Anatomy of a Migraine

The Phases of a Migraine Attack and Symptoms

Anxious mixed race woman sitting at table
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When many people think "migraine" they think only of the pain of migraine. In reality, 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

The Prodrome

The prodrome (sometimes called "preheadache") 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 30 to 40% 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
  • increased frequency of urination

The 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.

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 known 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 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 the headache develops.
  • difficult finding words and/or speaking
  • confusion
  • vertigo
  • partial paralysis
  • auditory hallucinations
  • a decrease in or loss of hearing
  • reduced sensation
  • hypersensitivity to feel and touch

Approximately 20% 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 the majority of episodes, there are some migraine episodes in which migraineurs experience aura but no headache. There are several terms used for this experience, including "silent migraine," "sans-migraine," and "migraine equivalent."

The Headache

The headache phase is generally the most debilitating part of a migraine episode. Its effects are not limited to the head only but affect the entire body.

The pain of the headache is so intense that it is difficult to comprehend by those who have not experienced it.

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. This phase usually lasts from one to 72 hours. In less common cases where it lasts longer than 72 hours, it is termed status migrainosus, and medical attention should be sought. The pain is often worsened by any physical activity. Other characteristics of the headache phase 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, severe anxiety
  • hot flashes and chills
  • dizziness
  • confusion
  • dehydration or fluid retention, depending on the individual body's reactions

The Postdrome

Once the headache is over, the migraine episode is still not over. The postdrome (sometimes called post-headache) 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 "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:

  • lowered mood levels, especially depression
  • or feelings of well-being and euphoria
  • fatigue
  • poor concentration and comprehension
  • lowered intellect levels

As we've seen, there's far more to an episode than just the headache phase. Not all migraineurs experience all phases, and those who do don't experience them with each episode. If it all sounds unpredictable -- it is.

For those who suffer from migraine, there can be a great advantage to learning about these components of migraine and how to recognize them. Once we know about them and learn to listen to our bodies, we have a better chance of avoiding the headache phase. In addition, there's always an emotional comfort factor to knowing what is causing us to feel depressed or have other symptoms. Anytime we can have that, it's a positive move.