What Is a Migraine

Many people consider a migraine to be a really bad headache. The truth is, it is a severe, neurologic condition. However, when perusing the medical literature, it becomes apparent that the term ‘migraine’ in many practical instances, is actually a name that we have given to a constellation of symptoms as opposed to a specific medical issue with a specific, identifiable cause.

If you go to WebMD or the Mayo Clinic or just Google the term “migraines”, what you’ll consistently find is that they are defined as very severe headaches. You’ll also find that they have all sorts of descriptive characteristics.  For example, they mostly affect women between ages 25 to 55, and can last anywhere from 4 to 72 hours, etc. Migraines typically have 4 phases:

  1. Prodrome - where people start to feel a bit off before their head pain sets in
  2. Aura – a period during which some patients experience symptoms such as flashing lights, unusual smell and sound sensitivity, etc.
  3. Headache - the actual experience of head pain; however, there are acephalalgic (i.e. painless) patients or atypical expressions of this stages where people experience, for example, primarily nausea and dizziness without the head pain
  4. Post-drome - which is akin to a post-seizure state during which the actual head pain has either abated or gone away, but the patient is left with acute after-effects such as drowsiness, confusion and/or irritability

While we have a broad range of characteristics that describe these headaches, at the end of the day, the question that migraine sufferers most want answered is ‘What causes them?’ In most cases, we don’t really know. This fact is demonstrated by the sheer number of medications and numerous classes of medications that are used to treat migraines. Examples of the latter include anti-seizure medications, pain medications, muscle relaxants, neuroleptics, antidepressants, serotonin-modulating drugs (like all the triptans), the new range of CGRP receptor antagonists and several others.  Generally speaking, in life as well as in medicine, when there are multiple different ways of treating a problem, one can rest assured that not one of those methods is supremely effective, otherwise everyone would be using it. I say to my patients that two most important questions for any diagnosis is to figure what is causing that problem and if you can figure that out, what can you do about it.

Peripheral nerve surgeons treat headaches differently when compared with the traditional way physicians are taught to think about these problems. We focus on specific peripheral nerve triggers that might be causing your headache.  Hence when we use the term occipital (meaning back of the head) neuralgia (meaning nerve pain), the real question is: “Can you figure out which ‘neur’ (i.e. nerve) is causing the ‘algia’ (i.e. pain). That is the crux of the diagnostic work up when a patient comes to see me for this issue.  At the end of the evaluation, with the help of a thorough history, physical examination and set of peripheral nerve blocks, I will have a much better sense of which nerve or nerves might be involved in your headache symptom complex and whether or not surgical intervention might be of benefit. 

The take home message is that the term “migraine” is often very non-specific and not often helpful.  While people with headaches caused by pinched nerves in the occipital area technically have “migraines” from a purely definitional standpoint, the more accurate diagnosis is ‘occipital neuralgia’ or even more specifically greater (and/or lesser, third) occipital neuralgia.  The reason the latter diagnosis is more useful is that it points to a specific cause which can be treated.  That is the reason we have these diagnostic terms in the first place.