The prodrome or premonitory phase of a migraine attack is the first of four possible phases. The prodrome and its potential symptoms have been discussed by physicians, researchers, and patients for many years. Sir Richard William Gowers mentioned the sleepiness that can occur in "A Manual of Diseases of the Nervous System," published in 1899.
A new review article in the journal Headache takes a look at what we know about the prodrome and what can be learned from it.
The Aim of the Review:
"This review aims to understand the prevalence of premonitory symptoms in migraine, postulate their mechanisms, and compare these with functional imaging studies."
- Researchers conducted a thorough literature review using PubMed for prevalence studies of premonitory symptoms in migraine and functional imaging studies in the premonitory phase.
- The majority of studies have been retrospective reporting a prevalence of 7-88 percent for premonitory symptoms in migraine.
- Only one study has investigated premonitory symptoms prospectively and used preselected patients with recognized premonitory symptoms.
- The majority of patients were able to predict correctly the onset of migraine headache.
- Only one functional imaging study has been conducted in the premonitory phase that showed activation of posterolateral hypothalamus, midbrain tegmental area and substantia nigra, periaqueductal gray, dorsal pons, and various cortical areas including occipital, temporal, and prefrontal cortex.
- "In this review, we have discussed the prevalence of premonitory symptoms and postulated their potential mechanisms.
- Although these symptoms seem to be common, we need prospective studies in unselected patient populations to ascertain their true frequency.
- The nature of these symptoms and their potential mechanisms suggests the earliest changes in migraine, before headache comes on, are likely to be in the brain.
- The imaging findings in the premonitory phase are in keeping with such a central origin. Various brain areas including subcortical areas like the hypothalamus, dorsal raphe nuclei, PAG and locus coeruleus, and cortical areas like the frontal, occipital, and limbic cortex are involved.
- Hypothalamic involvement can explain many of the premonitory symptoms. Involvement of the brainstem structures mentioned here along with the hypothalamus may lead to facilitation of trigeminocervical complex activity and in turn the perception of pain.
- Symptoms of increased sensitivity to external stimuli are likely to result from direct involvement of brain structures, at least in part, independent of pain.
- We now need well-designed, controlled, double-blinded trials to investigate if treatment during the premonitory phase can reliably prevent headache in selected patients who can predict a migraine headache.
- Researching this earliest clinical phase of migraine is likely to yield rich dividends for our understanding of the disorder and for the benefit of our patients."
Summary and Comments:
This review produced one of the most fascinating journal articles I've read. I haven't discussed here many of the details of specific prodrome symptoms and the authors' observation and discussion of physiological details because they were quite complex, and to write about them here would have resulted in a very long and complex piece.
To understand why this review and article are important to us, I urge you to read the review conclusions, which I've broken down into bullet points, a couple of times. More of this type of review as well as the needed trials mentioned in the review conclusions would lead to a far better understanding of migraine disease, which would, in turn, lead to better treatments.
More Helpful Information:
Maniyar, Farooq H., MD, MRCP; Sprenger, Till, MD; Montheith, Teshamae, MD; Schankin, Christoph J., MD; Goadsby, Peter J.; MD, PhD. "The Premonitory Phase of Migraine — What Can We Learn From It?" Headache. Early View. First published online April 28, 2015.
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