Characteristics of Migraine Headache
Migraine is characterized by recurrent attacks of moderate to severe headache lasting 4-72 hours, typically unilateral and pulsating, accompanied by nausea and/or vomiting, photophobia, and phonophobia, with aggravation by routine physical activity. 1
Core Headache Features
The pain itself has distinct characteristics that help identify migraine:
- Duration: 4-72 hours when untreated or unsuccessfully treated 1
- Location: Unilateral in the majority, though bilateral pain occurs in approximately 40% of patients 1. Side-locked headache (always same side) occurs in about 19% 2
- Quality: Pulsating or throbbing in 73-81% of cases 2, 3, though aching (74%), pressure (75%), and stabbing (43%) qualities also occur 3
- Intensity: Moderate to severe pain that interferes with daily activities 1
- Aggravation: Worsened by routine physical activity such as walking or climbing stairs, present in 90% of patients 3
Associated Symptoms
These accompanying features are critical for diagnosis:
- Nausea: Occurs in 91% of patients 2
- Vomiting: Present in 38-50% 2, 4
- Photophobia: Affects 77-83.5% 2, 5
- Phonophobia: Occurs in 72-77% 2, 5
- Osmophobia (sensitivity to smells): More common in migraine than tension-type headache 4
Temporal Phases
Migraine attacks unfold in distinct phases beyond just the headache:
Prodromal symptoms (before pain onset):
- Depressed mood
- Yawning
- Fatigue
- Food cravings 1
Postdromal symptoms (after headache resolution, lasting up to 48 hours):
- Tiredness
- Concentration difficulties
- Neck stiffness 1
Migraine with Aura
Approximately one-third of migraine patients experience aura with at least some attacks 1:
- Visual aura (>90% of aura cases): Classically fortification spectra (zigzag lines), flashing lights, or visual field defects 1
- Sensory aura (~31%): Unilateral paresthesia (pins and needles/numbness) spreading gradually in face or arm 1
- Speech/language disturbances: Aphasic symptoms 1
- Motor symptoms: Weakness (hemiplegic migraine) 1
Critical distinguishing feature: Aura symptoms spread gradually over ≥5 minutes and occur in succession, unlike transient ischemic attacks which have sudden, simultaneous onset 1. Each aura symptom typically lasts 5-60 minutes and is followed by headache within 60 minutes 1.
Additional Clinical Features
- Neck pain: Associated with attacks in 70.5% 2
- Face pain: Present in 73.5% 2
- Autonomic symptoms: Lacrimation, conjunctival injection, periorbital swelling, and nasal symptoms occur more commonly in migraine than tension-type headache 4
- Orthostatic pre-syncope and palpitations: More frequent in migraineurs 4
Diagnostic Thresholds
Migraine without aura requires:
- At least 5 attacks meeting criteria
- At least 2 of 4 pain characteristics (unilateral, pulsating, moderate-severe intensity, aggravation by activity)
- At least 1 associated symptom (nausea/vomiting OR photophobia and phonophobia) 1
Chronic migraine is diagnosed when:
Clinical Pearls
Common pitfalls to avoid:
- Don't dismiss bilateral headaches as "not migraine"—40% present bilaterally 1
- Patients often under-report milder headache days; ask specifically "Do you feel like you have a headache of some type on 15 or more days per month?" 6
- Many patients with aura also have attacks without aura—both diagnoses should be made 1
Epidemiologic context: