When many people think "migraine," they think only of the pain of migraine. In reality, a migraine (often called a “migraine attack”) consists of far more. The typical migraine attack actually consists of four parts, referred to as phases or components. It’s important to note that not every migraineur (a person with migraine disease) experiences all four phases. Also, attacks can vary with different phases experienced during different attacks.
The four potential phases of a migraine attack are:
The prodrome (sometimes called preheadache or premonitory phase) may be experienced hours or even days before a migraine attack. The prodrome may be considered to be the migraineur’s "yellow light," a warning that a migraine is imminent. It’s estimated that 30 to 40% of migraineurs experience prodrome, but it’s also thought that may be a low estimate. According to Dr. Peter Goadsby, the prodrome is “common if you ask about it, but patients often don’t think to tell about those symptoms.” For those who experience prodrome, it can actually be very helpful because, in some cases, it gives opportunity to abort the attack. For migraineurs who experience prodrome, it makes a solid case for keeping a migraine diary and being aware of one’s body. (See Recognizing the Migraine Prodrome for more information.
Potential symptoms of the prodrome include:
- concentration problems,
- difficulty reading (aphasia)
- difficulty speaking (aphasia)
- food cravings,
- increased thirst
- increased urination,
- repetitive yawning,
- sleep issues, and
- stiff neck.
The aura is perhaps the most talked about of the possible phases. The symptoms and effects of the aura vary widely. Some can be quite terrifying, especially when experienced for the first time. Some of the visual distortions can be exotic and bizarre. It’s interesting to note that migraine aura symptoms are thought to have influenced some famous pieces of art and literary works. One of the better know is Lewis Carroll’s “Alice in Wonderland.”
While most people probably think of aura as being strictly visual, auras can have a wide range of symptoms, including:
wavy lines, spots,
partial loss of sight,
blurry vision, phosphenes -brief flashes of light that streak across the visual field,
monocular blindness total blindness in one eye
allodynia hypersensitivity to feel and touch
aphasia difficult finding words and/or speaking
auditory hallucinations hearing things that aren’t really there
decrease in or loss of hearing
hemiplegia or motor weakness
neck pain Surprisingly, research has show that neck pain occurs as a migraine symptom more frequently than nausea.
olfactory hallucinations smelling odors that aren’t there
paresthesia tingling or numbness of the face or extremities on the side where the headache develops.
partial paralysis (only in hemiplegic migraine)
Approximately 25% of migraineurs experience aura. As with the prodrome, migraine aura, when the migraineur is aware of it, can serve as a warning, and sometimes allows the use of medications to abort the attack before the headache phase begins. As noted earlier, not all migraine attacks include all phases. Although not the majority of attacks, there are some migraine attacks in which migraineurs experience aura but no headache. There are several terms used for this experience, including “silent migraine,” “acephalgic migraine.” (See Acephalgic or Silent Migraine The Basics for more information.)
The headache phase is generally the most debilitating part of a migraine attack. It’s effects are not limited to the head only, but affect the entire body. The pain of the headache can range from mild to severe. It can be so intense that it is difficult to comprehend by those who have not experienced it. Characteristics of the headache phase may include:
- headache pain that is often unilateral on one side. This pain can shift to the other side or become bilateral.
- Although migraine pain can occur at any time of day, statistics have shown the most common time to be 6 a.m. It is not uncommon for migraineurs to be awakened by the pain.
- Because trigeminal nerve becomes inflamed during a migraine, migraine pain can also occur in the areas of the eyes, sinuses, and jaw.
- This phase usually lasts from one to 72 hours. In less common cases where it lasts longer than 72 hours, it is termed status Migrainous, and medical attention should be sought.
- The pain is worsened by any physical activity.
- phonophobia increased sensitivity to sound
- photophobia increased sensitivity to light
- osmophobia increased sensitivity to odors
- neck pain
- nausea and vomiting
- diarrhea or constipation
- nasal congestion and/or runny nose
- depression, severe anxiety
- hot flashes and chills
- vertigo sensation of spinning or whirling (not to be confused with dizziness or light-headedness)
- dehydration or fluid retention, depending on the individual body’s reactions
Once the headache is over, the migraine attack may or may not be over. The postdrome (sometimes called postheadache) follows immediately afterward. The majority of migraineurs take hours to fully recover; some take days. Many people describe postdrome as feeling "like a zombie" or "hung-over." These feelings are often attributed to medications taken to treat the migraine, but may well be caused by the migraine itself. Postdromal symptoms have been shown to be accompanied and possibly caused by abnormal cerebral blood flow for up to 24 hours after the end of the headache stage. In cases where prodrome and/or aura are experienced without the headache phase, the postdrome may still occur. The symptoms of prodrome may include:
- lowered mood levels, especially depression
- or feelings of well-being and euphoria
- poor concentration and comprehension
- lowered intellect levels
Migraine. As we’ve seen there’s far more to an attack than just the headache phase. Not all migraineurs experience all phases, and those who do don’t experience them with each attack. If it all sounds unpredictable it is. For those who suffer from migraine, there can be great advantage to learning about these phases of a migraine and how to recognize them. Once we know about them and learn to listen to our bodies, if we experience prodrome or aura symptoms, we have a better chance of avoiding the headache phase. In addition, there’s always an emotional comfort factor to knowing what is causing us to feel depressed or have other symptoms. Add in a bit of control once we learn to recognize these symptoms and use them in our migraine management, we gain a bit more control over migraine. Any time we can do that, it’s a positive move.
For More Information:
Headache Classification Committee of the International Headache Society. "The International Classification of Headache Disorders, 3rd edition (beta version)." Cephalalgia. July 2013 vol. 33 no. 9 629-808 10.1177/0333102413485658.
Goadsby, Peter J., MD PhD. “Premonitory Phase of Migraine - Biology and Clinical Characteristics.” Platform Presentation. 53rd Annual Scientific Meeting of the American Headache Society. Washington, DC. June 4, 2011. - See more at: https://www.healthcentral.com/migraine/c/123/141428/recognizing#sthash.gc14bi3X.dpuf Goadsby, Peter J., MD PhD. “Premonitory Phase of Migraine - Biology and Clinical Characteristics.” Platform Presentation. 53rd Annual Scientific Meeting of the American Headache Society. Washington, DC. June 4, 2011. - See more at: https://www.healthcentral.com/migraine/c/123/141428/recognizing#sthash.gc14bi3X.dpuf Goadsby, Peter J., MD PhD. “Premonitory Phase of Migraine - Biology and Clinical Characteristics.” Platform Presentation. 53rd Annual Scientific Meeting of the American Headache Society. Washington, DC. June 4, 2011. - See more at: https://www.healthcentral.com/migraine/c/123/141428/recognizing#sthash.gc14bi3X.dpuf
Goadsby, Peter J., MD PhD. “Premonitory Phase of Migraine - Biology and Clinical Characteristics.” Platform Presentation. 53rd Annual Scientific Meeting of the American Headache Society. Washington, DC. June 4, 2011.
Young, William B., MD; Silberstein, Stephen D., MD. “Migraine and Other Headaches.” AAN Press. St. Paul. 2004.
Calhoun, Anne H., MD; Ford, Sutapa, PhD; Millen, Cori, DO; Finkel, Alan G., MD; Truong, Young, PhD; Nie, Yonghong, MS. “The Prevalence of Neck Pain in Migraine.” Headache. Published Online: Jan. 20, 2010.
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_Reviewed by David Watson, MD. _
© Teri Robert, 2005 - Present, - Last updated December 4, 2014.
Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation’s Patient Partners Award and a Distinguished Service Award from the American Headache Society. Teri can be found on her website, and blog, Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.