Headache and Migraine: Diagnosis and Treatment
Headache is one of the most common neurological problems. For some people it is an occasional symptom, while for others recurrent attacks affect work, sleep, family life and everyday activity. The first task is not simply to relieve the pain, but to understand what type of headache is present and whether there are reasons to investigate a secondary cause.
Headache disorders affect billions of people
According to the World Health Organization, headache disorders are among the most common neurological conditions worldwide.
What does your headache feel like?
Different headache disorders may feel completely different. The pattern of the attacks often helps determine which diagnosis should be considered first.
Migraine
Attacks lasting hours, often with throbbing or intense pain, nausea and sensitivity to light or sound. Physical activity may make the pain worse.
Migraine with aura
Temporary visual, sensory or language symptoms before or during a migraine attack. A first or unusual aura may require additional evaluation.
Frequent or almost daily headache
When headache becomes frequent, it is important to assess chronic migraine and possible medication-overuse headache.
Cluster headache, SUNCT and SUNA
Extremely severe unilateral attacks, often around the eye, with tearing, redness of the eye, nasal symptoms or marked restlessness.
Facial pain and cranial neuralgias
Brief electric-shock-like attacks, pain triggered by touch, chewing or talking, or other forms of recurrent facial pain.
Headache after head or neck trauma
A new headache developing after trauma may resemble migraine or tension-type headache, but the relationship to the injury matters.
New or unusual headache
A first severe headache, a sudden change in the usual pattern, neurological symptoms or systemic signs require a different approach.
Headache associated with neck tension
Pain may coexist with muscular tension and discomfort in the neck, but neck pain alone does not establish the cause of the headache.
Not every headache is migraine
Tension-type headache is usually described as pressing or tightening rather than pulsating. It is often bilateral and is generally not aggravated by routine physical activity.
Nausea is usually absent, although sensitivity to light or sound may occur. Episodic attacks are common, but in some people the headache becomes frequent or chronic.
What matters clinically
Migraine and tension-type headache can coexist in the same person. When headaches become frequent, the distinction between individual attacks may become less obvious.
A headache diary is often useful for understanding the real pattern.
Primary or secondary headache?
Primary headache
The headache itself is the neurological disorder. This group includes migraine, tension-type headache, cluster headache and other primary headache syndromes.
Secondary headache
The headache is caused by another condition: for example trauma, infection, vascular disease, increased intracranial pressure, medication or another disorder.
The purpose of the neurological assessment is not to perform as many investigations as possible, but to decide which headache syndrome best explains the symptoms and whether there are clinical reasons to look for another cause.
What is important before choosing headache treatment?
Establish the diagnosis
Migraine, cluster headache, neuralgia and secondary headache require different treatment strategies.
Count headache days
Frequency determines whether acute treatment alone is enough or preventive therapy should also be discussed.
Review acute medication use
Frequent use of analgesics or migraine-specific acute treatment may contribute to medication-overuse headache.
Review previous preventive treatment
The choice of the next treatment depends on what has already been tried, for how long and with what result.
Assess comorbidities
Sleep, anxiety, depression, blood pressure, vascular risk, other pain disorders and medication can affect treatment selection.
Set a realistic treatment goal
The aim is usually not an absolute guarantee that headache will never recur, but a meaningful reduction in frequency, severity and disability.
When should a headache be evaluated?
Recurrent migraine or headache, increasing attack frequency, ineffective acute treatment, frequent use of pain medication or the need to discuss preventive therapy.
A new pattern of headache, clear progression in frequency or severity, new headache after age 50, post-traumatic headache or unusual symptoms accompanying attacks.
Sudden very severe headache reaching maximal intensity rapidly, new weakness or numbness, speech or vision disturbance, impaired consciousness, seizure, fever with neck stiffness or severe headache after significant trauma.
Does every patient with headache need an MRI?
No. A typical long-standing migraine with a normal neurological examination does not automatically require repeated brain imaging.
MRI or another investigation becomes more important when the headache is new or atypical, changes its usual pattern, is accompanied by abnormal neurological findings or other warning signs.
In an acute emergency — for example a sudden thunderclap headache — the correct first investigation may be urgent CT and vascular imaging rather than a routine outpatient MRI.
How a headache consultation is structured
Headache history
When the attacks started, how they developed, their frequency, duration, location and character.
Associated symptoms
Nausea, light and sound sensitivity, aura, autonomic symptoms and neurological complaints.
Neurological examination
Assessment of the neurological status and signs that may suggest a secondary cause.
Review of previous tests
MRI, CT, laboratory tests and other investigations are interpreted in the context of the clinical picture.
Review of previous treatment
Acute medication, preventive treatment, effectiveness, tolerability and frequency of medication use.
Individual treatment plan
Acute treatment, preventive strategy, need for additional investigation and follow-up.
Treatment methods for migraine and headache disorders
Treatment of an acute migraine attack
Depending on the clinical situation this may include analgesics, NSAIDs, triptans, gepants, antiemetics or other migraine-specific approaches.
Preventive migraine treatment
Preventive treatment is considered when attacks are frequent, disabling or difficult to control with acute therapy alone.
CGRP-targeted therapy
Modern migraine-specific preventive options include monoclonal antibodies and gepants targeting the CGRP pathway.
Botulinum toxin for chronic migraine
OnabotulinumtoxinA is an established preventive treatment for appropriately selected patients with chronic migraine.
Medication-overuse headache
Treatment includes recognising excessive acute medication use, reviewing the acute treatment plan and introducing an appropriate preventive strategy.
Other headache syndromes
Cluster headache, trigeminal autonomic cephalalgias, cranial neuralgias and post-traumatic headache require diagnosis-specific treatment.
Headache is not only about pain intensity
The real burden of headache is often determined by how many days are lost because of attacks and how much the patient has to reorganise life around the possibility of another episode.
Frequent headaches may affect work, sleep, physical activity, family plans and social life. Some patients begin avoiding travel, meetings or exercise because they are afraid of provoking an attack.
For this reason treatment should assess not only pain intensity, but also headache days, disability, acute medication use and the patient's ability to live normally between attacks.
Useful treatment markers
- number of headache days per month;
- number of migraine days;
- severity and duration of attacks;
- days requiring acute medication;
- missed work or daily activities;
- overall effect on quality of life.
Headache treatment with Dr Lidiia Prakhova
Dr Lidiia Prakhova is a specialist neurologist with more than 35 years of clinical experience. Headache disorders and migraine are among the areas of her outpatient neurological practice in Israel.
The consultation is aimed first at establishing the headache diagnosis, assessing headache frequency and previous treatment, and then selecting an individual strategy.
Treatment options may include optimisation of acute treatment, preventive medication, CGRP-targeted therapy and botulinum toxin treatment for chronic migraine when indicated.
Frequently asked questions about headache and migraine
How can migraine be distinguished from an ordinary headache?
Does migraine always require an MRI?
When is migraine considered chronic?
Can frequent pain medication make headaches more frequent?
Which is better for chronic migraine: CGRP therapy or botulinum toxin?
Can cluster headache be treated in the same way as migraine?
Main medical sources
- World Health Organization. Headache disorders. WHO Fact Sheet. Global prevalence estimates based on 2021 data.
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38(1):1–211.
- American College of Radiology. ACR Appropriateness Criteria: Headache. Revised 2022.
- Charles AC, Digre KB, Goadsby PJ, et al. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update. Headache. 2024;64:333–341. doi:10.1111/head.14692.
- Dodick DW, Turkel CC, DeGryse RE, et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the PREEMPT clinical program. Headache. 2010;50(6):921–936. doi:10.1111/j.1526-4610.2010.01678.x.
If headache has become part of everyday life, it is worth reassessing the diagnosis and treatment strategy
A neurological consultation can help determine what type of headache is present, whether further investigation is necessary and which treatment options are reasonable in your situation.
