Migraines Vary in Presentation-Diagnosis Can Be Difficult
by: J. Wes Tanner, MD
There is a spectrum of migraine presentations. On one end of the spectrum, there is “Give
me a barf bag and quiet, dark room in which to lie down, and I will try to live through it.” This
is most doctors’ idea of a migraine, and also, most patients’ idea. On the other end of the
spectrum, there are no migraines. In the middle, there are tension headaches, neckaches,
and sinus pain. In between “give me a barf bag” and tension pain, there are migraine-like
pain and milder migraines. If someone frequently presents with “give me a barf bag” type
migraines, then either the body is more sensitive than someone having fewer or no
migraines, or the risk factors for migraine are out of control, or both the body is more
sensitive and the risk factors are out of control. If someone presents primarily with tension
pain, then the body is less sensitive, and/or the risk factors are more controlled.
Migraines are thought of as interruptions in normal neurological functions manifested by
episodes of headaches. At least 20% of migraineurs (people who suffer from migraines)
meeting the International Headache Society (IHS) criteria have changed the pattern from
episodes of migraine into patterns of chronic headache. Chronic headache often does not
return to normal neurological function. This evolving process from episodic headache to
chronic headache is called transformation. In the population segment of chronic daily
headache, migraine appears to be a progressive neurological disease. The decline of
normal neurological function between episodes of migraine greatly exacerbates the
migraine syndrome. The migraine syndrome is the outward expression of the body’s
sensitivity to light, sound, smell, food, and/or stress, and presents as migraines, sinus or
neck pain, palpitations, irritable bowel syndrome (IBS), vertigo, hypoglycemia,
temporomandibular joint syndrome (TMJ), panic attacks, and/or fibromyalgia. The varying
presentations of the body’s sensitivity further complicate the clinical picture. Some doctors
either do not understand the connection of presentations, or specialize their focus and are
unable to see the total patient picture. Some patients either dismiss symptoms as not being
relevant to their main complaint for seeing the doctor, or have given up trying to seek
answers for their other problems.
Considering migraine in phases allows for consideration of the dynamic nature of an acute
episode of migraine. The IHS criteria for migraines only consider the headache phase
which is excellent for research purposes. However, migraine symptoms vary in presentation
both in individual attacks and in different patients. To explain the broad spectrum more
completely, the Convergence Hypothesis was developed. It connects the observed
symptoms with the underlying abnormal neurological functions and makes allowance for
varying presentations of migraines. It explains the different phases of the migraine and their
relationships. The prodrome phase represents changes in the normal balance of brain
processing. This beginning phase has symptoms that herald the coming migraine. The
aura phase represents the electrical discharge over a sensory portion of the brain and the
resulting effects are seen, smelt, or felt. In the headache phase, mild headache occurs
from decreased inhibition of sensory input in the brainstem. Moderate to severe headache
occurs from the painful activation of the facial, head, and neck nerves. Cutaneous allodynia
(the skin is painfully sensitive to touch) is caused by the nerves becoming hypersensitive.
In the resolution phase, the brain processes begin to return to normal. The postdrome
phase is caused by some residual neurological dysfunction.
In the case of episodic migraine, the brain function returns to the normal state when the
active migraine process is over. In the case of chronic migraine, it does not completely
return to normal. The migraine phases may not be fully evident in each migraine and even
though the IHS criteria are not met, the migraine process is going on. In other words, at
times migraine activity may be manifested as migrainous headache or tension-type
headache. Migrainous headache simply refers to the headache meeting most but not all
the IHS criteria. Often a migraineur is diagnosed as having migraines and tension-type
headache. However, a migraineur really does not have several diagnoses. Each of these
types of headaches is caused by the migraine process. In contrast, headaches caused by
meningitis, brain hemorrhage, hypertension, temporal arteritis, etc. have a different
process of headache production.
The Convergence Hypothesis can be illustrated in the following ways. The migraineur starts
experiencing the prodrome phase. He notices a visual aura. He begins to have mild
headache, sinus pain, and/or neckache. Then the sensitivity to light, sound, and/or smell is
heightened. Nausea and/or vomiting follows. His headache worsens, and he can feel his
head throbbing. Movement exacerbates the pain. Wearing his glasses feels very
uncomfortable. He is unable to work the next day. The pain starts subsiding. He feels tired
and achy. Any or several of the sentences in this paragraph could be omitted, but it is still
the same migraine process happening. The migraineur can have aura without headache.
The prodrome may be the only manifestation. A tension headache can be noted.
Therefore, the Converge Hypothesis considers the variable nature of migraine
presentations.
The significance of the Convergence Hypothesis in treating migraines is tremendous.
Although the IHS criteria are extremely important for research, it is the Convergence
Hypothesis that allows for extended treatment. In the Convergence Hypothesis the
impairment in neurological function is more completely judged. By accurately assessing
disability from migraine activity, the effectiveness of comprehensive care can be much
better evaluated.
About The Author
J. Wes Tanner, MD is a family practice and headache specialist who has been treating
people for about 30 years. He has extensive experience in treating migraines and
fibromyalgia with excellent success. In "Doctor, Why Do I Feel This Way?", Dr. Tanner
exposes the secrets and myths about fibromyalgia and the migraine syndrome. To find out
more, go to http://www.migrainesyndrome.net.
by: J. Wes Tanner, MD
There is a spectrum of migraine presentations. On one end of the spectrum, there is “Give
me a barf bag and quiet, dark room in which to lie down, and I will try to live through it.” This
is most doctors’ idea of a migraine, and also, most patients’ idea. On the other end of the
spectrum, there are no migraines. In the middle, there are tension headaches, neckaches,
and sinus pain. In between “give me a barf bag” and tension pain, there are migraine-like
pain and milder migraines. If someone frequently presents with “give me a barf bag” type
migraines, then either the body is more sensitive than someone having fewer or no
migraines, or the risk factors for migraine are out of control, or both the body is more
sensitive and the risk factors are out of control. If someone presents primarily with tension
pain, then the body is less sensitive, and/or the risk factors are more controlled.
Migraines are thought of as interruptions in normal neurological functions manifested by
episodes of headaches. At least 20% of migraineurs (people who suffer from migraines)
meeting the International Headache Society (IHS) criteria have changed the pattern from
episodes of migraine into patterns of chronic headache. Chronic headache often does not
return to normal neurological function. This evolving process from episodic headache to
chronic headache is called transformation. In the population segment of chronic daily
headache, migraine appears to be a progressive neurological disease. The decline of
normal neurological function between episodes of migraine greatly exacerbates the
migraine syndrome. The migraine syndrome is the outward expression of the body’s
sensitivity to light, sound, smell, food, and/or stress, and presents as migraines, sinus or
neck pain, palpitations, irritable bowel syndrome (IBS), vertigo, hypoglycemia,
temporomandibular joint syndrome (TMJ), panic attacks, and/or fibromyalgia. The varying
presentations of the body’s sensitivity further complicate the clinical picture. Some doctors
either do not understand the connection of presentations, or specialize their focus and are
unable to see the total patient picture. Some patients either dismiss symptoms as not being
relevant to their main complaint for seeing the doctor, or have given up trying to seek
answers for their other problems.
Considering migraine in phases allows for consideration of the dynamic nature of an acute
episode of migraine. The IHS criteria for migraines only consider the headache phase
which is excellent for research purposes. However, migraine symptoms vary in presentation
both in individual attacks and in different patients. To explain the broad spectrum more
completely, the Convergence Hypothesis was developed. It connects the observed
symptoms with the underlying abnormal neurological functions and makes allowance for
varying presentations of migraines. It explains the different phases of the migraine and their
relationships. The prodrome phase represents changes in the normal balance of brain
processing. This beginning phase has symptoms that herald the coming migraine. The
aura phase represents the electrical discharge over a sensory portion of the brain and the
resulting effects are seen, smelt, or felt. In the headache phase, mild headache occurs
from decreased inhibition of sensory input in the brainstem. Moderate to severe headache
occurs from the painful activation of the facial, head, and neck nerves. Cutaneous allodynia
(the skin is painfully sensitive to touch) is caused by the nerves becoming hypersensitive.
In the resolution phase, the brain processes begin to return to normal. The postdrome
phase is caused by some residual neurological dysfunction.
In the case of episodic migraine, the brain function returns to the normal state when the
active migraine process is over. In the case of chronic migraine, it does not completely
return to normal. The migraine phases may not be fully evident in each migraine and even
though the IHS criteria are not met, the migraine process is going on. In other words, at
times migraine activity may be manifested as migrainous headache or tension-type
headache. Migrainous headache simply refers to the headache meeting most but not all
the IHS criteria. Often a migraineur is diagnosed as having migraines and tension-type
headache. However, a migraineur really does not have several diagnoses. Each of these
types of headaches is caused by the migraine process. In contrast, headaches caused by
meningitis, brain hemorrhage, hypertension, temporal arteritis, etc. have a different
process of headache production.
The Convergence Hypothesis can be illustrated in the following ways. The migraineur starts
experiencing the prodrome phase. He notices a visual aura. He begins to have mild
headache, sinus pain, and/or neckache. Then the sensitivity to light, sound, and/or smell is
heightened. Nausea and/or vomiting follows. His headache worsens, and he can feel his
head throbbing. Movement exacerbates the pain. Wearing his glasses feels very
uncomfortable. He is unable to work the next day. The pain starts subsiding. He feels tired
and achy. Any or several of the sentences in this paragraph could be omitted, but it is still
the same migraine process happening. The migraineur can have aura without headache.
The prodrome may be the only manifestation. A tension headache can be noted.
Therefore, the Converge Hypothesis considers the variable nature of migraine
presentations.
The significance of the Convergence Hypothesis in treating migraines is tremendous.
Although the IHS criteria are extremely important for research, it is the Convergence
Hypothesis that allows for extended treatment. In the Convergence Hypothesis the
impairment in neurological function is more completely judged. By accurately assessing
disability from migraine activity, the effectiveness of comprehensive care can be much
better evaluated.
About The Author
J. Wes Tanner, MD is a family practice and headache specialist who has been treating
people for about 30 years. He has extensive experience in treating migraines and
fibromyalgia with excellent success. In "Doctor, Why Do I Feel This Way?", Dr. Tanner
exposes the secrets and myths about fibromyalgia and the migraine syndrome. To find out
more, go to http://www.migrainesyndrome.net.
