This article has been updated. Please see the revised article.
Migraine is a genetic neurological disease. Because there are several different types of Migraine, and some forms involve different genetic markers, some researchers theorize that it may actually be more than one disease. For now, however, Migraine is divided into two major subtypes, Migraine without aura (MWOA) and Migraine with aura (MWA). There is a single classification under Migraine without aura. MWOA is the most common form of Migraine. MWA is the second most common, occurring in 25-30% of Migraineurs. Few people have the aura phase with every Migraine attack. Thus, it’s quite common to be diagnosed with both MWA and MWOA.
For consistency in diagnosing and classifying head pain disorders, the International Headache Society’s International Classification of Headache Disorders, Second Edition (ICHD-II), is generally accepted as the “gold standard.” Hemiplegic and basilar-type Migraine are subtypes of Migraine with aura. For the purposes of this article, we’ll be discussing 1.2.1, “typical aura with migraine headache.” The ICHD-II classification criteria:
1.2 Migraine with aura Previously used terms: Classic or classical migraine, ophthalmic, hemiparaesthetic, hemiplegic or aphasic migraine, migraine accompagnée, complicated migraine
1.2.1 Typical aura with migraine headache
Description: Typical aura consisting of visual and/or sensory and/or speech symptoms. Gradual development, duration no longer than one hour, a mix of positive and negative features and complete reversibility characterise the aura which is associated with a headache fulfilling criteria for 1.1 Migraine without aura.
- At least 2 attacks fulfilling criteria B-D
- Aura consisting of at least one of the following, but no motor weakness*:
- fully reversible visual symptoms including positive features (e.g., flickering lights, spots or lines) and/or negative features (i.e., loss of vision)
- fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness)
- fully reversible dysphasic speech disturbance
- At least two of the following:
- homonymous visual symptoms1 and/or unilateral sensory symptoms
- at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
- each symptom lasts ≥5 and 4. Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows aura within 60 minutes
- Not attributed to another disorder
- If the aura includes motor weakness, code as 1.2.4 Familial hemiplegic migraine or 1.2.5 Sporadic hemiplegic migraine. (See Hemiplegic Migraine - The Basics.)
For more detailed information about aura symptoms, please see Anatomy of a Migraine.
Some differences in children:
- In children, attacks may last 1-72 hours.
- The headache of a Migraine attack is commonly bilateral (on both sides) in young children; an adult pattern of unilateral pain usually emerges in late adolescence or early adulthood.
- In young children, photophobia and phonophobia may be inferred from observing their behavior.
- The headache of a Migraine attack is usually frontotemporal (front and sides, toward the front, of head). Occipital (lower back of the head) headache in children, whether unilateral or bilateral, is rare and calls for caution in diagnosing as many cases are attributable to structural lesions. (See diagram.)
In MWA, a Migraine attack can consist of up to three phases:
- Headache Phase
The Prodrome 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. For the 30 to 40% of Migraineurs 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.
Potential symptoms of the prodrome are:
- food cravings
- constipation or diarrhea
- mood changes – depression, irritability, etc.
- muscle stiffness, especially in the neck
- increased frequency of urination
The Aura 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:
visual: flashing lights, wavy lines, spots, partial loss of sight, blurry vision
olfactory hallucinations – smelling odors that aren’t there
paresthesia - tingling or numbness of the face or extremities on the side where the headache develops.
aphasia - difficult finding words and/or speaking
partial paralysis (only in hemiplegic Migraine)
auditory hallucinations – hearing things that aren’t really there
decrease in or loss of hearing
allodynia - hypersensitivity to feel and touch
brief flashes of light that streak across the visual field (phosphenes)
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.”
The Headache 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
The Postdrome 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
See Anatomy of a Migraine for a complete description of these phases and their symptoms.
A MWA attack can skip the headache phase. In that case, it’s described as “acephalgic” or “silent” Migraine with aura; the diagnosis is still Migraine with aura.
It’s important to note that you can have more than one type of Migraine. It’s also not unusual to experience both headaches and Migraines. In fact, tension-type headaches can be a Migraine trigger.
If your doctor has diagnosed you with “Migraines,” ask for a more definitive diagnosis. That will make it easier for you to find information and learn about Migraine disease as it applies to you.
For information on types of Migraines and headaches, please see:
- Abdominal Migraine - The Basics
- Acephalgic or Silent Migraine - The Basics
- Alice In Wonderland Syndrome - The Basics
- Basilar-Type Migraine - the Basics
- Chronic Daily Headache - The Basics
- Cluster Headaches - The Basics
- Hemicrania Continua - The Basics
- Hemiplegic Migraine - The Basics
- Hypnic Headaches - The Basics
- Ice Pick Headaches - The Basics
- Migraine - What is It?
- Migraine Without Aura - the Basics
- New Daily Persistent Headache - The Basics
- Paroxysmal Hemicrania - The Basics
- Primary Exertional Headache - The Basics
- Pseudotumor Cerebri (IIH) - The Basics
- Retinal Migraine - The Basics
- Status Migrainous - The Basics
- Tension-Type Headaches - The Basics
- Transformed Migraine - The Basics
1 The International Headache Society. “International Classification of Headache Disorders, 2nd Edition.” Cephalalgia, Volume 24 Issue s1. May, 2004. doi:10.1111/j.1468-2982.2003.00823.x.
2 Young, William B., MD; Silberstein, Stephen D., MD. “Migraine and Other Headaches.” AAN Press. St. Paul. 2004.
3 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.
Medical review by John Claude Krusz, PhD, MD
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+.