Over the past couple of decades, the thought process about the biology of a migraine attack has shifted from a vascular to a neural one.
Specifically, research now suggests that migraine headaches stem from an imbalance of brain chemicals and nerve-related problems. Any blood vessel changes that occur with a migraine are viewed as a secondary effect and not sufficient enough on their own to cause a headache.
Despite the fact that migraine is no longer synonymous with the term “vascular headache,” secondary vascular headaches do exist. These headaches are described by the International Headache Society as “headaches attributed to cranial or cervical vascular disorders.”
This article provides an overview of the diagnosis and treatment of both migraine headaches and secondary vascular headaches. It also reviews when you should see a healthcare provider for your headache.
What Is a Migraine?
Migraine headaches affect around 10% of the population worldwide and are thought to be caused by the activation of pain receptors within the trigeminovascular system. The trigeminovascular system consists of trigeminal nerve fibers that connect to the blood vessels that supply the brain.
The trigeminal nerve is the largest of the 12 cranial nerves. During a migraine, its nerve fibers release substances that irritate and cause swelling of the brain’s blood vessels.
Migraine headaches are debilitating, throbbing, and worsen with physical activity. They are usually located on one side of the head and may be accompanied by nausea, vomiting, and sensitivity to light, sound, or smell.
Besides a headache, some people also experience other phases during a migraine attack. These phases include:
The prodrome phase develops before the headache by hours or days and is associated with a variety of symptoms like low mood, irritability, tiredness, and neck discomfort. A migraine aura occurs right before the headache and lasts up to one hour. It’s associated with reversible neurological disturbances, like seeing flashes of light or experiencing numbness or tingling sensations. The postdrome phase of a migraine attack occurs after the headache and lasts 24 to 48 hours. During this phase, most people report feeling drained or like they are in a fog.
Diagnosis
A migraine diagnosis is mainly determined by a careful medical history and exam.
Your healthcare provider will review the characteristics of your headache (e.g., location, quality, and severity) and ask you whether you have any other symptoms like nausea, light sensitivity, or facial sweating. They will also review triggers and your family history.
For patients with suspected migraine headaches, imaging of the brain is not generally indicated unless worrisome features are present or there is something abnormal on the neurological exam.
Treatment
The treatment of migraine headaches includes lifestyle modifications, medication, or a combination. Preventive strategies like avoiding triggers or taking medication are used to decrease the number and severity of headache attacks.
Mild to moderate migraine headaches can be treated with a nonsteroidal anti-inflammatory drug (NSAID) like Advil (ibuprofen) or Aleve (naproxen sodium), while more severe headaches usually require a triptan, like Imitrex (sumatriptan), or a combination NSAID/triptan, like Treximet (sumatriptan and naproxen sodium).
For people with migraine headaches who cannot take or tolerate a triptan, a calcitonin gene-related peptide (CGRP) blocker, such as Nurtec ODT (rimegepant), may be recommended.
What Are Secondary Vascular Headaches?
Secondary vascular headaches are usually throbbing or thunderclap in nature. They start suddenly and become severe quickly.
According to the International Headache Society, these headaches may arise from one of the following various blood vessel pathologies:
Stroke (blockage of blood flow or bleed in the brain) Nontraumatic intracranial hemorrhage (brain bleed) Unruptured vascular malformation (abnormally connected blood vessels) Arteritis (artery inflammation), such as giant cell arteritis (GCA) Cervical carotid or vertebral artery disorder, such as dissection (when a tear forms in an artery in the neck) Cranial venous (vein) disorder, including cerebral venous thrombosis (blood clot in a vein in the brain) Other acute intracranial arterial disorders, such as reversible cerebral vasoconstriction syndrome (when blood vessels in the brain suddenly narrow) Genetic vasculopathy, such as mitochondrial encephalomyopathy, lactic acidosis and stroke-like episode syndrome (MELAS) Pituitary apoplexy (bleeding into or loss of blood flow to the pituitary gland, located deep in the brain)
Diagnosis
Secondary vascular headaches can be dangerous, even potentially life-threatening, and may mimic primary headache disorders, like migraine or cluster headache.
If a secondary vascular headache is ever suspected, an imaging test such as computed tomography (CT) of the brain or magnetic resonance imaging (MRI) of the brain and its blood vessels will be performed.
Other tests that may be ordered to identify the cause of the headache include:
Transcranial Doppler (an ultrasound of blood flow through the brain’s blood vessels) Lumbar puncture (or spinal tap, using a long needle to remove a sample of cerebrospinal fluid between two lumbar vertebrae of the lower back) Laboratory tests—for example, checking for an elevated erythrocyte sedimentation rate (a blood marker indicating inflammation) to help diagnose GCA Genetic tests
Treatment
The treatment of a secondary vascular headache depends on the underlying diagnosis.
As an example, high doses of corticosteroids are used to treat giant cell arteritis. More dangerous headaches like stroke require monitoring within a hospital, intravenous (IV) medications, and, sometimes, surgery.
When to Seek Medical Attention
Most headaches can be managed at home and are not a cause for alarm. In some cases, though, a headache may be the only clue that something serious is going on in your body.
Scenarios that warrant a visit or call to your healthcare provider include:
Your headache pattern is changing (e. g. , becoming more severe or occurring more often). Your headaches are interfering with your daily activities. You have a new headache and are over age 65, are pregnant or postpartum, or have a history of cancer or human immunodeficiency virus (HIV). Your headache is triggered by coughing, exercising, or the Valsalva maneuver (a breathing technique that can slow a rapidly beating heart). You are experiencing a headache associated with taking painkillers regularly.
Summary
“Vascular headache” is an outdated term previously used to describe migraines. Migraine attacks are now believed to originate primarily from nerve-related problems in the brain, not blood vessel changes.
Is severe, begins suddenly, and/or is the “worst headache of your life"Is severe and accompanied by a painful red eye, vision changes, high fever, stiff neck, or confusionIs associated with symptoms of a possible stroke (e. g. , weakness, numbness, slurred speech)Occurs after an injury to your head
While the term “vascular headache” is no longer used, secondary vascular headaches do exist. These are headaches that arise from a blood vessel problem in the head or neck, such as a stroke or blood vessel tear.
A Word From Verywell
If you are experiencing migraine headaches, it’s important to get to the bottom of what is causing them. To help your healthcare provider make the right diagnosis, start by taking notes (either on paper or your phone) about your headache patterns.
Include things like the time of day your headaches occur, how long they last, their severity, and the symptoms you felt before, during, and after the headaches. It’s also a good idea to jot down your sleeping and eating schedules. This will help identify possible headache triggers.
