it’s just an internal clock — basically can sense when there’s less daylight or more daylight, and they will have cluster headache depending on these changes. 


So having a diagnosis is important so that you can differentiate between all these treatment options.


Molly: Are any of these types of treatments — you spoke a little bit about this — that work for migraine, do they work with other primary headache disorders, say, cluster or tension-type headache? And if not, what kind of treatment options are there available for those who have those other primary headache disorders?


Dr. Joshi: Absolutely. So there is an overlap, right? So for migraine headache prevention, they will use something called TCAs or something called amitriptyline or nortriptyline. These are also excellent and also first-line medications for tension-type headache, okay? So you could also use amitriptyline or nortriptyline for tension-type headache.


Now, with cluster headaches, they are also very responsive to sumatriptan, but primarily in the injection form. So there’s an overlap between migraine patients who use sumatriptan injections or triptan injection or a triptan nasal spray. They will be effective in cluster headache patients as well. Now, cluster headache patients also respond to oxygen, and the oxygen doesn’t tend to help migraine patients. 


So there are a lot of things within migraine treatment, acute and preventative, that can be used in cluster headache. In fact, the CGRP medications that I’ve mentioned, there is one drug call galcanezumab, which is approved both for cluster headache treatment as well as migraine prevention because the underlying mechanism has to do with CGRP. So there are some shared mechanisms with a lot of these headache disorders.


Remember, with new daily persistent headache, you’re treating the phenotype. So if the phenotype presents as a cluster headache, you’re treating it that way. If the phenotype presents as a tension-type headache, you’re presenting [sic] it that way. 


Now, another way to answer your question is that in migraine patients, we also treat with something called NSAIDs, which are nonsteroidal anti-inflammatory medicines like ibuprofen, diclofenac oral solution, indomethacin. These are anti-inflammatory medicines. But we also use them to treat tension-type headache as an adjunct. So ibuprofen can be used for treatment of tension-type headaches. 


There are some other — remember the TACs? Cluster headache is only one of the TAC. There are other TACs called hemicrania continua, which is very rare, and it basically is a headache on one side of the head that is continuous and that has these autonomic features, and it’s all day long, and it goes on. So indomethacin, which is an anti-inflammatory medicine that I mentioned, is a medicine that can be used for treatment of hemicrania continua, and people generally have a very, very good response, and that usually is a diagnostic indicator. So there’s a lot of overlap between treatments of triptans, between treatment of anti-inflammatory medicines, between CGRP medications that are preventative, and acute medications.


Molly: And it’s good to hear that old standards for migraine treatment are there, but we’re also getting new types of treatment options as well. So that’s exciting. And, again, for those types of headache disorders that don’t fall into the migraine category, some of those new medications can help as well. So it’s good to hear that.


As we move on here, as we kind of wind down, I’m curious if you can have any of these types of headache disorders overlapping?


Dr. Joshi: Absolutely. That’s a great question. And I think it’s an important question because there are a lot of women that may have mixed cluster and migraine headaches, but they may go throughout life with just a diagnosis of migraines. And they get diagnosed as migraines, but they are not looked as having cluster headaches as a separate entity. Part of that could be because migraines are just more common in women and the cluster headaches are more common in males. But what we’re learning throughout the last several years that there are actually more and more women who do have cluster headaches but just haven’t been diagnosed.


So there is that migraine-cluster overlap. These patients will be able to clearly tell you a difference between their cluster headaches and their migraine headaches based on the clinical profile that I mentioned before.


Now, another very important overlap is migraines and tension-type headaches, okay? And the reason why this is important is that there is different phases of a migraine, okay? And this is important for the audience. There is the prodrome phase, which not too many people know about. This phase occurs even before the actual aura phase or headache phase. So in the prodrome phase, which can occur anywhere from 12 to 72 hours before an actual headache phase, patients may complain of yawning a lot, peeing a lot, mood changes, neck stiffness, craving salty or sweet foods. That’s your early warning indicator that you may have a migraine coming. Part of that could be related to a part of the brain called the hypothalamic region, which is getting activated, causing these symptoms, okay? 


So you have that early warning phase, and you have aura phase, which is the flashing lights and the zigzag lines, and then you have the headache phase. But here’s the important caveat here, and this brings me to my point, that once you have the full-blown migraine, the next day there’s something called the hangover phase or the postdrome. It feels like you have a hangover or you got hit by a Mack truck. You might not have all the migrainous features, but you feel just like blah, and you feel achy. 


So a lot of patients will have that for a few days, and they will consider it as a separate headache, right? They might even consider it as a tension-type headache. So the older way of thinking was, okay, the migraine is the day where you have the throbbing headache, and that next day, when you don’t really have the throbbing pain but you just have a little ache and you feel maybe a little bit of nausea, that’s a tension-type headache. 


The new way of thinking is that that “tension-type headache” is part of the same spectrum of a migraine. I like to call it a baby migraine. So you have a full-blown migraine; you have a baby migraine just waiting to become a full-blown migraine based on triggers. So there is an overlap there, and part of that gives you a little bit of diagnostic questioning. So it’s important for patients to know that if they have a tension-type headache a few days after their migraine, it’s mostly part of their migraine, and it’s probably a baby migraine waiting to turn back out.


Molly: So, Dr. Joshi, you’re a physician and an educator. What else do you think needs to be done to improve the way that headache disorders are diagnosed?


Dr. Joshi: It’s a very important area. I think that with the 39 million people that suffer from migraines in the United States alone — worldwide it’s a huge amount as well too — I think that primary care education is very important. A lot of these patients are going through life with the diagnosis of “sinus headaches” or diagnosis of a tension-type headache. 


And by asking the right questions — for example, there’s an association between infantile colic later developing into migraines. And so if you’re able to elicit those things and ask those questions about family history, then most likely, that sinus headache that occurs one time during the month during the menstruation and it’s affected by weather changes is probably not just a sinus headache. A lot of these patients go through their life, and finally when they see an ENT doctor, they do a scan of the sinuses, and it’s all clear, and they wind up being sent to a neurologist or headache specialist.


So I think education with primary care is very important. I think if we can identify these earlier on in adolescent age, we can decrease the burden that patients suffer from migraines throughout their life. So education’s going to be very important. I think that educating primary care from a clinical point of view, but also even going back further to medical-school education, because a lot of the old textbooks are very outdated. 


And if I could go and give the lecture on updated migraine pathophysiology and treatment to my medical school, I would do it, or other medical schools. And they still talk about it as a blood vessel disease. So I think by starting out that way, you kind of bring that into your training and clinical practice, so we need to really go down to the grass roots of residents, fellows, and then also reinforce it later on in primary care.


Molly: I think those are all excellent steps to take.


Well, big thank you to Dr. Shivang Joshi for joining us here today. We really appreciate your time.


Dr. Joshi: You’re welcome.


Molly: And now we’ll wrap things up here on Spotlight on Migraine. I hope you enjoyed this conversation. If you want to learn more about migraine or other headache disorders, you can head over to our website at MigraineDisorders.org. 


Thanks so much for joining us today, and until next time, this is Spotlight on Migraine, and I’m Molly O’Brien. 




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