The Pain That's More Than Just a Headache
I used to think migraines were just really bad headaches. Then I got my first one, and I realized how wrong I was.
It started with seeing zigzag lines in my vision while I was driving. Twenty minutes later, I was in bed with the worst headache of my life, nauseous, and unable to tolerate even the dimmest light. I couldn't work for two days.
"That's a classic migraine," my doctor told me later. "And those visual disturbances you experienced? That was an aura—a warning sign many people don't recognize."
Migraines affect over 1 billion people worldwide, making them the third most common disease globally. Yet many people don't realize they're experiencing migraines because they don't know what to look for beyond head pain.
What Makes a Migraine Different From a Regular Headache
"A migraine is a complex neurological condition, not just a severe headache," explains Dr. Jessica Ailani, MD, a neurologist and director of the MedStar Georgetown Headache Center. "It involves changes in brain activity that can affect your entire body."
The Key Differences:
Regular Tension Headache:
- Dull, steady pressure or tightness
- Affects both sides of the head
- Doesn't worsen with activity
- No nausea or vomiting
- Lasts 30 minutes to a few hours
Migraine:
- Throbbing or pulsing pain (often one side)
- Moderate to severe intensity
- Worsens with physical activity
- Often includes nausea, vomiting, and sensitivity to light/sound
- Lasts 4-72 hours if untreated
But here's what most people don't know: The headache is just one part of a migraine attack, which progresses through distinct phases.
The Four Phases of a Migraine Attack
Phase 1: Prodrome (The Warning Phase)
This phase can start 24-48 hours before the headache hits. Many people miss these early warning signs:
Common prodrome symptoms:
- Food cravings (especially for sweets)
- Mood changes (irritability, depression, or euphoria)
- Neck stiffness
- Increased urination
- Constipation or diarrhea
- Excessive yawning
- Fluid retention
"If you can recognize your prodrome symptoms, you have a window of opportunity to take medication early, which is often more effective," Dr. Ailani notes.
Phase 2: Aura (The Neurological Phase)
About 25-30% of people with migraines experience auras—temporary neurological symptoms that develop gradually and last 5-60 minutes.
Visual auras (most common):
- Seeing zigzag lines, stars, or flashing lights
- Blind spots in your vision
- Tunnel vision
- Temporary vision loss
Other auras:
- Numbness or tingling, usually starting in the hand and spreading
- Speech or language difficulties
- Muscle weakness on one side
- Ringing in the ears
Important: These symptoms can mimic a stroke. If you're experiencing them for the first time, seek immediate medical attention to rule out something more serious.
Phase 3: Headache (The Attack Phase)
This is what most people think of as "the migraine"—but the characteristics can vary:
Common features:
- Moderate to severe throbbing pain
- Usually on one side of the head (but can be both)
- Worsens with movement or physical activity
- Accompanied by nausea and/or vomiting
- Extreme sensitivity to light (photophobia)
- Extreme sensitivity to sound (phonophobia)
- Sensitivity to smells (osmophobia)
"Some people have migraines without headache—called silent migraines or acephalgic migraines," Dr. Ailani explains. "They experience the aura and other symptoms without the pain phase."
Phase 4: Postdrome (The "Migraine Hangover")
After the headache subsides, many people feel wiped out for 24-48 hours.
Postdrome symptoms:
- Extreme fatigue
- Difficulty concentrating ("brain fog")
- Weakness
- Mood changes
- Dizziness
- Continued sensitivity to light and sound
"This phase is often overlooked, but it can be just as debilitating as the headache itself," says Dr. Ailani.
The Symptoms People Most Often Miss
1. Allodynia (Skin Sensitivity)
During a migraine attack, even light touch can feel painful. Brushing your hair, wearing earrings, or resting your head on a pillow becomes uncomfortable.
"Allodynia suggests that the migraine has become more established," Dr. Ailani notes. "It's a sign that you should take medication quickly."
2. Brain Fog and Cognitive Issues
Many people experience difficulty thinking clearly, problems with word-finding, or trouble concentrating during and after a migraine.
3. Sinus Pressure
"Many people think they have sinus headaches when they actually have migraines," Dr. Ailani explains. "Migraines can cause nasal congestion and facial pressure, leading to misdiagnosis."
If your "sinus headaches" come with nausea, light sensitivity, or throbbing pain, they're likely migraines.
4. Gastrointestinal Symptoms
Nausea and vomiting are well-known migraine symptoms, but migraines can also cause:
- Diarrhea
- Loss of appetite
- Stomach pain
- Constipation
5. Mood Changes
The depression, anxiety, or irritability you feel might not be separate from your migraines—they might be part of the prodrome or postdrome phase.
Common Migraine Triggers (and How to Identify Yours)
Triggers vary from person to person, but these are the most common:
Dietary triggers:
- Alcohol (especially red wine)
- Aged cheeses
- Processed meats with nitrates
- Artificial sweeteners
- MSG
- Caffeine (both too much and withdrawal)
- Skipping meals
Environmental triggers:
- Bright or flickering lights
- Strong smells (perfume, smoke, cleaning products)
- Weather changes (especially barometric pressure drops)
- Loud noises
Lifestyle triggers:
- Poor sleep (too little or too much)
- Stress (or the "let-down" after stress)
- Dehydration
- Intense physical exertion
- Hormonal changes (menstruation, menopause)
Keeping a migraine diary is the best way to identify your specific triggers. Track:
- Date and time of attack
- What you ate in the 24 hours before
- Sleep quality and quantity
- Stress levels
- Weather conditions
- Where you were in your menstrual cycle
- Any medications taken
When to See a Doctor
You should see a healthcare provider if you:
Definitely see a doctor:
- Experience sudden, severe headache ("thunderclap headache")
- Have a headache after a head injury
- Notice a change in your typical migraine pattern
- Experience headaches that progressively worsen
- Have new neurological symptoms
- Are over 50 and experiencing your first migraine
Consider seeing a specialist if:
- Migraines occur more than 4 times per month
- Over-the-counter medications aren't working
- Migraines significantly impact your daily life
- You're using acute medication more than 2 days per week (risk of medication overuse headache)
Treatment Options That Actually Work
Acute Treatment (Stopping an Attack)
Over-the-counter options:
- NSAIDs (ibuprofen, naproxen) taken early
- Combination medications with caffeine
- Aspirin
Prescription options:
- Triptans (sumatriptan, rizatriptan) - most effective when taken early
- CGRP antagonists (ubrogepant, rimegepant)
- Ergotamines (for severe attacks)
- Anti-nausea medications
"The key to acute treatment is taking medication at the first sign of a migraine, ideally during the prodrome or early headache phase," Dr. Ailani advises.
Preventive Treatment (Reducing Frequency)
If you have 4+ migraines per month, preventive medication might be recommended:
- Beta-blockers (propranolol, metoprolol)
- Antidepressants (amitriptyline)
- Anti-seizure medications (topiramate, valproate)
- CGRP monoclonal antibodies (erenumab, fremanezumab) - newer, very effective
- Botox injections (for chronic migraines)
Non-Medication Approaches
Research supports these lifestyle strategies:
- Regular sleep schedule: Go to bed and wake up at the same time daily
- Consistent meals: Don't skip meals
- Hydration: Aim for 8 glasses of water daily
- Regular exercise: Moderate aerobic activity, but avoid sudden intense workouts
- Stress management: Meditation, yoga, cognitive behavioral therapy
- Magnesium supplementation: 400-600mg daily (ask your doctor first)
- Riboflavin (vitamin B2): 400mg daily may reduce frequency
Living Well With Migraines
Having migraines doesn't mean accepting constant suffering. Here's what helped me:
- I learned my triggers and avoid them when possible (for me: red wine, skipping breakfast, and poor sleep)
- I take medication early, at the first sign of an aura
- I have a "migraine kit" ready: medication, eye mask, ice pack, ginger tea
- I practice good sleep hygiene religiously
- I stopped feeling guilty about canceling plans when I have an attack
Most importantly, I found a neurologist who specializes in headaches. General practitioners mean well, but specialists have more treatment options and experience.
Your Migraine Action Plan
This week:
- Start a migraine diary tracking potential triggers
- Schedule an appointment with a doctor if you haven't already
- Create a "migraine kit" with medication and comfort items
- Set up a consistent sleep schedule
This month:
- Identify your top 2-3 triggers
- Try one preventive lifestyle change
- Discuss treatment options with your doctor
- Consider seeing a headache specialist if needed
Migraines are a real, complex neurological condition—not just "bad headaches" or something you need to "push through." You deserve proper diagnosis and treatment. Don't ignore the symptoms. Pay attention, track patterns, and advocate for yourself.
Your brain is trying to tell you something. It's time to listen.
