Migraines & tension-type headaches

Headaches are a common problem that many people experience. Some headaches can be related to TMD. Other more common types of headache are known as ‘primary headaches’. They are known as primary headaches as they aren’t caused by another illness or disorder. There are four types of primary headache, but the two most common are migraine and tension-type headache. While both can cause substantial pain, they differ in symptoms, causes and treatment options.

Symptoms:

Migraine: Migraines often come with intense, throbbing pain that usually affects one side of the head in adults but can also be bilateral (especially so in children and adolescents).They can last from 4 hours to 72 hours. Along with the pain, people often feel nausea and/or vomiting, and/or sensitivity to light and/or sound. Sufferers also find that routine physical daily activity aggravates the pain. Sometimes people can experience an "aura" before a migraine. This aura is thought of as a warning sign and it comes on over around 5 minutes and can last up to 60 minutes within which period the migraine begins. Often it is thought of as simply flashing lights in the sufferer’s vision, but in reality, the aura can affect different areas including our visual, speech, movement, or sensory systems. Migraine produces such intense symptoms it is not uncommon for people to feel the need to understandably stop their daily tasks and rest.

Tension-Type Headaches (TTH): These feel like a dull, aching or tight/pressure pain in a band-like manner around your forehead and or the back of your head. Unlike migraines, tension headaches are not typically accompanied by nausea. They can be accompanied by either sensitivity to light or noise. They are not aggravated by physical daily activities. They are usually less severe and don't stop you from going about your daily tasks, but they can still be annoying and persistent.

Both Migraine and TTH are more common in those living with TMD. Some of the reasons for their common co-occurrence are likely to do with similar pain pathways and other factors which continue to be investigated.

Causes and triggers:

The causes of primary headaches are complex. In migraine, it is thought that abnormal brain activity underlies the migraine which causes changes in nerve signals, chemicals and blood vessels thereby creating the migrainous pain. For some people, there is an element of genetics within the causes of migraine and similarly there is ongoing research to see if genetics can influence the response to treatment. It is not, however, necessarily automatic that people ‘inherit’ migrainous tendencies.

Similarly, in TTH we only have an incomplete understanding of the causes which can be related to genetics, differences in pain pathways in the brain, differences in the sensitivity of muscles around the head and neck, and changes in chemicals and blood vessels in the brain.

Triggers for migraines to start include stress, certain foods (like chocolate or processed meats), bright lights, loud sounds, hormonal changes, and lack of sleep.

In TTH the triggers are very similar to those in migraine including head and neck muscle stress, and lack of, or disturbed sleep. Unlike migraines, however, they are not caused by triggers like certain foods or hormones.

Treatment:

For both diagnosis and treatment, it is important to keep a headache diary. This is so you can identify any triggers for your headache and map out patterns before, during and after treatment which can give clues to what works well for your headache. JawSpace can help you do this in line with the most commonly used headache diaries in specialist headache clinics. You can use your daily check in to record headaches you have and then download its data so you and your health care provider can review month by month how many days you had a headache and what they were like.

For Migraines:

• Medications: Over-the-counter painkillers like ibuprofen or aspirin can help mild migraines. Dissolvable aspirin is particularly effective in helping stopping a migraine that is just starting.

• For more severe migraines there are two treatment approaches: abortive treatment aimed at stopping the migraine from fully developing or shortening its length; prophylactic/preventative treatment to try and stop the migraines from starting in the first place.

• Preventative treatments tend to be used when you’ve regularly had substantial numbers of migraine days in a month. These preventative treatments use medications that target some part of the migraine’s cause for example blood pressure medication, anti-epileptics, and antidepressants all can be used. Newer injectable treatments are also available which include Botox injections from your forehead over your head and down to your neck, and a monthly or quarterly injection under your skin to block a key chemical messenger in migraine known as Calcitonin Gene-Related Peptide (CGRP).

• Abortive treatments are largely used when you only have a few migraine days per month. They involve triptans, which specifically target migraine pain rather than other types of pain like ibuprofen and aspirin.

• There have been substantial leaps forward in treating migraine in recent years with multiple new, more targeted medications with fewer side effects being released onto the market. One of the new types of medications (‘Gepants’) can work both as a preventative and an abortive by blocking a key chemical messenger (CGRP) in the migraine process. As Gepants are relatively recent to the market you would need to discuss with your healthcare provider if you would be eligible for them under your healthcare plan.

• Lifestyle changes: Identifying and avoiding triggers (such as certain foods, stress, or lack of sleep) can reduce the frequency of migraines. Staying well hydrated, reducing alcohol and caffeine and taking regular exercise can also help reduce the frequency and or severity of migraines.

• Other Therapies: Some people find relief through relaxation techniques, acupuncture, or low-level electrical stimulation (‘TENS’) on the forehead that changes pain pathways.

For Tension-Type Headaches:

• Medications: Over-the-counter pain relievers like ibuprofen or acetaminophen (Paracetamol) will often help ease the discomfort.

• Stress management: Since stress and muscle tension can trigger these headaches, practicing relaxation techniques, taking breaks during work, or doing gentle neck and shoulder stretches can help prevent them.

• Physical therapy: If muscle tension is a major factor, physical therapy, acupuncture or massages can sometimes relieve chronic tension headaches.
   

Prognosis:

Migraines: While there’s no cure for migraines, many people can manage them well with medication and lifestyle changes especially when they are treated early. Migraine frequency and severity may also decrease over time, especially for women after menopause. However, they tend to be a lifelong condition that requires ongoing attention.

Tension-Type headaches: These headaches are usually less severe and easier to manage. Many people experience them only occasionally, and they respond well to simple treatments.

Both migraines and tension-type headaches are common but manageable conditions. While migraines can be more debilitating, both types of headaches benefit from a proactive approach to treatment and prevention. A lot of what is recommended for lifestyle changes and achieving balance within JawSpace for TMD is suitable for migraine and TTH and clinicians frequently see improvements in one condition when the other improves. In rarer cases, however, migraine and TMD can work together to almost ‘reinforce’ one another and then it is important to see if you can jointly see a headache neurologist and an orofacial pain specialist so they can work together in tandem to help address both problems.

References:

1. Dodick, D. W., et al., An Update on Temporomandibular Disorders (TMDs) and Headache., Current Pain and Headache Reports 27, Article 12. 2023.

2. Franco, A. L., et al., Migraine Is the Most Prevalent Primary Headache in Individuals with Temporomandibular Disorders., Journal of Orofacial Pain 24, 287-292. 2010.

3. Glaros, A. G., et al., Headache and Temporomandibular Disorders: Evidence for a Shared Pain Basis., Cephalalgia 32, 1054-1063. 2012.

4. Olofsson, I. A., Migraine Heritability and Beyond: A Scoping Review of Twin Studies., Headache 64, 1049-1058. 2024.

5. Tsirelis, D., et al., The Impact of Genetic Factors on the Response to Migraine Therapy., Reviews in the Neurosciences 35, 789-812. 2024.