Distinguishing a Migraine From a Headache

Peter L. Salgo, MD: Migraine is a prevalent neurological disease, affecting 39 million men, women, and children in the United States and 1 billion people worldwide. Migraine is the third most common illness in the world, with approximately 12% of the population suffering from migraine. Migraine, defined as a painful, neurological disease with extremely incapacitating neurological symptoms lasting for 4 to 72 hours, is much more than a headache. Over 90% of migraine sufferers are unable to work or function normally during an attack.

Recently, there have been some exciting advances in the diagnosis and treatment of migraine. This AJMC^® Peer Exchange, with our panel of experts, is going to discuss the optimal management of migraine, including the role for newer, more specific therapeutic options. Stay with us.

I’m Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

Joining our distinguished panel to share their perspectives are: Ms. Jill Dehlin, a registered nurse, certified health education specialist, and patient advocate; Dr Peter Goadsby, director of the NIHR/Wellcome Trust King’s Clinical Research Facility and a professor of neurology at King's College London and the University of California, San Francisco; and Dr Malaika Stoll, senior medical director of Blue Shield of California.

All of you, thank you so much for joining us. Why don’t we just dive right in? I think we ought to get going by defining some terms. What is a migraine?

Peter Goadsby, MD, PhD: A migraine is an episodic disease of the brain that involves dysfunction, fundamentally, in sensory pathways. It involves pain, sensitivity to light, and sensitivity to sound. For two-thirds of patients, it’s sensitivity to light to just touching the head. Migraine is a pan-sensory disturbance, if I could put it that way.

Peter L. Salgo, MD: It sounds dreadful.

Peter Goadsby, MD, PhD: It is dreadful.

Peter L. Salgo, MD: Just for the sake of completeness, how does a visual migraine differ from that…from the visual disturbances without the other epiphenomenon?

Peter Goadsby, MD, PhD: About 25% of migraine sufferers have aura. It’s typically visual. It usually involves little jagged white lines that start in one part of the vision and then expand, leaving a loss behind—the so-called scotoma, or black spot. And then, over the course of about 30 to 60 minutes, it will completely dissipate. That’s the typical visual aura.

Peter L. Salgo, MD: We define migraine in terms of how bad it is. How does it differ, first of all, from a classic headache? All the time, I have patients who tell me, “Man, my headaches are just killers.” What’s the difference?

Peter Goadsby, MD, PhD: I think the big difference is that there are headaches with just pain, and there are headaches with pain and other things. A migraine, in essence, is a disabling headache. In this country, most patients who go to see a primary care physician for headache, more than 90% of them—94%, in fact—will have migraine. Migraine drives you to see the doctor and stops you from having a normal life, if I compare that to tension-type headaches, which have no other features and don’t tend to lead patients to doctors and stop them from doing anything. Most people, when they say, “I’ve got a bad headache,” usually mean that it’s severe or is stopping them from doing things. And, in the generality of things, most of them have migraine.