Migraine Symptoms, Phases and Treatments

If you have migraine, you’re not alone. According to the National Headache Foundation, about 40 million Americans experience one or more migraine headaches yearly. This figure corresponds to approximately 18% of cases in women and 6% in men – implying that migraine is two to three times more common in women than men. Globally, migraine impacts around 10% of the population (i.e., a staggering 1 billion people worldwide) and is also the leading cause of disability worldwide. Moreover, while migraines most often affect adults, kids and teens may also get them.

What is a migraine?

Migraine is not just a headache. It is a common disabling brain disorder that typically presents as repeated, intense attacks of throbbing or pulsating headache, often on one side of the head.

Migraine headaches can become more frequent over time. If they keep striking for at least 15 days every month for more than three months, you’re likely suffering from what the International Headache Society defines as chronic migraine.

What are the symptoms of migraine?

Classically, migraine symptoms progress through four distinct phases as follows:

  • Prodrome phase
  • Aura phase
  • Headache phase
  • Postdrome phase

These stages and their corresponding symptoms help differentiate a migraine from other headaches. With that said, it is essential to note that not all migraines proceed through all the stages. You may experience three, two, or just one of them. The headache phase is the most common, whereas the aura phase is the least common.

More importantly, there’s no clear distinction between the different phases. For instance, research shows that typical migraine headaches can occur even during the aura phase of the attack.

1. Prodrome phase

Experts often describe the prodromal phase as the “pre headache” or the premonitory phase. This stage precedes the migraine headache phase by a few hours to 2-3 days. Symptoms of this phase may be a warning of an impending migraine attack. However, it may not happen before every episode. With that said, identifying these early warning symptoms can help take appropriate measures to ward off the actual migraine bout.

Symptoms of this phase vary widely from person to person and include:

  • Mood changes, for instance, being unusually depressed or energetic
  • Irritability
  • Trouble focusing
  • Fatigue
  • Sensitivity to light and sound (causing you to avoid noisy and brighter places)
  • Excessive yawning
  • Sleeplessness, or insomnia
  • Nausea
  • Cravings for certain foods—especially for chocolate, which people may falsely assume a migraine trigger
  • Constipation or diarrhea
  • Tightness in the neck muscles (and shoulders or areas of the head not affected by migraine headache)
  • The need to pee more often

2. Aura phase

Migraine auras are signs that alert you of an oncoming migraine. Not all migraineurs experience the aura stage. However, for those who face it, the aura usually kicks in about an hour before the migraine headache and fades in less than 60 minutes. During this phase, sensory symptoms strike before or even during a migraine episode. These symptoms can include:

Visual disturbances. These are usually the result of a type of migraine called ocular/retinal migraine and include:

  • Seeing bright flashes of light
  • Developing a blind spot, which is a spot where your field of vision becomes remarkably hazy
  • Zigzag lines or floaters slowly floating across your field of vision

Nerve involvement symptoms. These occur when chemical waves move across the nerve cells and include:

  • Tingling or "pins and needles" in your hands or face
  • Numbness

Auditory symptoms (related to hearing)

  • Ringing in your ears (tinnitus)
  • Hearing voices that aren’t there for real (extremely rare)

3. Headache phase

A typical migraine headache:

  • is throbbing, pulsatile, or pounding in nature
  • usually begins in the side of your head (temples), forehead, or around your eye area
  • builds up over a period of 1–2 hours
  • may move to the back of your head and even involve your entire head
  • gets worse with movement or activity
  • can linger for hours or even days
  • also associated with nausea, vomiting, light-headedness, severe sensitivity to light, sound, and maybe touch and smell as well

4. Postdrome phase

Also known as the “migraine hangover” or “post migraine phase,” postdrome follows the headache phase. It lasts roughly between 24 to 48 hours.

The postdrome stage may leave you feeling overwhelmingly exhausted and irritable. Research shows that this phase strikes around 80% of migraineurs. That said, the length of the postdrome phase doesn’t necessarily correlate with the severity of the migraine attack.

What triggers migraine?

There are numerous factors known to precipitate migraine. How do these factors trigger migraine? Well, no one knows for sure. However, several hypotheses exist. One of the most widely accepted is that migraine results from a chain reaction of silencing waves that spread across the brain when brain cells become hyperexcitable (fire a lot). These waves may then stimulate chemicals to dilate (widen) brain blood vessels and cause pain.

Migraine triggers are highly variable from person to person. Potential migraine precipitators include:

  • High levels of stress
  • Menstrual periods
  • Too little or too much sleep
  • Chronic fatigue
  • Certain foods and drinks, especially those:
    • high in a chemical called tyramine, such as:
      • Aged cheeses
      • Pickles, e.g., pickled cucumbers, pickled peppers, pickled okra
      • Fermented foods like kombucha, kimchi, and sauerkraut
      • Alcoholic beverages, especially red wine
    • that cause a rise in serotonin, such as:
      • Chocolates and cocoa
    • containing too much caffeine like coffee and chocolates
    • packed with food additives like nitrates and monosodium glutamate (MSG)
  • Skipping meals or fasting
  • Weather fluctuations
  • Exposure to bright, flashing lights, certain odors, or loud noise
  • Smoking
  • Genetic component (there’s a 30% to 60% probability of getting migraine if one or both of your parents have it)

What is the treatment for migraine?

Treatment of migraine entails:

  • aborting the acute attack that has already started by what is known as the abortive therapy
  • preventing the attacks during the non-headache days, termed the prophylactic (or preventive) therapy
  • implementing lifestyle changes

Abortive therapy

This therapy involves using medications to cease migraine as soon as it begins. The abortive medications include:

Over-the-counter (OTC) medications. These meds help relieve mild to moderate migraine headaches.

  • Acetaminophen (Tylenol)
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen (Aleve), ibuprofen (Advil, Motrin), aspirin
  • Aspirin, acetaminophen, and caffeine combo, as in Excedrin Migraine

Prescription medications. Some commonly prescribed medications for migraine are:

Triptans. Approved by the Food and Drug Administration (FDA) for the treatment of migraine, these drugs emulate serotonin. They work by quieting the overactive nerves and shrinking blood vessels in a migraineur’s brain. If used too often, triptans can induce medication-overuse headaches. Hence, it’s best not to take them for more than three days a week. Common triptans include:

  • Sumatriptan (Imitrex)
  • Rizatriptan (Maxalt)
  • Zolmitriptan (Zomig)
  • Almotriptan (Axert)
  • Eletriptan (Relpax)
  • Naratriptan (Amerge)
  • Frovatriptan (Frova)

Ergot derivatives. Doctors reserve these drugs as a second-line treatment for moderate to severe migraine headaches that do not respond to OTC medications or triptans.

Ubrogepant (Ubrelvy). This is a new abortive migraine medication that blocks CGRP in your brain. CGRP stands for calcitonin gene-related peptide, a molecule that dilates the blood vessels in your brain, provoking an inflammatory response and pain. Thus, blocking CGRP keeps the brain blood vessels from dilating that might otherwise induce migraine.

In addition to abortive medications, some other tips may also help ease a migraine attack, such as:

  • lying down in a dark, quiet room
  • applying cool compresses to your head
  • practicing relaxation techniques such as meditation and deep breathing
  • drinking plenty of water to stay hydrated

Preventive therapy

This therapy aims to tame the frequency and severity of migraine attacks, make attacks more responsive to abortive therapy, and possibly improve your quality of life.

Medications are an essential part of preventive therapy. Preventive medications for migraine include:

  • Antidepressants
  • Certain blood pressure-lowering drugs
  • Certain anti-seizure drugs
  • CGRP blockers
  • Botox

Lifestyle changes

  • Identify and avoid triggers. If you don’t know what triggers your migraine, try keeping a journal/diary to track your activity at the time of migraine onset
  • Avoid smoking
  • Take regular, balanced meals
  • Set up a sleep schedule and practice healthy sleep hygiene
  • Exercise often
  • Learn how to manage your stress

References

Facts About Migraine. National headache foundation. Retrieved July 2022 from https://headaches.org/facts-about-migraine/

Law, H. Z., Chung, M. H., Nissan, G., Janis, J. E., & Amirlak, B. (2020). Hospital Burden of Migraine in United States Adults: A 15-year National Inpatient Sample Analysis. Plastic and reconstructive surgery. Global open, 8(4), e2790. https://doi.org/10.1097/GOX.0000000000002790

Peterlin, B. L., Gupta, S., Ward, T. N., & Macgregor, A. (2011). Sex matters: evaluating sex and gender in migraine and headache research. Headache, 51(6), 839–842. https://doi.org/10.1111/j.1526-4610.2011.01900.x

Steiner, T. J., Stovner, L. J., Jensen, R., Uluduz, D., Katsarava, Z., & Lifting The Burden: the Global Campaign against Headache (2020). Migraine remains second among the world's causes of disability, and first among young women: findings from GBD2019. The journal of headache and pain, 21(1), 137. https://doi.org/10.1186/s10194-020-01208-0

IHS Classification ICHD-3. Retrieved July 2022 from https://ichd-3.org/1-migraine/1-3-chronic-migraine/

Hansen, J. M., Lipton, R. B., Dodick, D. W., Silberstein, S. D., Saper, J. R., Aurora, S. K., Goadsby, P. J., & Charles, A. (2012). Migraine headache is present in the aura phase: a prospective study. Neurology, 79(20), 2044–2049. https://doi.org/10.1212/WNL.0b013e3182749eed

Houtveen, J. H., & Sorbi, M. J. (2013). Prodromal functioning of migraine patients relative to their interictal state--an ecological momentary assessment study. PloS one, 8(8), e72827. https://doi.org/10.1371/journal.pone.0072827

Giffin, N. J., Lipton, R. B., Silberstein, S. D., Olesen, J., & Goadsby, P. J. (2016). The migraine postdrome: An electronic diary study. Neurology, 87(3), 309–313. https://doi.org/10.1212/WNL.0000000000002789

Scheffer, M., van den Berg, A., & Ferrari, M. D. (2013). Migraine strikes as neuronal excitability reaches a tipping point. PloS one, 8(8), e72514. https://doi.org/10.1371/journal.pone.0072514

Sutherland, H. G., Albury, C. L., & Griffiths, L. R. (2019). Advances in the genetics of migraine. The journal of headache and pain, 20(1), 72. https://doi.org/10.1186/s10194-019-1017-9

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