There is no one-size-fits-all Migraine. Sometimes a patient will have symptoms that are so unique to appear as though it is not migraine at all. Perhaps you have migraine or know someone who does. To borrow a phrase from autism advocacy…
If you’ve met one migraineur, you’ve met one migraineur.
That’s how different we are. Even if you didn’t count our personalities, talents, weaknesses, family history, social environment, and all the things that make everyone unique we’re still an eclectic group.
The ICHD-3 is the gold standard for headache disorder diagnosis. It lists a few hundred different headache disorders and outlines the diagnostic criteria for all of them. For the purpose of this post, only a few migraine diagnoses will be addressed.
Migraine with aura
Patients experience an aura (most typically visual) 15-60 minutes before the onset of pain. Although this is the most widely known type of migraine, fewer than 25% of all migraineurs experience aura. The pain phase usually lasts 4-72 hours and may be accompanied by light and sound sensitivity, nausea, vomiting, fatigue, and more.
Migraine without aura
These patients do not experience aura, but may be able to identify prodrome symptoms that occur 24-48 hours before the onset of pain. These symptoms give the patient an early warning. Some are even able to abort an attack before the pain starts by recognizing their prodrome symptoms. The pain phase is the same duration as Migraine with aura as are the associated symptoms.
This is not a diagnosis, but a descriptor. Patients with either type of migraine are categorized as Episodic if they experience 14 or fewer attacks per month. Obviously there is a wide range. Some patients, like my father, only get attacks once or twice a year. On the other end are patients like I was prior to 1999 who routinely get close to 14 attacks every single month.
When a patient has 15 or more headache days per month and at least 8 of them are migraine attacks lasting 4 or more hours, then doctors begin to suspect Chronic Migraine. There are a number of headache disorders that mimic Chronic Migraine. These must all be ruled out before a diagnosis can be made. As with Episodic migraine, patients vary in the number and type of attack experienced. Some barely meet the criteria with just 15 or 16 attacks per month while others are never pain-free.
Medication Overuse Headache
One such headache disorder is Medication Overuse Headache. It is not Migraine, but looks like Chronic Migraine. The key differentiator is whether or not the patient is routinely taking pain medicine more than 10-15 days per month. Medication overuse headache must be ruled out before a diagnosis of Chronic Migraine can be made. This means that patients must undergo 8-12 weeks without any pain medicine to determine if that improves their situation. Once treated successfully, some patients revert back to Episodic Migraine. This was the case with me back in 1995.
This type of migraine is very unique in that stroke-like symptoms precede and accompany the acute phases. Most patients experience tingling, numbness, and even one-sided reversible paralysis. Stroke and TIA must be ruled out as part of the diagnostic process.
Treatment needs vary
Some patients do just fine treating the occasional migraine with OTC pain medicines like naproxen, ibuprofen, or Excedrin. Others cannot find relief with any medicines and seek help from nerve blocks, Botox injections, neurostim implants, or even surgery to remove nerve endings. Many patients require preventive medications to reduce the frequency and severity of attacks. Yet others do not need this. There are hundreds of available treatment options. Migraine management is as eclectic as the patients it serves.
Migraineurs, be nice!
Even though many migraineurs understand there are differences, it is still common to hear someone say, “She must not really have migraine.” when hearing the description of someone else’s symptoms. This type of comment is insensitive and ego-centric. Just because one migraineur’s symptoms don’t match another’s doesn’t mean their diagnosis isn’t correct. We’ve all had people question our truthfulness. The accusation that we are faking it to get attention or avoid unpleasant tasks has been leveled at all of us at least once. So please, don’t do that to one of your own.