Thu Feb 19

Migraine is more than just a headache. A neurologist explains the 4 stages

Written by Lakshini Gunasekera, PhD Candidate in Neurology, Monash University

A migraine attack ^[1] is not just a “bad headache”.

Migraine is a debilitating neurological condition which can cause nausea, vomiting, and sensitivity to light or sound, in addition to severe headaches.

Migraine affects roughly five million ^[2] Australians, but few people understand the different stages of a migraine attack.

Knowing the four distinct phases ^[3] can help you recognise the symptoms and manage pain at each stage.

Phase 1: Premonitory

The first phase of migraine development is the “premonitory” or “prodrome” phase. It functions like a warning period which begins 24 to 48 hours before a migraine attack fully sets in.

The premonitory phase has a lot to do with the hypothalamus ^[4]. The hypothalamus is the part of the brain which regulates key functions ^[5] such as body temperature, appetite, mood and sleep.

When a person experiences a migraine attack, their hypothalamus becomes abnormally activated ^[6]. The hypothalamus is connected to other parts of the brain with different functions, so this abnormal activation can also disrupt how those parts function.

This can lead to symptoms such as poor concentration, food cravings, irritability and insomnia. If you notice these early signs, you’re more likely to “catch” the start of a migraine attack and be able to treat it early.

Phase 2: Aura

The second phase of a migraine attack is called “aura”. Aura refers to various neurological symptoms ^[7] which affect your vision, speech or ability to feel sensations. Visual auras, which mainly affect your vision, are the most common kind.

Visual aura symptoms can include seeing flashing lights, swirling shapes or blind spots. A sensory aura can lead to numbness or tingling in your face or limbs. In severe cases, people may even have trouble speaking.

Research suggests a process called cortical spreading depression ^[8] contributes to aura symptoms. During this process, a wave of electrical activity spreads very slowly ^[9] through the brain and can impact how certain brain regions function.

Only 30% of people experience migraine with aura.

Phase 3: Headache

The third phase of a migraine attack is the headache. This is when people typically experience a throbbing or pulsating headache, alongside other symptoms like nausea and sensitivity to light and sound.

This phase usually lasts between four and 72 hours if untreated.

When different brain networks become activated during a migraine attack, other symptoms can develop in addition to headache.

When the medulla or “vomit centre ^[10]” of the brain is abnormally activated, it can lead to nausea and vomiting.

The trigeminal nerve ^[11], the nerve which allows you to feel sensations on your face, can also become abnormally activated. This causes the release of chemicals which may be perceived by the brain as pain.

One of these chemicals is a protein called calcitonin gene-related peptide (CGRP). Some injectable types of migraine medication block this protein ^[12] to reduce pain.

Phase 4: Postdrome

The fourth and final phase is the “postdrome”. It is also known as the “migraine hangover”.

During this recovery phase, your brain is working hard to return to its normal functioning. That is why you may feel even more fatigued or have difficulty concentrating after a migraine attack.

So, how can I manage a migraine attack?

It helps to know the symptoms and stages of migraine development.

If you have predictable symptoms, particularly during the premonitory phase, it’s best to carry pain medications or anti-nausea tablets with you. That way you can treat early symptoms as soon as they arise. It can also be a sign to rest, ideally before the headache phase sets in.

In the aura phase, taking migraine-specific pain medications such as triptans, aspirin or anti-inflammatory pain killers may stop the headache phase from starting.

If you have more than four migraine attacks each month, you may also consider taking preventive medications. These are usually daily tablets which help control the baseline level of head pain you experience. Injectable options are also available.

Finally, don’t ignore the postdrome phase. If you push yourself too hard during this recovery period, you may experience overlapping migraine attacks. This is when one migraine attack starts before the last one resolves itself. Overlapping migraine attacks are much harder to treat ^[13].

You may also experience other symptoms ^[14] related to the migraine attack. These can include dizziness, neck pain, or ringing in the ears. If you have any of these additional symptoms, you should consult your neurologist to check they are not caused by a more serious underlying condition.

And if you are a woman who experiences migraine with aura, speak to your doctor before starting hormone-based contraception. This is because you may need different treatment than someone who does not experience aura symptoms.

By understanding the different phases and symptoms of migraine, you will be better equipped to tackle any future attacks that come.