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Migraines Vary in Presentation-Diagnosis Can Be Difficult

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

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