Migraine is a common disabling primary headache disorder. Epidemiological studies have documented its high prevalence and high socioeconomic and personal impacts. It is now ranked by the World Health Organization as number 19 world-wide among all diseases causing disability. 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 considered to be one disease, and 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 more common form of migraine. MWA is less 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 migraine and other headache disorders, the International Headache Society’s International Classification of Headache Disorders, 3rd Edition (ICHD-3), is generally accepted as the “gold standard.” The two top-level types of migraine are migraine without aura and migraine with aura. Migraine with aura is further broken down into several subtypes including:
- migraine with typical aura,
- migraine with brainstem aura (previously called basilar-type migraine),
- familial hemiplegic migraine,
- sporadic hemiplegic migraine, and
- retinal migraine.
For the purposes of this article, we’ll be discussing ICHD-3 classification 1.2.1, “typical aura with migraine headache.”
Some differences in children:
- In children, attacks may last 1–72 hours.
- The headache of a migraine attack is commonly bilateral 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 four phases:
- Headache Phase
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. For more information about the potential symptoms of the prodrome phase, see 14 Migraine Prodrome Symptoms and Recognizing the Migraine Prodrome.
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. For more information on migraine aura symptoms, please see Migraine Aura Can Have Many Variations.
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 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, with this phase of the migraine attack including other symptoms. For some people, the headache symptom of a migraine attack is their worst symptom, but for others, some of the other symptoms may be worse than the headache. For more information on the potential symptoms of the headache phase, see Anatomy of a Migraine.
Once the headache phase 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. In cases where prodrome and/or aura are experienced without the headache phase, the postdrome may still occur. For more information on possible postdrome symptoms, see Anatomy of a Migraine.
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 “migraine,” your diagnosis is not complete. Ask which type or types of migraine you have. That will make it easier for you to find information and learn about migraine disease as it applies to you.
ICHD-3 Information and Diagnostic Criteria for Migraine with Typical Aura:
The ICHD-3 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: Migraine with aura in which aura consists of visual and/or sensory and/or speech/language symptoms, but no motor weakness, and is characterized by gradual development, duration of each symptom no longer than 1 hour, a mix of positive and negative features and complete reversibility.
- At least 2 attacks fulfilling criteria B and C
- Aura consisting of visual, sensory and/or speech/ language symptoms, each fully reversible, but no motor, brainstem or retinal symptoms.
- At least two of the following four characteristics:
- at least one aura symptom spreads gradually over 5 or more minutes , and/or two or more symptoms occur in succession
- each individual aura symptom lasts 5 - 60 minutes1
- at least one aura symptom is unilateral2
- the aura is accompanied, or followed within 60 minutes, by headache
- Not better accounted for by another ICHD-3 diagnosis, and transient ischaemic attack has been excluded.
1 When for example three symptoms occur during an aura, the acceptable maximal duration is 3 x 60 minutes.
2 Aphasia is always regarded as a unilateral symptom;
dysarthria may or may not be.
- If the aura includes motor weakness, code as 1.2.4 Familial hemiplegic migraine or 1.2.5 Sporadic hemiplegic migraine.
More Helpful Articles - Our Basics Series:
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.