Anatomy of a Migraine

The Phases of a Migraine Attack and Symptoms

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When many people think "migraine" they think only of the pain it causes. In reality, though, a migraine episode consists of far more.

The typical migraine episode actually consists of four parts, referred to as phases or components. It's important to note that not every migraineur experiences all four phases. Also, episodes can vary with different phases experienced during different episodes.

The four phases of a migraine episode are:

  • Prodrome
  • Aura
  • Headache
  • Postdrome

Prodrome

The prodrome (sometimes called "pre-headache") may be experienced hours or even days before a migraine episode. The prodrome may be considered to be the migraineur's "yellow light," a warning that a migraine is imminent.

For the approximately 60 percent of migraineurs that experience prodrome, it can actually be very helpful because, in some cases, it gives opportunity, to abort the episode. For migraineurs who experience prodrome, it makes a solid case for keeping a migraine diary and being aware of one's body.

Symptoms typical of the prodrome are:

  • Food cravings
  • Constipation or diarrhea
  • Mood changes: depression, irritability, etc.
  • Muscle stiffness, especially in the neck
  • Fatigue
  • Uncontrollable yawning
  • Fluid retention
  • Increased frequency of urination

Aura

The aura is the most familiar of the phases. Aura follows the prodrome and usually lasts less than an hour. The symptoms and effects of the aura vary widely, and some can be quite terrifying, especially when experienced for the first time.

While most people probably think of aura as being strictly visual, auras can have a wide range of symptoms, including:

  • Visual symptoms: flashing lights, wavy lines, spots, partial loss of sight, blurry vision
  • Olfactory hallucinations (smelling odors that aren't there)
  • Tingling or numbness of the face or extremities on the side where a headache develops
  • Difficulty finding words and/or speaking
  • Confusion
  • Vertigo
  • Partial paralysis
  • Auditory hallucinations (hearing things that are not there_
  • A decrease in or loss of hearing
  • Reduced sensation
  • Hypersensitivity to feel and touch

Approximately 20 percent 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 episode before the headache itself begins.

As noted earlier, not all migraine episodes include all phases. Although not very common, there are some migraine episodes in which a person experiences an aura, but no headache. There are several terms used for this experience, including "silent migraine," "sans-migraine," and "migraine equivalent."

Headache

The headache phase is generally the most debilitating part of a migraine episode. Its effects are not limited to the head but affect the entire body. The pain of the headache can be so intense that it's difficult to comprehend by those who have not experienced it.

This phase usually lasts from one to 72 hours. In less common cases where it lasts longer than 72 hours, it's termed status migrainosus, and medical attention should be sought. The pain is often worsened by any physical activity.

Other characteristics of the headache phase may  include:

  • Headache pain that is often hemicranial, or on one side (this pain can shift to the other side or become bilateral)
  • Phonophobia (sensitivity to sound)
  • Photophobia (sensitivity to light)
  • Nausea and vomiting
  • Diarrhea or constipation
  • Nasal congestion and/or runny nose
  • Depression or severe anxiety
  • Hot flashes and chills
  • Dizziness
  • Dehydration or fluid retention, depending on the individual body's reactions

Postdrome

Once the headache is over, the migraine episode is still not over. The postdrome (sometimes called post-headache) follows immediately afterward.

Many people describe postdrome as feeling "like a zombie" or "hungover." 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 and EEG readings 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 postdrome include:

  • Fatigue
  • Mood changes
  • Muscle weakness
  • Dizziness or lightheadedness
  • Poor concentration
  • Stiff neck

A Word From Verywell

The big picture here is that there's far more to a migraine episode than just the headache. But the good news is that for those who suffer from migraines, there can be a great advantage to learning about these phases. Once you are able to recognize them, you have a better chance of avoiding or at least reducing your head pain.

Sources:

Giffin NJ, Lipton RB, Silberstein SD, Olesen J, Goadsby PJ. The migraine postdrome. An electronic diary study. Neurology. 2016 Jul 19;87(3):309-13.

Headache Classification Committee of the International Headache Society. "The International Classification of Headache Disorders: 3rd Edition (beta version)". Cephalalgia 2013;33(9):629-808.

Lampl C, Rudolph M, Deligianni CI, Mitsikostas DD. Neck pain in episodic migraine: premonitory symptom or part of the attack? J Headache Pain. 2015;16:80.

National Institute of Neurological Disorders and Stroke. (2017). Headache: Hope Through Research.

Ng-Mak DS et al. Key concepts of migraine postdrome: a qualitative study to develop a post-migraine questionnaire. Headache. 2011 Jan;51(1):105-17.