phases of migraine attack

The Phases of a Migraine Attack – Breaking it Down

Living with migraine disease is hard! Some days, you feel normal, but on other days, you can feel down or different without knowing why, and then suddenly, you’re being caught off-guard by a migraine attack. Those who live with migraine often hear things like “It’s just a headache,” or “Why don’t you take some medicine and just keep on going?” These statements can be isolating and frustrating, especially for those experiencing a lot of disabling symptoms. An important first step in the treatment plan is to first understand what exactly is going on in the brain and then see the impact it can have on our bodies.

What Happens In The Brain During A Migraine Attack?

Migraine is a common, complex, and often hereditary/genetic neurological disease. It lies on a spectrum, meaning that its symptoms can vary from person to person (although the changes that happen in the brain are the same for all with this disorder). Changes in the brain vary based on which of the phases of a migraine attack we are in. These are the prodrome, aura, acute, postdrome, and interictal phases.

Scientists think that migraine attacks start from a trigger (either internal or in the environment), sometimes known to the person, and sometimes not. This trigger will carry signals to the brainstem where there will be a release of pain and inflammatory molecules. These molecules bind to receptors on blood vessels and the lining of the brain (the meninges), then send more signals to cause pain and other symptoms through our trigeminal nerve system and its connections to the rest of our brain (the cortex).

Phases of a Migraine Attack

Another way to think about what happens in the body during an attack is by thinking back to the clay volcanoes some of us may have made in school. The volcano can be thought of as our body and brain. The baking soda added to the volcano can be thought of as the trigger. When this is poured into the volcano, first there is some bubbling (the prodrome and aura phases), and then the volcano builds up, and the lava overflows (the acute phase). After overflowing, the activity slowly quiets down and then stops (the postdrome). Migraine is of course much more complicated than this, especially as this analogy does not include the interictal phase, but this can still be helpful in understanding some of the main changes occurring during an attack.

Let’s talk about the symptoms you can experience in each of the phases of a migraine attack:

Phases of a Migraine Attack

Prodrome

The prodromal phase of a migraine attack, often referred to simply as Prodrome, can begin from either hours to about 3 days before the aura or acute phases begin. Symptoms in this phase can include:

  • Mood changes, such as irritability or feeling foggy.
  • Changes in appetite, either having less appetite or experiencing food cravings.
  • Increased thirst or more frequent need to use the bathroom.
  • Muscle stiffness, including neck pain.
  • Fatigue or even insomnia.

These symptoms can sometimes serve as an early sign that an attack may happen, but at other times, they can be hard to separate from day-to-day life.

Aura

The aura phase of a migraine attack, often simply called Aura, does not occur in everyone living with migraine, and in those who do experience it, they will find that it happens to them about 30% of the time. It is usually considered the "warning phase," because it involves different neurological symptoms that can last from 5 to 60 minutes before the acute phase begins. The most common aura which people experience is visual, and includes things like:

  • Seeing zig zags.
  • Sparklers.
  • Tunnel vision.
  • Blind sports in the vision.

However, there are many other examples of experiences besides these! Other symptoms of the aura phasese can be:

  • Numbness.
  • Tingling.
  • Weakness.
  • Temporary paralysis of the one side of the body.
  • Trouble getting words out (aphasia).
  • Slurring of speech (dysarthria).
  • The room appears as if it's spinning (vertigo).
  • Feeling off balance.
  • Ringing in the ears (tinnitus).

Acute

This phase is considered the peak of the migraine attack by most. During the acute phase (which lasts at least 2 hours in children, and in adults can last from 4 hours up to many days), there can be

  • Intense headache, often described as throbbing or pulsing.
  • Nausea, vomiting, and diarrhea.
  • Sensitivity to the environment, including light, sound, and smell sensitivity.
  • Vertigo.
  • Body aches including neck pain and stiffness.
  • Worsening of pain with movement.
  • Tenderness of the scalp or body (allodynia).
  • Fatigue.

These symptoms are caused by the effects of pain molecules on different parts of our brain, so it’s easy to see from this list that a migraine attack is much more than “just a headache.”

Postdrome

This is the phase of the attack that has been coined the “migraine hangover.” Following the acute phase, the postdrome can cause:

  • Fatigue.
  • Trouble concentrating or brain fog.
  • Mood changes, lasting up to 48 hours.

These symptoms often cause disruption for many in the different aspects of their lives, although the significant pain and other symptoms are now typically absent.

Interictal

This is considered the time between attacks. More research needs to be done about this specific phase, but reported symptoms include:

  • Sensitivity to light and sound.
  • Nausea.
  • Fatigue.
  • Anxiety about experiencing another attack.

When to Seek Medical Attention

It's important to note that you should consult with a healthcare professional for personalized advice. Here are some warning signs that warrant a doctor's visit for migraine:

  • Sudden or Severe Headache:
    • If you experience an unusually severe headache that comes on suddenly, it could be a cause for concern.
  • First-Time Migraine Attack:
    • If you are experiencing a migraine attack for the first time, it's advisable to seek medical attention to confirm the diagnosis and rule out other potential causes.
  • Changes in Migraine Patterns:
    • Any significant change in the frequency, intensity, or duration of your migraine attacks should be discussed with a healthcare provider. This could include an increase in frequency, longer duration, or a shift in the characteristics of the headaches.
  • Aura Symptoms:
    • Some people with migraine experience auras, which are sensory disturbances that can include visual disturbances, tingling sensations, or difficulty speaking. If you experience new or unusual aura symptoms, it's important to consult a doctor.
  • Persistent Symptoms:
    • If your migraine attacks are persistent and not responding to over-the-counter medications or lifestyle changes, it's time to seek medical advice.
  • Associated Neurological Symptoms:
    • Neurological symptoms such as confusion, difficulty speaking, weakness, or numbness should be taken seriously and promptly evaluated by a healthcare professional.
  • Headaches Triggered by Physical Exertion:
    • If your headaches are consistently triggered by physical exertion or exercise, discussing this with your doctor is important.
  • Headaches with Other Medical Conditions:
    • If you have other medical conditions or are taking medications, discuss your migraine attacks with your healthcare provider to ensure there are no interactions or underlying issues.
  • Headaches in Pregnancy:
    • Pregnant women experiencing migraine attacks should consult their healthcare provider for guidance on managing headaches during pregnancy, as some medications may not be safe.
  • Symptoms in Children:
    • If a child is experiencing migraine attacks, it's crucial to seek medical attention to ensure an accurate diagnosis and appropriate management.

It's essential to communicate openly with your healthcare provider about your migraine symptoms, including their frequency, duration, and any associated factors. This information can help your doctor tailor a treatment plan that addresses your specific needs and ensures that any underlying issues are identified and managed appropriately. Regular follow-ups with your healthcare provider can also help monitor your progress and make adjustments to your treatment plan as needed.

Risk Factors

Migraine attacks can be influenced by a combination of genetic, environmental, and lifestyle factors. While the exact cause of migraine is not fully understood, several common factors are known to increase the likelihood of experiencing migraine attacks. It's important to note that individual triggers can vary, and what affects one person may not affect another. Here are some common factors associated with an increased risk of migraine attacks:

  • Family History:
    • Genetics play a significant role in migraine susceptibility. If one or both of your parents have a history of migraine, you are more likely to experience them yourself. Specific genetic factors that contribute to migraine are still being studied.
  • Hormonal Changes:
    • Hormonal fluctuations, particularly in women, are a well-known trigger for migraine attacks. Many women experience migraine related to their menstrual cycle, pregnancy, or menopause. Fluctuations in estrogen levels seem to be particularly influential.
  • Gender:
    • Women are more likely than men to be affected by migraine. Hormonal changes during the menstrual cycle, pregnancy, and the use of oral contraceptives are thought to contribute to this gender disparity.
  • Age:
    • While migraine can occur at any age, it often starts during adolescence or early adulthood. The frequency and severity of migraine attacks may change over the years, with some people experiencing fewer migraine attacks as they get older.
  • Medication Overuse:
    • Overuse of certain medications, particularly pain relievers or migraine-specific medications, can lead to a rebound effect, increasing the frequency and intensity of migraine attacks.
  • Caffeine:
    • While some people find relief from migraine with caffeine, others may experience migraine triggered by excessive caffeine consumption or sudden caffeine withdrawal.
  • Physical Activity:
    • Intense physical exertion or strenuous activities can trigger migraine in some individuals.
  • Certain Health Conditions:
    • Individuals with certain medical conditions, such as depression, anxiety, high blood pressure, and sleep disorders, may have an increased susceptibility to migraine.
  • Environmental Sensitivities:
    • Sensitivity to environmental factors such as changes in barometric pressure, strong smells, or flickering lights can contribute to migraine attacks in susceptible individuals.

Triggers

Certain environmental or lifestyle factors, known as triggers, can precipitate migraine attacks. Common triggers include:

  • Food and drinks: Certain foods and beverages like aged cheese, chocolate, caffeine, and alcohol.
  • Environmental factors: Changes in weather, strong odors, bright lights, or loud noises.
  • Stress: Emotional or physical stress is a common trigger for many individuals.
  • Sleep patterns: Irregular sleep patterns, lack of sleep, or oversleeping can contribute to migraine.

Explore Migraine Medications

Empowering yourself with knowledge about various medications used in migraine treatment is a crucial step in effectively managing and controlling your symptoms. Migraine can vary widely among individuals, and what works for one person may not be the best option for another. Therefore, understanding the range of available medications and their mechanisms can be invaluable in finding the most suitable treatment for your specific needs.

Learn more about migraine medications

  • Acute Medications: These are taken at the onset of a migraine attack to alleviate symptoms.
  • Preventive Medications: These medications are taken regularly to reduce the frequency and severity of migraine attacks. They are generally recommended for individuals who experience frequent or severe migraine attacks.

It's crucial to note that finding the right medication or combination of medications often involves a trial-and-error process. Personalized treatment plans are key, taking into consideration the individual's medical history, coexisting conditions, and lifestyle factors.

Here's why consulting with a healthcare professional is essential:

  • Individualized Assessment:
    • A healthcare provider can assess your specific migraine symptoms, triggers, and overall health to determine the most appropriate treatment plan for you.
  • Medication Safety:
    • Some medications may not be suitable for certain individuals due to underlying health conditions or potential interactions with other medications. A healthcare professional can ensure that prescribed medications are safe and appropriate for your situation.
  • Monitoring and Adjustment:
    • Regular follow-ups with your healthcare provider allow for monitoring the effectiveness of the chosen treatment and making adjustments if needed. This is crucial in achieving optimal migraine management.
  • Education and Support:
    • Healthcare professionals can provide valuable education about medications, potential side effects, and lifestyle modifications to complement treatment.

Summary

Migraine is complex and is a spectrum disorder. Like all diseases, symptoms can vary amongst people, including what may happen between attacks or phases in the same person. Sometimes, especially for those living with chronic migraine, it can even be hard to tell which phase you are currently in, as attacks happen so frequently. Understanding the changes occurring in our brain and the possible symptoms of each phase can help better relay the educational component of advocacy, as well as help to emphasize the important, unifying fact that you are not alone.

Migraine Phases Infographic

References:

Written by Ionel, Dana DO. Headache Fellow; University of Kentucky, Department of Neurology (2023).

Graphics by Biswas, Sudipa D., Hennessy, Elise, Sanguinetti, Shayna

American Headache Society (https://americanheadachesociety.org/wp-content/uploads/2018/05/NAP_for_Web_-_Pathophysiology_of_Migraine.pdf)

American Migraine Foundation (https://americanmigrainefoundation.org/resource-library/migraine-symptoms-between-attacks/)

Dodick, D.W. (2018), A Phase-by-Phase Review of Migraine Pathophysiology. Headache: The Journal of Head and Face Pain, 58: 4-16. https://doi.org/10.1111/head.13300

Sudipa Biswas

Sudipa Biswas, M.D.

Sudipa Biswas is currently a Headache Medicine Fellow at Cleveland Clinic.

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