The Four Phases of a Migraine: A Clinical Overview
Migraines are intricate neurological events that unfold in a sequence of stages, each characterized by specific symptoms and physiological changes. Understanding these phases can empower individuals to recognize early warning signs, implement timely interventions, and manage migraines more effectively.
1. Prodrome: The Prelude to Pain
Onset: Several hours to days before the headache phase
The prodrome phase serves as the body’s initial alert system, indicating that a migraine may be imminent. Symptoms are often subtle and can include:
- Unusual food cravings
- Mood fluctuations, such as irritability or sudden euphoria
- Neck stiffness or discomfort
- Increased thirst or urination
- Frequent yawning
Recognizing these early signs allows for proactive measures, such as rest, hydration, or preemptive medication, potentially mitigating the severity of the impending migraine.
2. Aura: The Neurological Interlude
Duration: Typically 20–60 minutes; may occur before or during the headache
Approximately one in four individuals with migraines experience an aura, characterized by transient neurological disturbances that are usually reversible and develop gradually. These may include:
- Visual anomalies (e.g., flashing lights, shimmering lines, blind spots)
- Sensory changes (e.g., tingling or numbness, typically in the face or upper limbs)
- Speech or language difficulties
- Auditory changes or ringing in the ears (less common)
- Muscle weakness (in rare subtypes such as hemiplegic migraine)
While aura can be unsettling, it often serves as a critical window for early therapeutic intervention.
3. Headache: The Apex of Discomfort
Duration: 4 to 72 hours if untreated
The headache phase is the most recognizable stage of a migraine attack, often described as throbbing or pulsating pain that commonly affects one side of the head, though it may occur bilaterally. Accompanying symptoms frequently include:
- Nausea or vomiting
- Sensitivity to light (photophobia), sound (phonophobia), and sometimes smell
- Worsening of pain with routine physical activity
- Visual blurring or dizziness
Effective treatment at this stage typically involves targeted medication, sensory modulation, and environmental adjustments to reduce exposure to triggers.
4. Postdrome: The Aftermath
Duration: Up to 48 hours after headache resolution
Following the acute pain phase, many individuals enter a recovery state known as the postdrome. Although the head pain subsides, patients may continue to experience residual effects as the brain returns to baseline function. Symptoms may include:
- Persistent fatigue or low energy
- Difficulty concentrating
- Lightheadedness or sensitivity to stimuli
- Mild residual head pressure
- Emotional fluctuations
This phase is often referred to as the “migraine hangover,” and supportive care—including hydration, rest, and avoidance of further triggers—is recommended.
Clinical Considerations
Migraine phases vary significantly between individuals. Some may not experience all four phases, and the duration or severity of symptoms can differ from one episode to another. Accurate recognition of each phase supports more effective treatment planning and improved outcomes.
At the Brisbane Headache and Migraine Clinic, our team is dedicated to diagnosing and treating migraine-related conditions, including chronic and complex presentations. If you suspect your symptoms may be related to migraine, we encourage you to seek a comprehensive clinical assessment.
Migraine with Aura
In many sufferers, migraines can also be accompanied by ‘migraine aura’. Aura is the term used to describe the gradual development of neurological symptoms, which precedes a migraine attack. It lasts from 20-30 minutes, followed by the main attack.
Symptoms may include:
– Altered vision with flickering lights, dark or white spots, lines, waves, or in some cases temporary loss of vision
– Sensory symptoms such as a burning or prickling sensation, or loss of sensation
– Speech disturbances
– Nausea and or vomiting
– Sensitive to light, sound and smell
– Abnormal sensation, weakness or numbness down one side of the face or body
– Confusion
Migraine without Aura
Migraine without aura occurs in approximately 70-90% of people with migraines. This refers to a migraine attack without visual disturbances such as flickering lights, colourful lines, dark or white spots, or temporary vision loss. These attacks will usually occur without warning and pain is usually felt on one side of the head.
Symptoms may include:
– Nausea and or vomiting
– Confusion
– Mood changes
– Fatigue
– Sensitivity to light, sound or smell
– Diarrhoea
Migraine without Headache (Silent Migraine)
Migraine attacks without headache, as the title suggests, are for those who suffer with the associated migraine symptoms, however without any typical head pain or headache. This indicates that the actual pain in the head is completely absent. Although the headache pain is absent, a migraine without headache can still be debilitating due to the other side effects it comes with.
Symptoms may include:
– Altered vision with flickering lights, dark or white spots, lines, waves, or in some cases temporary loss of vision
– Speech disturbances
– Nausea and or vomiting
– Sensitive to light, sound and smell
– Abnormal sensation, weakness or numbness down one side of the face or body
– Confusion
– Mood changes
– Fatigue
– Diarrhoea
Chronic Migraine
Chronic migraine is classified by having frequent migraine attacks more than 15 days per month, for more than 3 months in a row. Of these attacks, at least 8 out of the 15 attacks need to be true migraines. The remaining 7 out of the 15 attacks for people with chronic migraine can be other types of headaches, such as tension-type headaches. These migraines can be with or without aura, and are usually disabling due to the frequency of attacks per month.
Episodic Migraine
Episodic Migraine is classified by having migraines and headache attacks less than 15 days per month. These migraines can be with or without aura, and are usually disabling due to the frequency of attacks per month. Including both episodic and chronic migraines, it affects approximately 14% of the world’s population and up to 18% of women.
Migraine with Brainstem Aura (Basilar-Type Migraine)
Migraine with Brainstem aura occurs more commonly in children and adolescents. It most often occurs in teenage girls and can be associated with the commencement of their menstruation. This migraine includes ‘Migraine with Aura’ symptoms, and usually originates from the brainstem, without the symptoms of motor weakness (muscle weakness). Due to the origin of this disorder, it can affect the balance of that person with vestibular symptoms.
Symptoms may include:
– Dizziness
– Imbalance issues
– Vertigo
– Poor muscle coordination
– Tinnitus (ringing in the ears)
– Fainting
– Temporary partial or total vision loss or double vision
– Throbbing pain on either side of the head
Hemiplegic Migraine
Hemiplegic migraine is a form of migraine that causes temporary paralysis to one side of the body. This usually occurs prior to or during a migraine attack, which can last from one hour to several days. During an attack the person will experience temporary weakness which can involve the face, arm or leg, and is usually accompanied by pins & needles or numbness. The attack can be terrifying as symptoms mimic and are similar to a person suffering from a stroke. The severe headache can be similar to a typical migraine with aura, or at times be absent.
Symptoms may include:
– Vertigo
– Pricking or stabbing sensation
– Swallowing difficulties
– Speaking difficulties
– Confusion
– Weakness on one side of the body
– Temporary partial or total vision loss
Ocular Migraine
Ocular migraines, sometimes referred to as retinal migraines, are a rare type of migraine that can cause temporary vision loss or visual disturbances in one eye. These episodes are usually brief, lasting from a few minutes to an hour, and often accompany or precede a migraine headache. While the exact cause is not fully understood, it is believed that changes in blood flow or nerve signals within the eye or brain may play a role.
Symptoms may include:
- Temporary vision loss in one eye
- Flickering or flashing lights
- Blurry vision
- Blind spots
- Headache following visual disturbances
Abdominal Migraines
Abdominal migraines primarily affect children, though they can occasionally occur in adults. These migraines are characterised by recurrent episodes of moderate to severe abdominal pain, without headache pain typically associated with other migraine types. Each episode may last from one hour to several days. While the exact cause isn’t completely understood, abdominal migraines may share the same neurological roots as traditional migraines, involving a sensitised brainstem.
Symptoms may include:
- Moderate to severe abdominal pain, usually centred around the belly button
- Nausea and vomiting
- Loss of appetite
- Pale skin or flushing
- Sensitivity to light or sound
- Fatigue or lethargy during episodes
Menstrual Migraine
Menstrual migraines, sometimes referred to as hormonal migraines, are migraines that occur in relation to the menstrual cycle. While hormonal fluctuations were once thought to be the sole cause, recent research suggests that menstrual migraines do not stem from hormonal abnormalities alone. Instead, they are believed to result from a sensitised brainstem, which reacts to the natural changes in hormone levels.
Symptoms may include:
- Throbbing or pulsating headache pain
- Sensitivity to light, sound, and smell
- Nausea or vomiting
- Visual disturbances such as flashing lights or blind spots
- Increased severity compared to other migraine types
Lifestyle Strategies for Migraine Management
While targeted treatment and having your migraine diagnosed professionally are essential for effectively addressing migraines, adopting supportive lifestyle strategies can also significantly enhance your overall migraine management. Many patients find relief by identifying and actively avoiding migraine triggers, such as certain foods (e.g., caffeine, chocolate, processed meats), stress, irregular sleep patterns, and strong sensory stimuli.
Incorporating daily relaxation techniques like mindfulness meditation, gentle yoga, or controlled breathing exercises can help reduce stress (known to trigger migraines) and minimise the frequency of attacks. Maintaining a regular sleep schedule, staying well-hydrated, and engaging in consistent, moderate exercise can also contribute to preventing migraine episodes.
For a fully comprehensive education on migraine management strategies, get in touch with our team today to organise your initial assessment.
