What Is Migraine?

Migraine is a primary headache disorder, meaning the headache itself is the condition—not a symptom of another disease such as a brain tumor, sinus infection, or stroke. It is a neurologic disorder involving altered processing of pain signals within the brain and cranial nerves.

One of the most important cranial nerves involved in migraine is the trigeminal nerve, the primary sensory nerve of the face. The trigeminal nerve carries pain and light-touch sensation from the face and also supplies the muscles that close the jaw, including those associated with the temporomandibular joint (TMJ). In addition, the trigeminal nerve innervates the TMJ itself via the auriculotemporal nerve.

Dentists routinely work with the trigeminal nerve because it innervates the teeth, gums, and supporting bone. However, the trigeminal nerve extends far beyond the teeth. When abnormal pain signaling occurs within this nerve system, it can activate migraine pathways and produce pain that is felt in the head, face, jaw, teeth, or around the eyes.

For this reason, the evaluation and management of primary headache disorders—including migraine—falls within the scope of an orofacial pain specialist, whose training focuses on disorders of the trigeminal nerve, jaw muscles, temporomandibular joint, and related pain pathways.

Migraine attacks are typically recurrent and can range from moderately painful to severely disabling. Although migraine is common, it is frequently misunderstood, misdiagnosed, or mistaken for sinus headaches, TMJ disorders, or “stress headaches.”

How Migraine Is Diagnosed

Migraine is diagnosed clinically, based on a detailed history and symptom pattern—not by X-rays, MRIs, or blood tests. The diagnosis is based on criteria established in the International Classification of Headache Disorders, 3rd edition (ICHD-3).

To make these criteria easier to understand, Dr. Hirschinger created the mnemonic 5472 PUMA PPNV

5472 — Headache Attack History

To meet diagnostic criteria for a migraine, a person must have:

  • At least 5 separate headache attacks
  • Each attack lasting 4 to 72 hours (when untreated or unsuccessfully treated)

This requirement helps distinguish migraine from isolated or situational headaches. If your headache meets the 5472 criteria, move on to PUMA

PUMA — Headache Characteristics

During a migraine attack, at least 2 of the following 4 features must be present:

  • Pulsating or throbbing pain
  • Unilateral pain (one side of the head)
  • Moderate to severe pain intensity
  • Aggravation by routine physical activity (such as walking or climbing stairs)

*Migraine can occur on both sides of the head. Unilateral pain is common but not required.

PPNV — Associated Symptoms

During the headache, at least 1 of the following must be present:

  • Photophobia and Phonophobia (sensitivity to light and sound)
  • Nausea and/or Vomiting

These associated symptoms reflect the neurologic nature of migraine and help differentiate it from tension-type headache.

Migraine With and Without Aura

Migraine Without Aura

This is the most common form of migraine and meets the criteria outlined above without neurologic warning symptoms.

Migraine With Aura

Some people experience an aura, which consists of fully reversible neurologic symptoms that typically occur before—or sometimes during—the headache phase.

Common aura symptoms include:

  • Visual disturbances (flashing lights, zigzag lines, blind spots)
  • Sensory changes (tingling or numbness)
  • Speech or language difficulty

Aura symptoms usually last 5–60 minutes and must resolve completely in about one hour.

Chronic Migraine

Migraine is considered chronic when:

  • Headache occurs on 15 or more days per month, and
  • Migraine features are present on at least 8 of those days,
  • For more than 3 months

Chronic migraine often overlaps with neck pain, jaw pain, sleep disturbance, medication overuse, and heightened nervous system sensitivity.

Migraine and Orofacial Pain

Migraine frequently involves pain beyond the temple or forehead and may present as:

  • Facial pain
  • Jaw pain or pressure
  • Tooth pain without dental disease
  • Sinus-like pressure
  • Neck and shoulder pain

Because migraine pain travels along branches of the trigeminal nerve, it is commonly mistaken for TMJ disorders or sinus problems. This overlap is a major reason migraine patients are often misdiagnosed or undertreated.

Common Migraine Triggers

Triggers do not cause migraine but may lower the threshold for an attack. Common triggers include:

  • Stress or emotional let-down
  • Sleep disruption
  • Hormonal changes
  • Skipped meals or dehydration
  • Certain foods or alcohol
  • Bright lights, strong smells, or noise

Triggers vary from person to person, which is why pattern recognition is more important than avoiding long lists of “forbidden” items.

Why Accurate Diagnosis Matters

Migraine shares symptoms with other headache and facial pain disorders, but management strategies differ significantly. Treating migraine as muscle pain, sinus disease, or TMJ dysfunction often leads to ineffective care and unnecessary procedures.

Accurate diagnosis allows for:

  • Appropriate treatment selection
  • Avoidance of overtreatment
  • Better long-term outcomes
  • Improved patient understanding and reassurance

How Migraine Is Managed

Migraine care is individualized and may include:

  • Education and reassurance
  • Identification of personal triggers and patterns
  • Behavioral and lifestyle strategies
  • Coordination with medical providers when medications are indicated
  • Conservative, non-invasive approaches when appropriate

There is no single treatment that works for everyone. Effective care begins with understanding which headache disorder is present.

When to Seek Further Evaluation

Headaches should always be evaluated if they:

  • Are new or significantly different
  • Worsen rapidly
  • Occur with neurologic symptoms that do not resolve
  • Follow head trauma
  • Occur with fever or systemic illness

These features may suggest a secondary headache, which requires a different diagnostic approach.

Key Takeaway

Migraine is a neurologic primary headache disorder, not simply a bad headache. A careful history and pattern-based diagnosis—using criteria such as 5472 / PUMA / PPNV—is essential for effective, conservative, and appropriate care.

Aura and Subtypes

Some people experience an aura, which are transient neurologic symptoms that usually occur before or during the headache phase. Common aura features include:

  • Visual changes (flashing lights, zigzag lines)
  • Sensory symptoms (pins and needles)
  • Speech or language disturbances
    These symptoms are fully reversible and typically last minutes to an hour. 

Migraine is further classified into:

  • Migraine without aura
  • Migraine with aura
  • Chronic migraine (headache on ≥15 days/month, with migraine features on ≥8 days) 

What Migraine Feels Like

Typical migraine attacks involve:

  • Moderate to severe throbbing or pounding head pain on one or two sides
  • Sensitivity to light and sound, and many times smells
  • Nausea and sometimes vomiting
  • Worsening with physical activity
  • Pain can last up to several days
  • Dark, quiet rooms are mandatory
  • Some migraines include and aura

Why Accurate Headache Diagnosis Matters

Because migraine shares features with other headache types — and because treatments differ markedly — an accurate diagnosis is essential for effective care. Mislabeling migraine as “TMJ pain” or “sinus headaches” often delays relief and leads to unnecessary treatments.

Migraine Triggers & Patterns

While triggers can vary, common factors include:

  • Stress
  • Sleep irregularities, including too much and too little
  • Hormonal changes
  • Certain foods or smells
  • Sensory overstimulation
  • Dehydration

    Keeping a headache diary can help identify patterns over time. 

How Dr. Hirschinger Approaches Migraine Care

Migraine care focuses on:

  • Detailed history and symptom mapping
  • Identifying personal triggers and patterns
  • Joint decision-making about lifestyle and behavioral strategies
  • Coordinated treatment plans with you and your medical providers
  • Non-invasive therapies where appropriate