What are the stages of a migraine?

Stages of Migraine

Migraine attacks progress through up to four distinct phases: prodrome, aura (in approximately one-third of patients), headache, and postdrome, with an interictal period between attacks. 1, 2

The Four Phases of a Migraine Attack

1. Prodrome (Premonitory Phase)

• Begins as early as 3 days before the headache phase and serves as a warning sign of an impending attack 2
• Common prodromal symptoms include:
  • Depressed mood 1
  • Yawning 1, 3
  • Fatigue 1, 3
  • Food cravings 1, 3
  • Irritability 4
  • Face changes 4
  • Neck stiffness 4
• Approximately 67-71% of pediatric patients and a similar proportion of adults experience at least one prodromal symptom 4
• This phase involves complex interplay between cortical and subcortical brain regions, including the hypothalamus and brainstem nuclei that modulate pain signaling 2

2. Aura Phase (When Present)

• Occurs in approximately one-third of individuals with migraine, either with every attack or intermittently 1, 5
• Characterized by fully reversible transient focal neurological symptoms that usually precede but sometimes accompany the headache 1, 5
• Visual aura is most common (>90% of those with aura), classically presenting as:
  • Fortification spectra (zigzag lines) 1
  • Bright scintillating lights 6
  • Scotomas (blind spots) 6
  • Gradual spreading of visual disturbances over 5-20 minutes 6
• Sensory symptoms occur in approximately 31% of those with aura, typically as:
  • Predominantly unilateral paresthesia (pins and needles) 1, 6
  • Numbness that spreads gradually in the face or arm 1, 6
• Symptoms develop gradually over at least 5 minutes and last 5-60 minutes with complete resolution 6
• This phase likely correlates with cortical spreading depression—a slowly propagating wave of neuronal and glial cell depolarization and hyperpolarization 2
• Important caveat: Visual aura symptoms can occur without subsequent headache and still remain part of the migraine spectrum 6

3. Headache Phase

• Lasts 4-72 hours when untreated or unsuccessfully treated in adults (2-72 hours in children) 1, 3, 5
• Typical pain characteristics include:
  • Unilateral location (though bilateral pain occurs in ~40% of cases) 1
  • Pulsating quality 1, 3
  • Moderate to severe intensity 1, 3
  • Aggravation by routine physical activity 1, 3
• Associated symptoms include:
  • Photophobia 1, 3
  • Phonophobia 1, 3
  • Nausea and/or vomiting 1, 3
• This phase involves activation of the trigeminovascular system, a well-characterized pain pathway 2

4. Postdrome Phase

• Can last up to 48 hours after headache resolution 1, 3
• Research distinguishes two types of postdromal symptoms:
  • Persistent symptoms: onset before headache cessation that continue afterward (reported by 91% of patients) 4
  • True postdrome: symptoms with onset after headache cessation (reported by 82% of patients) 4
• Common postdromal symptoms include:
  • Tiredness/fatigue 1, 3
  • Concentration difficulties 1, 3
  • Neck stiffness 1, 3
  • Thirst 4
  • Somnolence 4
  • Food craving 4
  • Visual disturbances 4

The Interictal Period (Between Attacks)

• The burden of migraine may persist between attacks, sometimes called the "interictal phase" 7
• Interictal symptoms can include:
  • Allodynia 7
  • Hypersensitivity 7
  • Photophobia 7
  • Phonophobia 7
  • Osmophobia 7
  • Visual/vestibular disturbances 7
  • Motion sickness 7
• A patient's trepidation to make plans due to unpredictability of attacks contributes to poorer quality of life during this phase 7

Clinical Implications

Migraine with and without aura can coexist in the same patient, meaning the presence or absence of the aura phase may vary from attack to attack 5. Understanding all phases is critical because functional imaging shows that brain activations in areas like the hypothalamus and brainstem may begin before headache onset and persist after headache relief, explaining why symptoms span multiple phases 4.