In Germany, around 70% of the population occasionally suffer from headaches, approximately 10–15% from migraines, with 1–2% being chronically affected, and about 38% experiencing severe headaches several times a month. The editorial team of Leading Medicine Guide learned what can be done effectively about this in a conversation with headache specialist Dr. Regina Becker, MD.
Headaches and migraines are among the most common neurological complaints in Germany and can significantly limit quality of life. Fortunately, a wide range of effective medical measures is available today—from targeted diagnostics and drug therapies to preventive strategies—that can help those affected relieve symptoms and actively reclaim their lives.
Headaches and migraines arise from different processes in the brain and the surrounding structures.
„If you ask what exactly happens in headaches or migraines, you first need to know that there are more than 200 different types of headaches overall. Fundamentally, we distinguish between primary and secondary headaches. Secondary headaches are a symptom that occurs in connection with another illness—such as a cold, the flu, or even a brain injury.
A typical example is the well-known sinus headache associated with sinusitis. Primary headaches, on the other hand, do not arise because of another illness. The most important forms include migraine, tension-type headache, and—although less common—cluster headache.
Migraine is a particularly complex form in which an interplay between the brain, nerve cells, blood vessels, and certain neurotransmitters plays a decisive role. Many sufferers also have a genetic predisposition: Their nervous system reacts hypersensitively to stimuli such as stress, hormonal fluctuations, lack of sleep, certain foods, or even changes in the weather.
When a migraine attack occurs, a wave of activity spreads through the brain, altering blood flow and stimulating the release of inflammatory substances. These stimulate the pain fibers of the trigeminal nerve, the fifth cranial nerve. This activation triggers the release of additional inflammatory substances that irritate the meninges and set off an inflammatory response—this is exactly what causes the typical migraine pain, usually throbbing and pulsating, which may occur on one or both sides.
Sufferers often experience not only moderate to severe headaches, but also a variety of additional symptoms: nausea, vomiting, sensitivity to light, noise, and odors, problems concentrating, as well as worsening pain during physical activity.
That is why many people withdraw to a dark, quiet room during an attack until the symptoms gradually subside. A migraine attack usually lasts between four and 72 hours, but in some cases it may last significantly longer“, explains Dr. Regina Becker at the beginning of our conversation, before elaborating on the special aspects of a possible genetic predisposition:
„There are people who never develop headaches at all. Some people have this predisposition, others do not. In those affected, a positive family history can often be established, especially in migraine: Often at least one close relative is affected as well. Nevertheless, this does not automatically mean that you will develop the condition simply because you carry these inherited genes.
Whether migraine actually breaks out often depends on additional life circumstances. In women, hormones play an important role, as do stress and general lifestyle. These factors can add up and ultimately lead to a migraine attack. This also explains why many women of childbearing age experience problems particularly often, while symptoms frequently diminish again during menopause.
Many patients also report that the pain occurs especially intensely and frequently during stressful periods in which they find little relaxation or sleep poorly. In many migraine patients, the symptoms begin as early as childhood or upon entering puberty. Nevertheless, there are also people who only develop migraine later in life. Both courses do occur“.
There are some rare forms of headache that are significantly more difficult to recognize than migraine or tension-type headache. These include the trigeminal autonomic headaches, whose best-known representative is cluster headache.
Dr. Becker explains: „Typical of this group are strictly unilateral, often very severe pain attacks that can hardly be treated with standard painkillers. Some patients report tearing in one eye or redness of the eye, a runny nose, or nasal congestion on one side—these are typical trigeminal autonomic symptoms. Trigeminal autonomic headaches often respond exclusively to indomethacin, which is why targeted diagnostics are so important.
Many of these patients have years of misdiagnoses behind them because they are mistakenly treated as migraine or tension-type headache patients. In cluster headache, which occurs more frequently in middle-aged men, extreme, ´devastating´ unilateral pain usually occurs at night. Those affected are so restless that they pace around—in contrast to migraine patients, who seek rest.
In the acute phase, fast-acting triptans help, for example as a nasal spray or injection pen. In addition, inhaling pure oxygen can bring noticeably rapid relief. That is why patients are often provided with oxygen tanks and a mask. These rare disorders are extremely distressing, and that is precisely why education and specialized diagnostics are so important“.
Migraine is a neurological disorder in which vascular and nerve-related processes trigger inflammatory signals in the trigeminal nervous system and cause pulsating, usually unilateral headaches, often accompanied by nausea, sensitivity to light and noise, as well as occasional aura symptoms. Cluster headaches are thought to result from dysregulation in the hypothalamus and manifest as extremely severe, unilateral pain around the eye or temple, typically in periodic phases with several attacks per day. Sinus headaches are caused by inflamed paranasal sinuses and present as dull pressure with nasal congestion or a mild fever, while medication-induced or secondary headaches may also occur. Symptoms vary depending on the form: tension-type headaches are more dull and pressing, migraines strongly pulsating, and cluster headaches stabbing and accompanied by tearing or a runny nose. Triggers range from stress and hormonal influences to muscle tension, sleep disturbances, or infections.
Various diagnostic procedures are used to determine the exact cause of headaches or migraines, selected individually depending on the symptoms.
Dr. Becker describes this as follows: „When a patient comes to us complaining of sleep disturbances, concentration problems, declining performance at work, and regular headaches, we first begin with a detailed medical history interview. In doing so, we try to find out what causes may lie behind the symptoms—for example, changes in lifestyle, caffeine consumption in the evening, or a high level of engagement with multimedia and work-related tasks that extend into sleep time.
In addition, we perform technical examinations, such as recording brain waves, in order to detect abnormalities in nerve cell activity. We also carry out ultrasound examinations of the vessels in the neck and head, and if necessary, we refer patients for an MRI in order to rule out secondary causes of headaches.
Migraine and tension-type headache are diagnoses of exclusion: There is no definitive test that proves the condition. In the vast majority of cases, the examination findings are unremarkable, making it possible to determine that no secondary factors are present“.
Today, different medication options are available for the treatment of migraine, both for acute pain therapy and for prophylactic prevention, tailored individually to the patient.
„The treatment of headaches depends on how frequently they occur. In the case of occasional symptoms, acute therapy with painkillers may be sufficient and provide quick, reliable relief. In the case of regular headaches, long-term use of painkillers is problematic because it can actually worsen the symptoms. In such cases, migraine prophylaxis is recommended, including both pharmacological and non-pharmacological measures.
These include sleep hygiene, stress reduction, relaxation techniques such as progressive muscle relaxation, yoga, Pilates, or endurance sports, as well as regular food and fluid intake. If these measures are not sufficient, specific medications are used, with the choice depending on comorbidities such as depression or sleep disorders. Antidepressants can be useful here because they can also alleviate accompanying symptoms.
Today, particularly effective treatments for migraine include CGRP antibodies, which are injected once a month and block a naturally occurring protein that plays a central role in migraine attacks. This therapy is well tolerated, effective, and intended for long-term use over nine to twelve months, followed by individual adjustment. A common problem is medication-overuse headache, which develops when painkillers are taken on more than ten days per month.
This causes headaches to worsen and respond less well to medication. To avoid this, the 10–20 rule applies: painkillers on no more than ten days per month. In cases of severe overuse, inpatient withdrawal from pain medication may also become necessary. At the same time, however, headache or migraine prophylaxis is initiated in order to reduce attacks and lower the long-term need for painkillers“, says Dr. Becker, adding:
„In an acute migraine attack, it actually makes sense to take the pain medication in a sufficiently high dose to eliminate the headache completely. Too low a dose may only partially relieve the pain, causing it to flare up again and again.
With ibuprofen, for example, this means that 400 to 600 mg should be taken rather than spreading only half the dose over several days. This way, the migraine responds better to treatment, and the attack can be ended effectively. Among the migraine patients we treat, the main age group is between about 20 and 55 years, although we also see adolescents from age 15 onward.
In women in particular, the peak in symptoms is usually seen from the early 20s to the early 50s. There are older patients as well, but they make up a smaller proportion. In general, we observe that headache disorders are diagnosed more frequently today than they were 30 years ago. One reason is that science has advanced and knowledge about these disorders has increased, so symptoms are now taken more seriously and treated more specifically.
Patients are also more likely to go to the doctor today because they pay greater attention to their health. A rise in headaches is particularly evident among younger people, which is partly related to the intense sensory overload caused by smartphones and digital media. Constant notifications, continuous screen use, and a lack of quiet periods place stress on the brain and can, especially in the presence of a genetic predisposition, increase susceptibility to headaches.
This also frequently results in sleep disturbances because young people are hardly able to unwind anymore“.
The use of botulinum toxin (BTX) and other specialized therapies is particularly appropriate in chronic and treatment-resistant migraine when conventional medications for acute treatment or prophylaxis are not sufficiently effective or are not tolerated.
Dr. Becker elaborates: „Botox therapy is approved for chronic migraine, meaning for patients with at least 15 headache days per month, half of which are migraine-typical. Many sufferers also have additional tension in the jaw muscles caused by teeth grinding (craniomandibular dysfunction) or in the neck and shoulder muscles.
During treatment, Botox is injected specifically into the forehead, where, among other things, the exit points of the trigeminal nerve are located, as well as into the jaw muscles and the neck and shoulder muscles. This desensitizes pain fibers and reduces muscular tension, which shows very good results, especially in chronic headaches.
The idea comes from the treatment of other neurological disorders with muscular overactivity, for example spasticity after strokes. It became apparent there that Botox interrupts the constant overactivity of the muscles. Applied to migraine, it means that the brain receives fewer continuous stimuli from tense muscles, and the vicious cycle of pain and tension is broken. Botox is now also used in other pain disorders, such as nerve pain after shingles, because desensitizing the nerve fibers often brings significant relief without the need for highly burdensome pain medications“.
Chronic migraine is defined as ≥ 15 headache days per month, of which at least 8 are migraine-like, and BTX is used specifically in this patient group. BTX does not work like a conventional painkiller, but rather intervenes in the neurobiological pain mechanisms.
Non-pharmacological approaches play an important role in the long-term relief of headaches and migraines, especially as a complement to drug therapy.
„To avoid headaches as much as possible, regular sleep, exercise, and mindful nutrition are especially crucial. Major mistakes include irregular sleeping times—for example, sleeping too little during the week and too long on the weekend—as well as alcohol and histamine-rich foods such as beer, red wine, tomatoes, eggplants, or ripe bananas, all of which can trigger headaches in many patients.
Light endurance exercise two to three times per week helps loosen the muscles and reduce stress, although overexertion should be avoided. Here, heart rate monitoring can be useful so that the pulse does not exceed around 160 beats per minute. Seasonal factors also play a role: darker seasons or transitional months can intensify headaches and mood swings.
In such cases, daylight or infrared light can help, as can spending time outdoors regularly. Ultimately, it is about paying attention to your own triggers, optimizing lifestyle factors, and reducing stress in order to prevent headaches in the long term“, recommends Dr. Regina Becker.
The Neurozentrum München-Schwabing has a clear focus on headaches and treats a great many patients with different headache disorders.
„We have the necessary expertise to recognize and treat rare and difficult-to-diagnose headache disorders. Another advantage of our practice is our close network with radiology colleagues, which makes prompt evaluations, for example by MRI, possible. In addition, we still maintain contacts with the university hospital so that patients can be integrated into a specialized center when needed.
When it comes to lifestyle, the hormonal situation is especially important in women of childbearing age. Estrogen-containing contraceptives can be counterproductive in migraine with aura because they increase the risk of stroke. In menstrual migraine, on the other hand, a continuous progestin-only pill may be useful to stabilize the hormonal cycle. Similar considerations apply to women in perimenopause or menopause, where targeted hormone therapy, for example with progesterone preparations, can help relieve symptoms.
In this way, we take into account both the individual triggers and the hormonal influences in the counseling and treatment of our patients“, emphasizes Dr. Regina Becker, and with that we conclude our conversation.
Thank you very much, Dr. Becker, for this important educational insight into the topic of headaches!
- Board-certified neurologist with a focus on headache and migraine treatment
- Many years of experience, former head of the Upper Bavarian Headache Center at LMU University Hospital Munich
- Practice in Munich-Schwabing, specializing in acute, chronic, and treatment-resistant forms of headache
- Diagnosis and treatment of migraine, tension-type headaches, and cluster headaches
- Use of modern, guideline-based procedures, including botulinum toxin (BTX) for chronic migraine
