Understanding Migraine Head Pain - Characteristics, Source, and Rating
Despite the advances in research and the increased efforts to spread accurate information, there are still misconceptions about the pain of a migraine attack. Many people think that the pain is always severe. In reality, the pain can range from mild to severe, or be absent altogether. A migraine attack can occur without the headache phase. When this occurs, the migraine is described as "acephalgic" or "silent." You can read more about that in Acephalgic or Silent Migraine - The Basics.
Migraine pain is usually different from the pain of other headache disorders. It differs in location and other characteristics. Let's take a look at the characteristics of migraine pain as well as how it's measured.
Characteristics of migraine pain:
- The pain is often, but not always, unilateral (one-sided).
- It's often, but not always, pulsatile (throbbing).
- It's usually aggravated by routine physical activity, such as climbing stairs or bending over.
- It may also occur along the three branches of the trigeminal nerve - above the eyes and along the sinus cavities and jaw due to inflammation of the trigeminal nerve that occurs during a migraine attack.
Migraine pain is not caused by vasodilation (dilation of blood vessels) as was once thought. It has now been shown that if there is vasodilation, it occurs after cortical spreading depression - waves of abnormal activity that spread across the surface of the brain (the cortex), as well as excitation of nerve centers deep within the brain (the brainstem).2 In fact, it has now been shown that vasodilation doesn't always occur and that vasodilation may occur as part of the disorder, but is not required for migraine pain.
Some of us have multiple headache disorders. For example, I have both migraine with and without aura and tension-type headaches. There are times when a "headache" begins, but I'm not sure if it's a migraine or a tension-type headache. The third point above, migraine being worsened by activity, can sometimes help me determine which it is. I bend over and touch the floor. That will aggravate the pain of a migraine, but not a tension-type headache. This is helpful because my treatments are different, and I need to know which one to use.
Rating pain intensity:
Most doctors ask patients to rate their migraine pain intensity on a scale of 0 to 10; a minority use a 0 to 5 scale. When working with young children, the Wong-Baker FACES Pain Rating Scale is most frequently used.3 One of the problems with pain scales is that they're often used incorrectly. When we're asked to rate our pain on a scale of 0 to 10, saying it's a 12 defeats the purpose. For more, see our video, Migraine Pain Scale Effectiveness.
Since rating pain is so subjective, many doctors find that they can tell more about their patients by having them rate the level of disability each of their migraines causes them. For this reason, many doctors ask migraineurs to record both pain and disability levels in their migraine diaries/journals.
Dr. Richard Lipton and Dr. Walter Stewart developed the five-question MIDAS (Migraine Disability Assessment) questionnaire to help patients and doctors measure the overall impact migraines have on our lives. The MIDAS questionnaire can be found many places online, where it will score it for you. The five questions are:5
- On how many days in the last 3 months did you miss work or school because of your headaches?
- How many days in the last 3 months was your work productivity at work or school reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school.)
- On how many days in the last 3 months did you not do household work (such as housework, home repairs and maintenance, shopping, caring for children and relatives) because of your headaches?
- How many days in the last 3 months was your productivity in household work reduced by half or more because of your headaches? (Do not include days you counted in question 3 where you did not do household work).
- On how many days in the last 3 months did you miss family, social or leisure activities because of your headaches?
Migraine pain often has characteristics that differentiate it from headache pain. We're often asked to rate our pain levels, but that can be difficult given that it's so subjective and that the migraine can also have our levels of neurotransmitters, such as serotonin and norepinephrine, fluctuating, rendering us more emotional. We need to take that into account and rate our pain as accurately as possible so the ratings can actually mean something and help our doctors treat us. Adding a disability scale to our diary or journal can be helpful to us and our doctors.
Researchers are still learning about the pathophysiology of migraine pain. As more is learned about not only the pain, but the pathophysiology of all of a migraine attack, better treatments can be developed, treatments that can vastly improve our quality of life.
Better understanding of migraine pain, pain scales, and disability scales is vital to our success in working with our doctors as treatment partners.
1 Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd edition.” Cephalalgia. July 2013 vol. 33 no. 9 629-808 10.1177/0333102413485658.
2 Charles, Andrew, MD. "Migraine: Questions and Answers for Patients." UCLA Headache Research and Treatment Program.
3 Interview: Teri Robert with Andrew D. Hershey, MD, PhD, FAHS; Director, Headache Center, Children's Hospital Medical Center; Cincinnati, Ohio. February 21, 2010.
4 Wong-Baker FACES Foundation Web Site.
5 Lipton, Richard B., MD; Stewart, Walter F., MPH, PhD. "MIDAS." ACHE, The Fred Sheftell Education Center.
6 Charles, Andrew, MD. "Migraine Pathophysiology Update." Presented at the American Headache Society Scottsdale Symposium. November 19, 2010.
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Reviewed by David Watson, MD.
© Teri Robert, 2014, • Last updated August 4, 2014.