Migraine headaches are far more than ordinary headaches. People who suffer from migraines often describe the pain as unbearable, comparing it to having an “ice pick” pushed through the head or feeling like their brain is “on fire.”
These attacks can leave people unable to work, study, drive, or even tolerate light and sound.
Migraines affect more than one in 10 Americans and are one of the leading causes of disability worldwide.
Despite how common they are, doctors still diagnose and treat migraines mostly by listening to patients describe their symptoms. There are no simple blood tests or scans routinely used to confirm exactly what type of migraine a person has.
Now, a new study from Stanford Medicine may help change that. Researchers used advanced brain imaging to identify two distinct biological types of migraine, a discovery that could eventually improve treatment and help doctors predict which patients are likely to develop more severe disease.
The study was published in the journal Cephalalgia.
Migraine symptoms can vary greatly from person to person. Some people experience intense throbbing pain on one side of the head, while others suffer nausea, vomiting, dizziness, visual disturbances, and extreme sensitivity to light, sound, or smells. Attacks can last for hours or even days.
Doctors currently classify migraines mainly into two groups. People with headaches on fewer than 15 days each month are labeled as having episodic migraine, while those with headaches on more than 15 days per month are considered to have chronic migraine.
This system helps guide treatment decisions. Patients with chronic migraine are more likely to receive preventive medicines taken daily, such as beta blockers or anticonulsant drugs. Insurance companies often use this classification when deciding whether to cover expensive treatments.
However, researchers have long suspected that the chronic-versus-episodic system may not fully capture the true biology of migraine disease. Some patients with fewer headache days still experience extremely disabling symptoms, while others with frequent headaches may respond differently to treatment.
Dr. Robert Cowan, a neurologist and headache specialist at Stanford Medicine, said migraine treatment today often feels like “darts in the dark.” Doctors frequently rely on trial and error because they lack clear biological markers that explain why migraines happen differently in different people.
To better understand migraine biology, Cowan and his colleagues carried out the largest brain imaging study of migraine patients to date.
The study included 111 people with migraines and 51 volunteers without migraines. Researchers collected detailed information about participants’ symptoms, health history, and demographics.
Participants also underwent two kinds of MRI scans. Structural MRI looked at the physical structure of the brain, while functional MRI, also known as fMRI, examined brain activity by measuring blood flow between different brain regions.
Instead of starting with a specific theory about migraine causes, the researchers used computer analysis to search for hidden patterns in the imaging data.
The results revealed two clear migraine subtypes.
One group, called cluster 1, appeared more similar to healthy control participants in their brain scans. People in this group generally had less severe migraines overall.
The second group, called cluster 2, showed major differences in brain activity patterns, especially in communication between the brain’s cortex and deeper subcortical regions.
Researchers believe these brain differences may affect how migraine patients process sensory information. In healthy people, the brain normally reacts to dangerous or unusual sensory signals by triggering pain or discomfort as protection.
But in people with cluster 2 migraines, the brain may overreact to ordinary sensory experiences, leading to severe migraine attacks.
Patients in cluster 2 also showed important clinical differences. They were generally older, had migraines lasting longer periods, and were more likely to be seriously disabled by their condition.
Interestingly, there was no major difference in headache frequency between the two groups. This finding challenges the traditional idea that migraine severity is mainly defined by how often headaches occur.
The researchers believe this may explain why some patients with “episodic” migraines still suffer greatly and might benefit from preventive treatment even if they do not officially qualify for it under current guidelines.
The study also raises questions about insurance policies that restrict coverage for preventive migraine treatments based only on headache frequency.
Researchers now hope the biological subtype system may eventually help doctors make more personalized treatment decisions. Instead of using trial and error, physicians may someday match treatments to specific migraine biology.
The team is also exploring whether blood tests and detailed symptom patterns could help identify the same migraine subtypes without requiring expensive fMRI scans.
This would be important because functional MRI is costly and not widely available for routine migraine care.
The researchers are particularly interested in determining whether patients in certain biological subtypes are more likely to respond to preventive medications, even if they do not meet the official criteria for chronic migraine.
The findings are exciting because they suggest migraines may not be one single disease but rather several biologically different conditions that produce similar symptoms. Understanding these hidden differences could lead to more accurate diagnosis and better treatment in the future.
However, the research is still early, and more studies will be needed before brain imaging can become part of routine migraine care. Scientists also still need to confirm whether these biological subtypes consistently predict treatment response.
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The study was published in Cephalalgia.
Source: Stanford Medicine.
