Migraine is a common and often debilitating neurovascular disease affecting up to 35 million people in the US. Despite its relative frequency and oft times severity, migraine remains under-diagnosed, under-treated and poorly understood. One source of misunderstanding might be that “migraine” is so often equated with “headache.” In fact there are many who continue to believe that migraine is “just a bad headache.”
So rather than risk perpetuating that myth by jumping straight to the headache part of migraine disease, let’s look at the five stages of migraine as they occur.
Note that most classifications include only 4 stages, but we’ll add the “between migraine” stage – which is appropriate. While there are many with migraine whose lives are only modestly impacted by the disease, those with moderate to severe migraine are more likely to feel its impact every day of their life.
Sometimes also referred to as the “premonitory stage” this phase can begin hours or even days prior to the onset of the acute pain phase. It may be characterized by sleepiness, irritability, other change in mood or any number of diverse symptoms specific to the individual sufferer.
About half of all migraine patients report consistent awareness of a prodrome stage. They ‘just know’ when a migraine is coming. However, it has been found that about 80% of those with migraine can learn to recognize a prodrome stage. By keeping a migraine journal, and armed with the knowledge that most migraine attacks are preceded by tell tale signs, an individual can usually learn to recognize the sometimes subtle clues that precede the attack. Those clues might include tiredness, irritability, intense hunger, yawning, slightly slurred speech, feeling less coordinated or some other constellation of signs and symptoms that consistently emerge in the hours or days before a migraine attack. The ability to anticipate an attack can provide an advantage in that it allows one to make or change plans appropriately and especially because it might allow for early, more effective treatment. Essentially all migraine medications work best when taken as early as possible after the attack has begun. Nonetheless, despite its ‘advantages’, the prodrome represents a period of diminished function and adds to the burden of migraine.
The migraine aura is a complex of neurological symptoms that usually precede but may accompany the headache phase or even occur in isolation. A commonly held misconception (by those who don’t suffer with migraine) is that all true migraines are preceded by aura. In fact migraine with aura is relatively less common migraine without aura. Only 20-30% of those with migraine ever get an aura, and many of those with aura only sometimes have an aura. While generally brief, and not specifically painful, migraine patients who experience aura often describe it as extremely unpleasant.
The aura usually develops over 5-20 minutes and lasts less than 60 minutes. It is most often visual but can involve any of the other senses. The most common visual aura is what’s called a scintillating scotoma (about 65% of all auras.) A scintillating scotoma begins with a change in visual perception near the center of the visual field, then gradually expands outward in a ‘shimmering’ pattern and eventually includes a dark spot or blind spot, usually in the same part of the visual field where the aura began.
Paresthesias (strange feelings such as tingling in part of the body) are reportedly present in about 40% of auras. The most common form is called “cheiro-oral” which is generally defined by numbness starting in the hand which then migrates to the arm before ‘jumping’ to the face, lips, and tongue. Sensory aura most often follows visual aura, but may occur alone. Just as with the visual aura where a positive symptom (lights, change in perception) is followed by a negative one (dark spot or blind spot) so paresthesias are often followed by numbness.
The rate at which an aura spreads helps distinguish it from the stroke-like transient ischemic attack (TIA). Both visual aura and paresthesias usually take about 10-20 minutes to spread. This is a much slower progression of symptoms than is witnessed in the case of a stroke or TIA.
The aura is not harmful and results in no permanent damage. But for someone who has never had a migraine, or never had an aura, the experience can be a very frightening one.
The aura usually disappears before the start of headache pain, which usually follows the aura by a few minutes to an hour. Infrequently the aura may continue during the time of headache pain. Even more infrequently the headache pain may never arrive. When an aura is not followed by a headache, it is called a migraine equivalent, acephalic migraine or silent migraine.
Migraine Headache – Acute Pain Stage:
The characteristic feature of migraine disease is, of course, the migraine headache. But even the term, “migraine headache” is, if not entirely misleading, at least deficient. While the headache pain may be severe, the symptoms of an acute attack are not limited to pain. Migraine headache is accompanied by a host of autonomic symptoms. These may include nausea, vomiting, aversion to bright lights (photophobia), aversion to loud sounds (phonophobia), aversion to strong odors (osmophobia), and any number of other symptoms.
The headache of migraine generally exhibits at least some of the following characteristics:
- Throbbing, pounding, or pulsating pain
- Often on just one side of the head, or begins on one side before spreading to both sides
- Pain may alternate sides from one attack to the next
- Made worse with mild activity, such as walking or bending
- Most intense pain is often concentrated around the temple(s) – on the side of the forehead
- Commonly lasts from 4 to 72 hours in adults, 30 minutes to 48 hours in children
- Nausea is reported by almost 90% of migraine sufferers
- Vomiting may occur with up to 35% of migraine attacks
Other symptoms frequently accompanying migraine headache:
- Dizziness, described as being light headed
- Loss of appetite
- Visual disturbances, blurred vision (different than the aura)
- Eye pain
- Parts of your body may feel numb, weak, or tingly
- Irritability or altered mood
- Impaired concentration
- Nasal stuffiness
- Frequent urination (polyuria)
- Pallor (look pale) or sweating
- Neck pain and/or facial pain
- Scalp tenderness
- Bulging veins or arteries
- Allodynia – even light touch results in a painful sensation
Also referred to as “postdrome,” this is a period of diminished functioning experienced by many migraine patients after the pain of migraine headache has resolved. Simply stated, the migraine headache is gone but migraine disease remains active. Commonly, patients experience migraine-associated non-headache symptoms for an additional 24 to 48 hours. Frequent symptoms include fatigue, lethargy, muscle soreness, poor concentration and lack of appetite. Impaired functioning during this phase adds substantially to the burden of migraine.
Given an average prodrome stage lasting 24 hours, an acute pain stage that averages 24-48 hours and post-headache impairment lasting an additional 24-48 hours, the total duration of migraine impairment, per attack, can be from three to six days. Of course some attacks are more or less severe, and the extent to which migraine impairs functioning is obviously greatest during the acute pain stage. Nonetheless, considering that a person with moderate migraine disease may experience two to four attacks per month, it is often the case that there are more days with migraine impairment than there are without migraine impairment.
Also referred to as “interictal” period, this is the entire period between attacks. While there may be differences in autonomic functioning, especially increased pain perception between attacks, the primary burden of migraine during this time period relates to the expectation (dread) of the next attack. Patients are unable to plan with confidence. Work, family and social interactions can be severely affected. Anxiety and depression are common. These may result, at least in part, from the perceived (and actual) loss of control that comes with recurring migraine attacks.