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.
For consistency in diagnosing and classifying head pain disorders, the International Headache Society’s International Classification of Headache Disorders, 3rd Edition (ICHD-3), is generally accepted as the “gold standard.” The ICHD-3 classification criteria for Migraine without aura is:
1.1 Migraine without aura
Previously used terms: Common migraine, hemicrania simplex
Description: Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral (one-sided) location, pulsating quality (throbbing or varying with the heartbeat), moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia (increased sensitivity to light) and phonophobia (increased sensitivity to sound).
- At least 5 attacks fulfilling criteria B-D
- Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
- Headache has at least two of the following characteristics:
- unilateral location
- pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
- During headache at least one of the following:
- nausea and/or vomiting
- photophobia and phonophobia
- Not better accounted for by another ICHD-3 diagnosis.
Some differences in children:
- In children and adolescents (under 18) attacks may last 2-72 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 MWOA, 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 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
- neck pain
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
A MWOA attack can skip the headache phase. In that case, it’s described as “acephalgic” or “silent” Migraine without aura; the diagnosis is still Migraine without 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 other types of Migraine, see:
- Abdominal Migraine - The Basics
- Acephalgic or Silent Migraine - The Basics
- Alice In Wonderland Syndrome - The Basics
- Cervicogenic Headache - The Basics
- Chronic Migraine - The Basics
- Cluster Headaches - The Basics
- Headache Attributable to IIH
- Hemicrania Continua - The Basics
- Hypnic Headaches - The Basics
- Ice Pick Headaches - The Basics
- Idiopathic Intracranial Hypertension (IIH) - The Basics
- Migraine - What is It?
- Migraine With Aura - the Basics
- Migraine With Brainstem Aura - The Basics
- Migraine Without Aura - the Basics
- New Daily Persistent Headache - The Basics
- Orgasmic and Preorgasmic Headache - The Basics
- Paroxysmal Hemicrania - The Basics
- Post-Traumatic Headache - The Basics
- Primary Exertional Headache - The Basics
- Retinal Migraine - The Basics
- Sporadic and Familial Hemiplegic Migraine - The Basics
- Status Migrainous - The Basics
- Stroke - The Basics
- Tension-Type Headaches - The Basics
- Vestibular Migraine - The Basics
1 Headache Classification Committee of the International Headache Society (IHS). “International Classification of Headache Disorders, 3rd Edition.” Cephalalgia, 33(9) 629-808. July, 2013. DOI: 10.1177/0333102413485658.
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 David Watson, 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+.