What is the difference between a migraine and a tension headache?

A migraine is usually one-sided, throbbing, and made worse by movement, often with nausea, light sensitivity, and sometimes aura (visual disturbances). A tension headache is usually a band-like tightness around the head, less intense, and not made worse by movement. They have different drivers and different treatments.

When should I get a brain MRI for headaches?

You should get a brain MRI for headaches when SNOOP red flags are present, when symptoms change suddenly, or when a new headache pattern starts after age 50. Most chronic migraine patients have a normal MRI, so we order it based on history rather than as a default.

Is a thunderclap headache always an emergency?

Yes, a thunderclap headache is always an emergency until proven otherwise. A sudden severe headache that peaks in seconds can be a subarachnoid hemorrhage (bleeding around the brain). Even if the pain eases, a thunderclap deserves an immediate ER visit and a CT scan.

Can a headache be caused by my period?

Yes, a headache can absolutely be caused by your period. Estrogen drops just before menstruation, which can trigger menstrual migraine. We test hormones on Day 21 and often use targeted hormonal strategies to soften the drop.

What is medication overuse headache?

Medication overuse headache is a chronic daily headache caused by frequent use of pain medication. It happens when you use ibuprofen, acetaminophen, or triptans more than 10 to 15 days per month. The fix is a careful taper of the offending medication, often with neuromodulation devices or CGRP medications as a bridge.

Are CGRP medications safe?

CGRP medications appear safe based on data through 5 to 7 years of use, with the main side effect being constipation. We use them at the lowest effective dose and monitor for blood pressure changes. They have changed migraine outcomes meaningfully since 2018.

Can I prevent migraines without medication?

Yes, many patients prevent migraines without medication using sleep work, glucose stability, magnesium, riboflavin, CoQ10, and stress regulation. The key is consistency, not perfection. We measure and adjust based on attack frequency every 6 to 12 weeks.

How long until I see fewer attacks?

Most patients see fewer attacks within 8 to 12 weeks of a structured plan. Quick wins (sleep, hydration, magnesium) often appear in 2 to 4 weeks. Hormonal and metabolic shifts take a full quarter to play out.

Can a sinus infection cause a migraine?

A sinus infection can cause facial pressure that mimics migraine, but most patients diagnosed with "sinus headache" actually have migraine. The clue is light sensitivity, nausea, and one-sided throbbing pain, which point to migraine. We treat what is actually there, not just what the diagnosis sounds like.

Is a headache after exercise dangerous?

A headache after exercise is usually benign exertional headache, but a sudden severe exertional headache deserves urgent evaluation to rule out a brain aneurysm or other vascular cause. If the pattern is new, particularly in someone over 40, we order imaging.

Can high blood pressure cause headaches?

Mild to moderate high blood pressure rarely causes headaches. A blood pressure above 180 over 120 with a severe headache, vision changes, or neurologic symptoms is a hypertensive emergency that needs the ER. Routine blood pressure of 140 over 90 is unlikely to be the cause of your daily pain.

Can a brain tumor cause headaches?

Yes, brain tumors can cause headaches, but they are a rare cause of chronic headache. Tumor-related headaches typically worsen over weeks to months, are worse in the morning, and come with neurologic signs like weakness, vision changes, or seizures. SNOOP catches most of these patterns.

What about a headache during pregnancy?

A headache during pregnancy needs careful evaluation, particularly in the second half of pregnancy, because it can signal preeclampsia (a dangerous rise in blood pressure with kidney involvement). Always loop in your OB-GYN for any new or worsening headache pattern in pregnancy.

Can chronic Lyme cause migraine-like headaches?

Yes, chronic Lyme and other tick-borne infections can cause persistent headaches in some patients, particularly after exposure in the Wissahickon, the Poconos, or South Jersey. We screen with Lyme antibodies, Babesia, and Bartonella when the history fits. Treatment is nuanced.

What is occipital neuralgia?

Occipital neuralgia is sharp, shooting pain at the base of the skull caused by irritation of the greater occipital nerve. It often comes from cervical spine tightness or whiplash. Targeted physical therapy and occasional nerve blocks usually help. We coordinate with structural physical therapists in Philly who specialize in this.

Can mold exposure cause migraines?

Yes, mold exposure in damp Philly rowhomes can trigger migraines through inflammation and histamine release. If your basement is musty or you feel worse at home than away, a professional mold inspection is reasonable. Indoor humidity above 50% is the most common driver.

Are nerve blocks effective for migraine?

Yes, occipital nerve blocks can be very effective in selected patients, particularly those with pain at the base of the skull or chronic migraine that does not respond to oral medications. The injection uses lidocaine and sometimes a small amount of steroid. We refer to neurology partners who perform these.

Does sleep apnea cause morning headaches?

Yes, sleep apnea is a classic cause of morning headaches. Disrupted breathing raises CO2 overnight, which dilates brain vessels and triggers pain. A WatchPAT home study is a low-friction way to rule it in or out, even if you do not snore loudly.

Can a headache be from my jaw?

Yes, a headache can come from jaw tension, particularly in patients who clench or grind at night (TMJ dysfunction, where the temporomandibular joint that connects your jaw to your skull is irritated). A custom night guard, targeted physical therapy, and stress regulation usually help.

What about ketogenic diet for migraine?

Ketogenic diets help some patients with migraine, particularly those with strong glucose-driven triggers. Ketones are an alternative brain fuel that bypass glucose. Long-term keto is hard to sustain. We sometimes try a structured 4 to 6 week trial to see if benefit is real.

Can perimenopause make migraines worse?

Yes, perimenopause often makes migraines worse, particularly in patients with a history of menstrual migraine. Progesterone declines first, which fragments sleep. Estrogen swings then add unpredictable triggers. Bio-identical progesterone often helps.

Is daily aspirin safe to prevent headache?

Daily aspirin is not first-line for migraine prevention because of bleeding risk and rebound headache potential. We use it carefully in selected patients, usually for cardiovascular reasons, and pair it with a stomach-protective strategy. Daily over-the-counter pain medication usually causes more headaches than it prevents.

Should I see a neurologist or an internal medicine doctor first?

For most chronic headaches, a thoughtful internal medicine doctor is the right starting point because the drivers are often metabolic, hormonal, and lifestyle-based. A neurologist is the right next step for refractory cases, severe migraine, or any SNOOP red flag. We bridge both worlds.

What is the difference between a migraine and a tension headache?

A migraine is usually one-sided, throbbing, and made worse by movement, often with nausea, light sensitivity, and sometimes aura (visual disturbances). A tension headache is usually a band-like tightness around the head, less intense, and not made worse by movement. They have different drivers and different treatments.

When should I get a brain MRI for headaches?

You should get a brain MRI for headaches when SNOOP red flags are present, when symptoms change suddenly, or when a new headache pattern starts after age 50. Most chronic migraine patients have a normal MRI, so we order it based on history rather than as a default.

Is a thunderclap headache always an emergency?

Yes, a thunderclap headache is always an emergency until proven otherwise. A sudden severe headache that peaks in seconds can be a subarachnoid hemorrhage (bleeding around the brain). Even if the pain eases, a thunderclap deserves an immediate ER visit and a CT scan.

Can a headache be caused by my period?

Yes, a headache can absolutely be caused by your period. Estrogen drops just before menstruation, which can trigger menstrual migraine. We test hormones on Day 21 and often use targeted hormonal strategies to soften the drop.

What is medication overuse headache?

Medication overuse headache is a chronic daily headache caused by frequent use of pain medication. It happens when you use ibuprofen, acetaminophen, or triptans more than 10 to 15 days per month. The fix is a careful taper of the offending medication, often with neuromodulation devices or CGRP medications as a bridge.

Are CGRP medications safe?

CGRP medications appear safe based on data through 5 to 7 years of use, with the main side effect being constipation. We use them at the lowest effective dose and monitor for blood pressure changes. They have changed migraine outcomes meaningfully since 2018.

Can I prevent migraines without medication?

Yes, many patients prevent migraines without medication using sleep work, glucose stability, magnesium, riboflavin, CoQ10, and stress regulation. The key is consistency, not perfection. We measure and adjust based on attack frequency every 6 to 12 weeks.

How long until I see fewer attacks?

Most patients see fewer attacks within 8 to 12 weeks of a structured plan. Quick wins (sleep, hydration, magnesium) often appear in 2 to 4 weeks. Hormonal and metabolic shifts take a full quarter to play out.

Can a sinus infection cause a migraine?

A sinus infection can cause facial pressure that mimics migraine, but most patients diagnosed with "sinus headache" actually have migraine. The clue is light sensitivity, nausea, and one-sided throbbing pain, which point to migraine. We treat what is actually there, not just what the diagnosis sounds like.

Is a headache after exercise dangerous?

A headache after exercise is usually benign exertional headache, but a sudden severe exertional headache deserves urgent evaluation to rule out a brain aneurysm or other vascular cause. If the pattern is new, particularly in someone over 40, we order imaging.

Can high blood pressure cause headaches?

Mild to moderate high blood pressure rarely causes headaches. A blood pressure above 180 over 120 with a severe headache, vision changes, or neurologic symptoms is a hypertensive emergency that needs the ER. Routine blood pressure of 140 over 90 is unlikely to be the cause of your daily pain.

Can a brain tumor cause headaches?

Yes, brain tumors can cause headaches, but they are a rare cause of chronic headache. Tumor-related headaches typically worsen over weeks to months, are worse in the morning, and come with neurologic signs like weakness, vision changes, or seizures. SNOOP catches most of these patterns.

What about a headache during pregnancy?

A headache during pregnancy needs careful evaluation, particularly in the second half of pregnancy, because it can signal preeclampsia (a dangerous rise in blood pressure with kidney involvement). Always loop in your OB-GYN for any new or worsening headache pattern in pregnancy.

Can chronic Lyme cause migraine-like headaches?

Yes, chronic Lyme and other tick-borne infections can cause persistent headaches in some patients, particularly after exposure in the Wissahickon, the Poconos, or South Jersey. We screen with Lyme antibodies, Babesia, and Bartonella when the history fits. Treatment is nuanced.

What is occipital neuralgia?

Occipital neuralgia is sharp, shooting pain at the base of the skull caused by irritation of the greater occipital nerve. It often comes from cervical spine tightness or whiplash. Targeted physical therapy and occasional nerve blocks usually help. We coordinate with structural physical therapists in Philly who specialize in this.

Can mold exposure cause migraines?

Yes, mold exposure in damp Philly rowhomes can trigger migraines through inflammation and histamine release. If your basement is musty or you feel worse at home than away, a professional mold inspection is reasonable. Indoor humidity above 50% is the most common driver.

Are nerve blocks effective for migraine?

Yes, occipital nerve blocks can be very effective in selected patients, particularly those with pain at the base of the skull or chronic migraine that does not respond to oral medications. The injection uses lidocaine and sometimes a small amount of steroid. We refer to neurology partners who perform these.

Does sleep apnea cause morning headaches?

Yes, sleep apnea is a classic cause of morning headaches. Disrupted breathing raises CO2 overnight, which dilates brain vessels and triggers pain. A WatchPAT home study is a low-friction way to rule it in or out, even if you do not snore loudly.

Can a headache be from my jaw?

Yes, a headache can come from jaw tension, particularly in patients who clench or grind at night (TMJ dysfunction, where the temporomandibular joint that connects your jaw to your skull is irritated). A custom night guard, targeted physical therapy, and stress regulation usually help.

What about ketogenic diet for migraine?

Ketogenic diets help some patients with migraine, particularly those with strong glucose-driven triggers. Ketones are an alternative brain fuel that bypass glucose. Long-term keto is hard to sustain. We sometimes try a structured 4 to 6 week trial to see if benefit is real.

Can perimenopause make migraines worse?

Yes, perimenopause often makes migraines worse, particularly in patients with a history of menstrual migraine. Progesterone declines first, which fragments sleep. Estrogen swings then add unpredictable triggers. Bio-identical progesterone often helps.

Is daily aspirin safe to prevent headache?

Daily aspirin is not first-line for migraine prevention because of bleeding risk and rebound headache potential. We use it carefully in selected patients, usually for cardiovascular reasons, and pair it with a stomach-protective strategy. Daily over-the-counter pain medication usually causes more headaches than it prevents.

Should I see a neurologist or an internal medicine doctor first?

For most chronic headaches, a thoughtful internal medicine doctor is the right starting point because the drivers are often metabolic, hormonal, and lifestyle-based. A neurologist is the right next step for refractory cases, severe migraine, or any SNOOP red flag. We bridge both worlds.

Migraine vs. Serious: When to Worry About a Headache

TL;DR30-second take

Most headaches are frustrating but not dangerous. A specific list of red flags called the SNOOP checklist tells you when a headache needs urgent imaging or an ER visit. Once those red flags are ruled out, we focus on prevention through metabolic stability, sleep, and targeted medications.

You wake up with a pounding head. The light from the bedroom feels like daggers. You wonder, for the third time this month, whether something is really wrong this time. The internet is no help. Most search results either send you to the ER or shrug it off.

"A headache is a signal that your nervous system is overwhelmed. I do not just want to numb the pain. I want to find the why. Is it a glucose spike? Sleep debt? A cervical spine issue? We rule out the scary stuff first, then build a fortress of prevention."

What Is the SNOOP Checklist for Headache Safety?

The SNOOP checklist is a quick clinical framework we use to decide whether a headache needs imaging or an urgent evaluation. SNOOP stands for the five categories of red flags that point to something more than a standard migraine.

S, Systemic symptoms. Fever, chills, sudden weight loss, or signs of infection or cancer.
N, Neurologic signs. Confusion, weakness, numbness, slurred speech, or vision changes.
O, Onset that is sudden. A thunderclap headache that peaks in seconds (the "worst headache of my life").
O, Older age. A new type of headache that starts after age 50.
P, Pattern change. A clear change in frequency, intensity, or location, or pain that gets worse when you lie down or stand up.

If any of these features show up, we prioritize urgent evaluation, which often includes advanced brain imaging or a neurology referral.

What Are the Pillars of Migraine Management?

The pillars of migraine management are prevention, identification, and rescue. Once the SNOOP audit is negative, we turn to long-term prevention and a rescue kit that works for your biology.

Trigger identification. A 14-day log tracks diet, sleep, weather, hormones, and stress against attack timing. Patterns guide testing.
Metabolic stability. Blood sugar crashes (reactive hypoglycemia) are a major and often missed trigger. Stabilizing insulin and glucose is step one for many patients.
Hormonal balance. Many women experience menstrual migraine tied to estrogen drops. We use hormone optimization to smooth those transitions.
Targeted therapeutics. From magnesium and B2 to CGRP receptor antagonists like Nurtec, we build a kit matched to your specific attack profile.

When Should I Go to the ER for a Headache?

Go to the ER or call 911 for a headache that fits any of the SNOOP red flags. These are not Fishtown Medicine cases. They are time-sensitive emergencies.

The thunderclap. Sudden severe pain that peaks in seconds. This can be a subarachnoid hemorrhage (a type of brain bleed).
Neurologic deficits. Weakness, numbness, facial droop, slurred speech, or vision loss.
Fever with a stiff neck. Possible meningitis (an infection of the brains lining).
After a head injury. Particularly if pain worsens or you become drowsy.
Headache that wakes you from sleep. Particularly if it is a new pattern.

If you are not sure, call 911 or your nearest ER. Speed matters when red flags appear.

Actionable Steps in Philly

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A practical plan for safer headache management.

Memorize SNOOP. Take a screenshot. Share it with the people who live with you.
Track 14 days of attacks. Note time, food in the prior 4 hours, sleep, stress, and cycle day. Bring the data to your visit.
Stay hydrated and salty. Dehydration and low sodium are common triggers. Aim for 2 to 3 liters of fluid plus electrolytes if you sweat heavily.
Try magnesium. Start at 200 to 400 mg of magnesium glycinate or threonate before bed.
Get the right labs. Fasting insulin, hemoglobin A1c, vitamin D, magnesium RBC, and a full thyroid panel. Add Day 21 hormones if attacks track with your cycle.

Key Takeaways

SNOOP first. The gold-standard quick safety check.
Sudden or new in older adults. These almost always need imaging.
Prevention is metabolic. Glucose, sleep, and hormones move the needle most.
Internal medicine bridges the gap. Between primary care and neurology.

Scientific References

Dodick DW. "Pearls: headache." Seminars in Neurology. 2010 (SNOOP framework).
Goadsby PJ, et al. "CGRP-targeted therapies for migraine prevention." Nature Reviews Neurology. 2020.
Yablon LA, Mauskop A. "Magnesium in headache." Magnesium in the Central Nervous System. 2011.
MacGregor EA. "Hormonal influences on migraine." Neurologic Clinics. 2009.
Edmeads J. "The worst headache ever: Ominous causes and management." Postgraduate Medicine. 1989.

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Ashvin Vijayakumar MD (Dr. Ash) is a board-certified internal medicine physician specializing in preventive medicine and healthspan optimization at Fishtown Medicine in Philadelphia.

Fishtown Medicine | Symptoms

2418 E York St, Philadelphia, PA 19125(267) 360-7927 hello@fishtownmedicine.comHSA/FSA Eligible

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