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.
Let’s break down what happens during the phases of a migraine attack:
What is happening 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 the phase of the 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).
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 phase of the attacks:
This part of the attack can begin from either hours to about 3 days before the aura or acute phases begin. Symptoms in this phase can include mood changes (like irritability or feeling foggy); having less appetite or food cravings; feeling more thirsty than usual or needing to use the bathroom more often; muscle stiffness (including neck pain); and 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.
This phase 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, or blind spots in the vision. However, there are many other examples of experiences besides these! Other symptoms of the aura phase can be numbness, tingling, weakness, or temporary paralysis of one side of the body; trouble getting your words out (aphasia) or slurring of your speech (dysarthria); and the room appearing as if it’s spinning (vertigo), being off balance, or ringing in the ears (tinnitus).
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 (such as 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); and 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.”
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/brain fog, and mood changes for 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.
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, and anxiety about experiencing another attack.
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.
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
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