#406 ‒ Migraine, cluster headache, and tension headache: symptoms, causes, prevention, and treatment | Brian Grosberg, M.D.

August 30, 2026

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5 min read

Migraine, cluster headache, and tension headache: what distinguishes them, what drives them, and how treatment has changed

Brian Grosberg, a headache specialist and director of the Hartford Healthcare Headache program, entered the field almost by accident. During his first year of neurology residency, he cared for a litigator who had been out of work for six weeks with a prolonged migraine. After taking a detailed history and consulting a mentor, he watched the patient receive treatment in the hospital and leave completely headache-free. That experience was an epiphany: headache medicine was an invisible disease that he had received almost no training on, yet it was one of the most common neurologic symptoms in existence. Today, only about 50 fellowship-trained headache neurologists graduate each year in the United States, despite migraine affecting roughly 12 percent of the global population—about 45 million Americans—with a three-to-one female-to-male ratio.

The three primary headaches and how they differ

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What you'll learn

1 (00:13) **Episode Introduction** - Peter Attia introduces the topic and guest, Dr. Brian Grosberg, a leading headache specialist.
2 (02:28) **Dr. Grosberg's Path to Headache Medicine** - Dr. Grosberg describes how a chance encounter with a patient led him to specialize in a field with minimal formal training.
3 (07:51) **The Challenge of Diagnosing Without Biomarkers** - The discussion highlights the difficulty of diagnosing headache disorders when there are no objective tests like CT scans or MRIs.
4 (11:09) **The "Big Three": Tension Headache, Migraine, & Cluster Headache** - Dr. Grosberg outlines the defining characteristics of the three most common primary headache disorders.
5 (14:00) **The Four Phases of a Migraine Attack** - Migraine is more than just a headache; it has distinct phases that guide treatment timing and strategy.
6 (20:26) **Prevalence, Genetics, & the Role of Hormones** - Migraine affects 12% of the population (1 in 5 women), and its strong genetic and hormonal links are explored.
7 (31:32) **Triggers vs. Causes & the Headache Diary** - Dr. Grosberg clarifies that triggers are not the cause of migraine but factors that elicit an attack in a biologically predisposed person.

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Show Notes

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Brian Grosberg is a world-renowned headache specialist who joins Peter to provide a master class on the diagnosis and treatment of headache disorders. In this episode, Brian explains the distinction between primary and secondary headaches and breaks down the defining features of the "big three" primary headache types (migraine, cluster, and tension headache)—highlighting how often they are misdiagnosed and how they are treated. He explores the epidemiology of headaches, describing migraine as an invisible disease affecting about 12% of the population, disproportionately affecting women, while cluster headaches more often affect men. He discusses the major gap between demand for headache care and available specialists, and he offers advice on when to see a physician. Brian dives into the multifactorial nature and pathophysiology of migraine, including genetic and hormonal influences, neurovascular changes, and inflammatory signaling, and connects these mechanisms to modern therapies. Throughout the conversation, he emphasizes the individualized nature of headache disorders and the importance of a detailed headache diary. Brian shares practical strategies for treating headaches including lifestyle changes, medications, and neuromodulation devices.

We discuss:

Brian's interest in headaches and how Peter met Brian [2:15];
Differentiating the types of headaches: primary versus secondary headache and tension versus migraine headache [7:30];
The epidemiology and burden of migraine, its disproportionate affect on women, and the shortage of headache specialists [20:00];
Genetic susceptibility to migraine and the role of hormones [24:45];
Migraine triggers, the impact of hormones, and the importance of a headache diary [31:15];
The phases of a migraine: premonitory symptoms, aura, the headache itself, and the postdrome [38:15];
Tension headaches: symptoms, causes, and prevalence [41:45];
Cluster headaches: extreme pain, distinctive symptoms, and frequent misdiagnosis as a sinus infection or allergies [43:15];
Lifestyle interventions to prevent headaches [51:15];
Pharmacological treatments to prevent headaches [1:05:00];
What's known about the patho