Migraine is not a bad headache. It is a threshold disorder.

THE CONDITION · MIGRAINE

Migraine is not a bad headache. It is an inherited disorder of a brain that handles change poorly. The headache is one of its outputs, not the thing itself.

What is a migraine?

A migraine brain overreacts to change — in sleep timing, in blood sugar (glucose), in hormones, in air pressure (barometric pressure), in sensory load. An attack is that system tipping over. It runs a course with phases. First comes a prodrome, hours to a day ahead (yawning, food cravings, mood shift, neck stiffness). Sometimes an aura follows. Then the headache. Last is a postdrome, when you feel wrung out for a day.

Spotting the prodrome is worth more than any other single skill here. That is because the treatment window is early, and most people miss it.

How is migraine diagnosed?

• Attacks lasting 4 to 72 hours untreated.
• At least two of: one-sided, throbbing, moderate or severe, worse with routine activity.
• At least one of: nausea or vomiting, or sensitivity to both light and sound.
• Not better explained by something else.

No scan confirms it. Imaging is for ruling out other things when the exam or history calls for it — when that applies.

What is a migraine aura?

Only a minority have aura. When it is there, it is usually visual — a spreading zigzag or blind spot that builds over 5 to 20 minutes and clears within an hour. But it can affect feeling or speech. The build-and-fade is the signature. Sudden and unchanging is a different problem. Aura that shows up for the first time after 50 should be checked, not assumed.

What causes frequent migraines?

Three attacks a year or fifteen a month? The trigger list rarely decides that. Insulin resistance and chronic metabolic inflammation lower the threshold at which any change becomes an attack. Unstable glucose widens the swings the brain must absorb. Neither shows on imaging. Neither is touched by an abortive (attack-stopping drug).

The third driver is not biological. It is the one that decides whether any plan survives: a work and sleep pattern with no rhythm to it. Think shift rotation, meals eaten when the shift allows, and weekend sleep that moves by hours. That is why a headache visit here includes bloodwork and a look at your real week.

How is migraine treated?

The abortive half treats an attack. The preventive half cuts how often attacks start. It becomes worth discussing at around four headache days a month. A great many people have been stepped up through abortives for years, and the second half was never written. That is also the mechanism that produces medication overuse headache.

Preventive is a category, not one drug. It includes oral agents, CGRP-targeted treatments, botulinum toxin for chronic migraine, and nerve blocks where the exam supports them. Which one applies is a clinical decision based on your history. It is not a menu.

Frequently asked questions

How do I know if it is migraine or just a bad headache?

The criteria above are the practical test. Nausea or light-and-sound sensitivity is the usual tie-breaker — why nausea carries so much weight.

Is migraine hereditary?

Largely, yes. A family history is common and worth mentioning. But having none does not rule it out.

Can migraine start later in life?

It usually begins before 40. A truly new headache after 50 deserves a proper check, not a guess — new headache after fifty.

What is the single most useful thing I can do before an appointment?

Keep a diary for two weeks with headache days, medication days and clock times. It answers more than any test — how.

What are the phases of a migraine attack?

A migraine attack runs a course. The prodrome comes hours to a day before the pain, with yawning, food cravings, a mood shift or neck stiffness. Some people then have an aura. Next comes the headache itself. Last is the postdrome, when you feel wrung out for about a day. Spotting the prodrome matters most, because the treatment window is early.

What triggers a migraine?

Change. A migraine brain responds strongly to shifts in sleep timing, blood sugar, hormones, barometric pressure and sensory load. An attack is that system tipping over. How often it tips depends less on the trigger list than on the threshold. Insulin resistance and chronic metabolic inflammation lower that threshold. An irregular work and sleep pattern keeps pushing against it.

When should you start migraine prevention?

Prevention becomes worth discussing at around four headache days a month. Preventive treatment is a category, not one drug. It includes oral agents, CGRP-targeted treatments, botulinum toxin for chronic migraine, and nerve blocks where the exam supports them. Which one fits is a clinical decision made from your history. At that frequency, relying on attack treatment alone is half a plan.

Do you need a brain scan to diagnose migraine?

No. No scan confirms migraine. The diagnosis is clinical, made from the pattern of attacks and the exam. Imaging is used to rule out other causes when the history or exam calls for it. Here is one example. An aura that appears for the first time after age 50 should be checked, not assumed to be migraine.

Go deeper

• When it becomes chronic
• Aura and vision changes
• Hormonal patterns
• Preventive options
• The two counts

Dizziness is four complaints wearing one word, and one of them is a migraine variant.