What if I have migraine, vertigo, and tension headache all at once?

If you are looking for an article that will help you understand your headache and dizziness, you have come to the right place. I will try to explain why your head aches or spins, what is the current medical knowledge available out there, and how can you help yourself minimize these attacks. While this is in no way a substitute to a professional medical advice, I hope that this article can help alleviate some fears and pain that is bothering you.

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Dr. Jeffrey Arboleda
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Headache and Dizziness are broad symptoms that have different types and presentations. The key to understanding it is knowing which type do you have.  

We will focus on the most common complaints - Migraine Headache, Tension-Type Headache, and Vertigo (most prevalent type of dizziness along with lightheadedness).

Do you recognize these symptoms?

The following table shows anecdotes from patients experiencing different forms of headache and dizziness.

Migraine Headache

  • Before an attack,
    “there are flashes of light”, or “my vision becomes blind”, or “I feel like I will have a stroke” 
  • During an attack,
    “Feels like someone is drilling on my skull”, or “I can feel my brain pulsating” 
  • After an attack,
    “I am so exhausted”, or “Nauseated”, or “I’m afraid to move because it might happen again”

Tension Headache

  • “My head is wrapped by a tight rubber band” 
  • “Nagging pain on my nape” 
  • “As if someone is squeezing my head”

Vertigo (distinct from dizziness/lightheadedness)

  • “That feeling when you just got off a spinning carnival ride” 
  • “I can feel the world rotating”
  • “I feel woozy when I look down” 
  • “I feel like vomiting”
Migraineurs know that they will have an attack because of what we call, auras.  These can be in the form of flashing light, noise out of nowhere, or symptoms similar to a stroke.  

During an attack, they experience excruciating pain that pulsates on one side of their head. It is so bad that they want to be in a dark, quiet room.  

This may last for hours or even days! After an attack, they feel very tired and nauseated.  

Patients with Tension-Type Headache feel the pain around the head and at the nape.

Unlike the migraine headache, they do not have an aura.  

Their attacks usually occur when they are stressed but these are not aggravated with physical activity.

Lastly, patients with Vertigo describe their dizziness as rotatory - as if the world around them is moving.  

They also get nauseated and may sometimes also feel headache, similar to that of a migraine.

What do we know about headache and dizziness?

Just like most brain conditions, there is much left to know about headache and dizziness. Its mystery revolves around the limitations in studying the brain, short of cutting your skull open.  Nonetheless, we know enough about it to provide relief.  

Here are the available medical knowledge on both, headache and dizziness.

Headaches Overview

  • Worldwide, about half of the population experience headache annually, and almost everyone will say they have it for most of their lifetime.  It is the most common neurologic disease.
  • Women are 2 to 3 times more likely to have a Migraine Headache and are also more affected with Tension-Type Headache.  
  • Headache is associated with anxiety and mood disorders, allergies, chronic pain disorders and epilepsy.
  • There is a strong genetic component in Migraine Headache while Tension-Type Headache occurs primarily because of mechanical and psychological stress.
  • Check this fact sheet for more.

Classification of Headaches

There are two classifications of headache - primary and secondary.

Primary headaches are those that occur by themselves, without any external cause. Examples are cluster headache, tension-type headache, and migraine headache.

On the other hand, secondary headaches have external causes. These can be caused by an enlarging brain mass, a brain bleed, or a brain infection.  

Thankfully, despite common belief that headache equates to a serious neurologic problem, only 4% of all headaches are considered to be of high-risk origin.

Dizziness Overview

  • About 15-20% of the adult population experience dizziness.  A quarter of the cases of dizziness is attributable to vertigo.
  • Vertigo is described as rotatory dizziness, differentiating it from disequilibrium (feeling of imbalance), light-headedness (sensation of giddiness), and presyncope (sensation of feeling faint).
  • Women are 2 to 3 times more likely to experience vertigo compared to men.
  • It is associated with changes in head position, upper respiratory tract infection, stress or trauma, anxiety, and even migraine.

Classification

Vertigo can also be classified into two - peripheral and central vertigo.

When the problem arises from the inner ear or from the vestibular nerve, it is classified as peripheral vertigo.

Examples include inflammation of the labyrinth or labyrinthitis, Meinere’s Disease caused by swelling of the inner ear structures, Benign Paroxysmal Positional Vertigo (BPPV)caused by calcium debris in the inner ear and Vestibular neuritis or inflammation of the vestibular nerve.  

On the other hand, when the problem arises from the cerebellum or brain stem, it is classified as central vertigo. Examples include a brain mass, brain infection or stroke.  

Overlap of Symptoms (not unusual).

Still unsure what type of condition you have? Sometimes, it is really not as easy as described in paper.  

Even the International Headache Society recognizes the difficulty in differentiating one from another.  

Tension-Type Headache and Migraine, in the absence of aura, may become confusing for both health professional and patient alike.

What makes it more difficult is the fact that patients who have frequent headaches often have both types of headache.  

This is not surprising as they share common physiologic and psychologic factors that predispose a patient to frequent attacks.

There is also another group of patients who suffer from both migraine headache and vertigo and that condition is called Vertiginous Migraine.

In a Chinese study, around 10% of Migraine patients were observed to have vestibular symptoms as well.  

The scientific explanation for this is still unclear and the confusion now lies in the overlap of Meniere’s Disease and Migraine Headache, especially if the patient just presents with dizziness.  

Indeed, aside from taxes and work, there are a whole lot of reasons why our head hurts and spins and for most, they usually are just that - headaches and vertigo.  

You take a pill and they will go away. However, we have talked about the possibility of secondary headaches and central vertigo - the ones that may have underlying, serious conditions. How do you know it’s not a stroke? A brain tumor? A ruptured aneurysm? Do all patients suffering from headache and dizziness need a brain MRI or a CT scan?

Do I need to See a Doctor?

headache-dizziness-migraine
The stark difference in the risk between primary and secondary headache and peripheral and central vertigo explains the need to take these symptoms seriously. That is why it is always prudent to have yourself checked by a medical professional.  

Depending on the severity of your symptom, you might be seen by a primary care physician, an emergency room physician, an ENT doctor or a neurologist:

  • You will be asked questions to check your cognition, such as simple mathematics and abstract reasoning.
  • Your vision, hearing, taste, touch and pain sensations will be tested.
  • You will be asked to perform various movements to check your motor strength, coordination and ability to follow instructions.
  • Tests may also be done to elicit pain or dizziness.
  • Other organ systems that may also be assessed are the eyes, ears, neck and the heart . Lastly, the doctor has to assess your psychological state to know
  • You may be asked to undergo a CT scan or MRI of the brain and a few lab tests to rule out other conditions.

In all these, it is crucial that you remain patient and honest. It may seem taxing, usually lasting for 10-30 mins, and some questions may even sound silly, but these are all necessary to make certain that all you have is just a primary headache or a peripheral vertigo.

The treatment is mostly targeted to provide symptom relief or to prevent future attacks:

  • Pharmacologic intervention ranging from simple analgesics, to non-steroidal anti-inflammatory drugs and even antidepressants may be given to relieve headache
  • Anti-histamine and anti-emetics may be given to relieve nausea, vomiting and dizziness.
  • Non-pharmacologic intervention includes relaxation exercises, physical therapy and music therapy.

What exactly happens during my headache? Or, Why does my head hurt?

When we experience headache, it feels like our brain is being torn, squeezed and even drilled into.

Ironically, our brain, the organ that makes us experience the world, the organ that tells us that needles hurt and cotton feels nice, does not feel pain.

Wait...what then causes our suffering? These are what we call the pain-sensitive structures of our head.

Outside the skull, we have the skin, muscle, sinuses, dental structures and blood vessels that feel pain.

While inside the skull, we have the large arteries, venous sinuses, dura mater (tough outer covering of the brain), and the cranial nerves.

The trigeminal nerve that primarily innervates these structures will send the pain information to the ventroposteromedial thalamus, cerebral cortex and the pain-modulating systems of the hypothalamus and brain stem.  

Headaches then happen when these pain-sensitive structures are stimulated because of injury, stretching or when the pain-modulating pathways of our peripheral and central nervous systems are blocked off inappropriately.  

There are multiple theories about the pain mechanism of migraine headache. Some suggests that migraine headaches are caused by spasm of vessels that deprive the brain of blood supply. It is this temporary lack of blood supply that causes the aura before an attack, very similar to how a stroke occurs.

A more biochemical approach looks into the inappropriate release of vasoactive neuropeptides such as nitric oxide (NO), 5-hydroxytryptamine (5-HT)and calcitonin gene-related peptide (CGRP) at the vascular termination of the trigeminal nerve.  

Unfortunately, none of these theories have been completely proven.

migraine-headache-mechanism

Tension-type headaches (TTH), on the other hand, originate extracranially at the skin and muscles or the myofascial component of the head and neck.

There is a marked tenderness of these structure that sends signal to the brain. Chronic painful signal from these structures also causes dysfunction in the central pain pathways of the brain.

Here's quick fact sheet about TTH.

muscles-tension-headaches

Why vertigo happens? Why does my head spin?

In our inner ear, there are parts for hearing (cochlea) and there are parts for balance or the vestibular system (semicircular canals and otolith organs).

Similar to headache, there are just specific culprits in our head that cause vertigo.  Specifically, the semicircular canals, oriented in different angles, are hollow bony structure where fluid passes through.  

For every change in head direction, there is a corresponding movement of fluid and little brushes in your inner ear sense that, bringing you the information that you have just moved your head.  

Inner Ear Rotation

Now imagine this fluid to be contaminated with crystal debris, or the canals or the nerves that transmit these information are swollen. Your brain will get a false information of your head movement, thereby causing peripheral vertigo.  

Your brain may also be a culprit for central vertigo. Specifically, you may have problem with your brain stem where your vestibular nerve enters cerebellum and where all vestibular input is sent and processed.  

Together with rotatory dizziness, you may also feel hearing loss, tinnitus (a high-pitched sound), and experience nystagmus (a fast, repetitive movements of the eyes) because of the close association of the systems of balance, hearing and vision.

Key Factors in Play: Headaches & Dizziness

headaches-causes-sleep-stress-sanity

Headaches and Dizziness may have their own distinct, elaborate neuropathologic mechanisms that differentiate them from each other, but decades of research have shown that they share common physiological and psychological factors.  

I would like to focus on 3 key S’s that we can take control of - Sleep, Stress, and Sanity.

Sleep

Sleep is an active and crucial brain process that maintains our metabolism. Sleep is so important that recent sleep studies have shown that sleep duration less than 7 hours has an increased risk of death.  

You can just imagine the damage we do to our brain when we deprive ourselves of good sleep. As much as one-half to two-thirds of patients with migraine and tension-type headache report insomnia, making it the most common sleep complaint.  

Patients with obstructive sleep apnea have also shown to have poorer performance in vestibular function tests.

Stress

Stress is our body’s response to an internal or environmental obstacle.  

The stress response originates in an area of the brain called amygdala, more popularly known as the seat of emotion. The amygdala then sends signal to the command center of the brain, the hypothalamus, that will activate a sympathetic response towards the pituitary and adrenal cortices.  

This type of physiologic stress has been known to trigger migraine attacks and is reported to be present in 70% of migraineurs.

On the other hand, dizziness is a common symptom of stress and anxiety.

Sanity

The relationship of headache and vertigo with mental disorders can be likened to a chicken-and-egg situation.  

Headache and vertigo can occur even before the onset of mental disorders. In fact, 11% of participants in a mental disorder study had migraine prior to onset of their psychiatric illness such as Major Depression and Bipolar Disorder.  

On the other hand, chronic pain and dizziness can also lead to uncontrollable stress that may lead to anxiety disorders.

It's important to note that brain areas responsible for dizziness is also believed to interact with the brain areas responsible for anxiety.

Diagnostic Criteria

Doctors use a standard criteria to diagnose patients with a specific headache or dizziness disorder.  

Particularly, the International Headache Society lays down the criteria for each and every primary headache here.

Diagnostic criteria: Migraine without aura

  • [A] At least five attacks fulfilling criteria B-D
  • [B] Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated)
  • [C] Headache has at least two of the following four characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
  • [D] During headache at least one of the following: nausea and/or vomiting, photophobia and phonophobia
  • [E] Not better accounted for by another ICHD-3 diagnosis

Diagnostic criteria: Migraine with aura

  • [A] At least two attacks fulfilling criteria B and C
  • [B] One or more of the following fully reversible aura symptoms: visual, sensory, speech and/or language, motor, brainstem, retinal
  • [C] At least three of the following six characteristics: at least one aura symptom spreads gradually over ≥5 minutes; two or more aura symptoms occur in succession; each individual aura symptom lasts 5-60 minutes; at least one aura symptom is unilateral; at least one aura symptom is positive; the aura is accompanied, or followed within 60 minutes, by headache;
  • [D] Not better accounted for by another ICHD-3 diagnosis.

Diagnostic criteria: Tension-Type Headache

  • [A] At least 10 episodes of headache occurring on 1-14 days/month on average for >3 months (≥12 and
  • [B] Lasting from 30 minutes to 7 days
  • [C] At least two of the following four characteristics: bilateral location; pressing or tightening (non-pulsating) quality; mild or moderate intensity; not aggravated by routine physical activity such as walking or climbing stairs;
  • [D] Both of the following: no nausea or vomiting; no more than one of photophobia or phonophobia
  • [E] Not better accounted for by another ICHD-3 diagnosis.

Diagnostic criteria: Benign Paroxysmal Positional Vertigo

  • [A] At least five attacks fulfilling criteria Band C and B.    
  • [B] Vertigo occurring without warning, maximal at onset and resolving spontaneously after minutes to hours without loss of consciousness
  • [C] At least one of the following five associated symptoms or signs: nystagmus, ataxia, vomiting, pallor, fearfulness;
  • [D] Normal neurological examination and audiometric and vestibular functions between attacks
  • [E] Not attributed to another disorder.

Red Flags: how serious it is?

There is an easy-to-remember mnemonic to see if you have the red flag signs of headache and it is called SNOOP.  

Red flags are alarming signs and symptoms that necessitate further evaluation and testing. Now, it has been upgraded to SNNOOP 10 which is less catchy and can be a bit confusing to the ordinary people, so I’ll just summarize it here (for a more comprehensive list, visit this study).

While these are made for headache sufferers, vertigo sufferers may also find these red flags useful. After all, they are both neurologic symptoms.  

If you or your loved ones have any of these, please go to the emergency room immediately.

  1. Systemic symptoms
  2. Does your headache come with fever?
  3. Headache, fever and neck stiffness compose the triad of meningitis or an infection of the covering of the brain. While this is not always consistently seen in patients with neurologic infections, headache with fever alone is already alarming, especially when accompanied by relevant symptoms.  
  4. Or does it come with weight loss, decrease in appetite and chronic fatigue?
  5. These are some of the red flags for cancer and in the next paragraph you’ll see that history of cancer is also a red flag for headache.
  1. Secondary Risk Factors
  2. Do you also have HIV or do you think you have HIV?
  3. If you have the risk factors for HIV such as promiscuous sexual behavior or you think that you have it, a headache can be a symptom of opportunistic infections associated with HIV.  In fact, headache is the number one pain complaint of HIV patients.  
  4. Or do you have a history of cancer?
  5. Headache in patients with history or suspicion of cancer may be a sign that the cancer might have gone up to the brain. Headache can be a symptom of a growing mass that presses on the pain-sensitive structures of the brain.
  1. Neurologic Symptoms
  2. Does your headache come with facial drooping, arm drift, slurring of speech?
  3. Headache with sudden loss or altered consciousness, facial drooping, slurring of speech,arm or leg weakness, and loss of balance may mean that you are having a stroke.  
  1. Onset is sudden, abrupt or split-second
  2. Is it the worst headache of your life?
  3. A severe, abrupt headache, also known as a thunderclap headache, may be the only initial symptom of a subarachnoid hemorrhage. The suspicion rises if you are older than 40 years old, with neck pain and loss of consciousness.  
  1. Older age
  2. Are you older than 65 years old when it happened?
  3. In general, headache in this age group is more likely to be serious compared to younger patients. A particular form of inflammation of the temporal artery otherwise known as Giant cell arteritis is also likely.
  1. Previous headache history
  2. Did you note any pattern change?
  3. Or is this the first time this happened?
  4. A new-onset headache or a recent change in pattern is more likely to be serious compared to a chronic one with similar pattern every attack.  

There is another overlapping disease that does not get much recognition probably because of how it is portrayed in movies and television.  However, its recognition could spell the difference between an early life-saving treatment and a debilitating neurologic condition. It is called seizure.  

Seizures

“Really? But I don’t spasm”, you might ask.  

You may be more familiar with a generalized tonic-clonic seizure that presents with sudden jerking of extremities and upward rolling of eyes.

However, there are other presentations of seizures. Blinking of eyes? Could be a seizure. Lipsmacking? Could be a seizure. Seeing flashing of light or hearing noises? Could be a seizure.  

Seizures have a lot of surprisingly overlapping features with headaches, specifically, Migraine Headache.

Just like Migraine Headache, seizures have a strong genetic predisposition and is caused by an imbalance with the neural signals in your brain.  They also present with aura that may be seen also in the form of flashing lights, stroke-like symptoms or hallucinations.  Pretty much we can say that Migraine and Seizure are buddies that one is usually a comorbidity of the other and they even share similar treatment options.

In fact, some anti-epilepsy medications maybe used for migraine.

Although occurring less commonly, seizure can also be confused with vertigo. If the patient has the classic picture of epilepsy and just with concurrent dizziness, it can be a straight forward epileptic vertigo.

However, this study shows that rarely, dizziness may be the only presentation of seizure.  This is where the confusion comes in because it becomes difficult to differentiate it from the peripheral causes of vertigo.

Diagnostics and Tests

At this point, you already have a good grasp of the difference between headaches and dizziness.  

But as you can see in each diagnostic criteria, your doctor has to make sure that it is not attributable to another medical condition, or worse to a medical emergency.  

And that’s where the diagnostic tests come in. Again, it is your doctor’s discretion whether or not they will request the following tests, depending on your symptoms:

Brain MRI or Cranial CT Scan

These are imaging modalities that look at your brain tissue along with its blood supply.  This is particularly helpful if tumors, bleed or infarct are being considered.  

CT scan has significant radiation exposure but lasts just a few minutes and the results come out fast. On the other hand, MRI does not have radiation but you have to lie still for 30 minutes with a loud, pounding noise that you’ll hear from the machine.  External metals and metallic implants are also not allowed inside the room.

EEG

If your doctor is highly suspecting seizure that disguises as headache, you might be requested to undergo an ElectroEncephaloGram to check your brain waves.

You will be asked to lie flat as they attach electrodes to your head.  During the procedure, you will be asked to perform simple tasks such as closing your eyes. External stimuli such as flashing light or sounds may also be given to see if the seizure will be triggered.

Lumbar Puncture

This is an invasive procedure that involves sticking a needle between your spine to get fluid from your brain.

This fluid contains a lot of information such as if you have an infection, bleeding, or cancer.  

Audiometry test

This is a test that may be requested if Meniere’s Disease is being suspected.

You will wear a headset and will be asked to identify sound in different frequencies. It may reveal either a sensorineural hearing loss or a bone-conduction hearing loss

Complete Blood Count

A simple extraction of blood will show systemic signs of infection or cancer that can help the doctor see the complete picture.

Of course, again, these are not routine procedures for headache, per se. These are just done to rule out other medical conditions.  The doctor will always decide based on your presentation.

So what's the problem and why nothing works?

Because probably you, like myself, experience symptoms on the intersection of several conditions such as ON, CGH, Migraine, Tension headaches, and more.

Since we are dealing with the mix symptoms (research is not yet clear on how it all manifests), targeting one symptom in isolation is a painful (and costly) waste of time.

We need to address underlying processes on a more global scale that sometimes means getting results which are not immediate but sustainable (assuming you are not fainting right at this moment because of unbearable pain; call emergency now if that's the case).

The idea is:  Let's deal with the pain and distress so we can have energy, motivation, and mental clarity for a more radical treatment.

The time to fix the roof is when the sun is shining.’

We're going to prepare ourselves (help the sun to come out) in order for the true healing process to even begin (fixing the roof).

Physical pain and emotional frustration (resulting from not understanding what's happening and how to deal with it) is what turns our lives into a miserable existence. Generally, we experience a lack of will to do anything until this continuous confusion goes away.

You can learn here why your emotional and mental states can literally generate physical pain.

We need to clear the fog, so to speak, in order to breath freely for a moment so we can gather energy and realize that there's a way out of all this.

Let's do it.

I've created a simple, easy-to-follow model for self-healing. It's simple. It's universal. It's free.

Here are some of the references used for this article:

  1. American Migraine Foundation (2017). Guide to Triggers & How to Manage Them.Retrieved from https://americanmigrainefoundation.org/resource-library/top-10-migraine-triggers-and-how-to-deal-with-them/
  2. Anxiety and Depression Association of America(2018). Headaches. Retrieved from https://adaa.org/understanding-anxiety/related-illnesses/headaches
  3. Australian Family Physician (2016). An approach to vertigo in general practice. Retrievedfromhttps://www.racgp.org.au/afp/2016/april/an-approach-to-vertigo-in-general-practice/
  4. Bigley,GK (1990). Headache. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK377
  5. Do, TP et al(2018). Retrieved from https://www.researchgate.net/profile/Mark_Obermann/publication/329939433_Red_and_orange_flags_for_secondary_headaches_in_clinical_practice_SNNOOP10_list/links/5c2ddacb92851c22a35712bd/Red-and-orange-flags-for-secondary-headaches-in-clinical-practice-SNNOOP10-list.pdf?origin=publication_detail
  6. Espi-Lopez,GV, et.al (2014). Effectiveness of Physical Therapy in Patients with Tension-Type Headache: Literature Review. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4316547/#!po=35.4167
  7. Goadsby,P.J. Pathophysiology of Migraine. Ann Indian Acad Neurol. 2012 Aug; 15(Suppl1): S15–S22.
  8. Harvard Medical School(2011). Understanding the stress response. Retrieved from https://www.health.harvard.edu/staying-healthy/understanding-the-stress-response
  9. International Association for the Study of Pain (2011). Epidemiology of Headache. Retrieved fromhttps://s3.amazonaws.com/rdcms-iasp/files/production/public/Content/ContentFolders/GlobalYearAgainstPain2/HeadacheFactSheets/1-Epidemiology.pdf
  10. International Association for the Study of Pain (2011). Tension-Type Headache.  Retrievedfromhttps://s3.amazonaws.com/rdcms-iasp/files/production/public/Content/ContentFolders/GlobalYearAgainstPain2/HeadacheFactSheets/3-TensionType.pdf
  11. InternationalHeadache Society (nd). Classification of Primary Headaches. Retrieved fromhttps://ichd-3.org/classification-outline/
  12. Kajal,M., Malik, M., Kumari, R. (2017). Correlation fo Stress with Migraine - A review. Retrieved from https://www.ijcrr.com/uploads/1271_pdf.pdf
  13. Kim, DW & Lee, SK(2017) Headache and Epilepsy. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540694/
  14. Morris,L. (20150). Dizziness Related to Anxiety and Stress. Retrieved fromhttp://www.neuropt.org/docs/default-source/vsig-english-pt-fact-sheets/anxiety-and-stress-dizziness4ca035a5390366a68a96ff00001fc240.pdf?sfvrsn=80a35343_0
  15. Neuhauser,HK (2016). The epidemiology of dizziness and vertigo.  Retrieved fromhttps://www.ncbi.nlm.nih.gov/pubmed/27638063
  16. NHS (2019).Migraine. Retrieved from https://www.nhs.uk/conditions/migraine/prevention/
  17. NHS (217).Vertigo. Retrieved from https://www.nhs.uk/conditions/vertigo/
  18. Rains,J., Poceta, S. (2010). Sleep and Headache. Retrieved from https://pubmed.ncbi.nlm.nih.gov/20842485/
  19. Standford Health Care (nd). Headache Treatment and Headache Relief. Retrieved from https://stanfordhealthcare.org/medical-conditions/brain-and-nerves/headache/treatments.html
  20. Tarnutzer,A., et. al. (2014). Epileptic Vertigo and Dizziness - A Systematic Review of the Literature.  Retrieved from https://n.neurology.org/content/82/10_supplement/p3.227
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