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Managing Pain 2020

The symptoms and stages of a migraine

Ria Bhola

Headache Nurse Specialist, The Migraine Trust

The debilitating effects of migraine are poorly understood. To understand migraine is to realise it is much more than ‘just a headache’ and that, during the most productive years of life, its impact is huge.

Migraine is ‘featureful’

In reality, a migraine attack will follow four or five stages, each occurring with a range of distinct features.

This goes beyond the common perception of a migraine attack as a throbbing headache, which often confines you to a dark room. Not everyone will experience all of the symptoms of each stage and the stages can overlap. The severity and duration may also vary across attacks.

Symptoms and stages of an attack:

The premonitory phase

The premonitory phase is often described as the warning stage, where one may experience tiredness, yawning, food cravings, mood changes (high or low), thirst, neck stiffness and passing more urine. These symptoms will last up to 24 hours and precede the next stages. It is important to recognise this stage as a useful warning, but also distinguish the symptoms from a trigger. For example, if a particular food like chocolate, is consumed during a sweet craving where the attack had in fact already started, this may be incorrectly regarded as a trigger.

The aura phase

The aura phase is experienced by about a quarter of people with migraine who have ‘migraine with aura’. It results from a wave of nerve activation that spreads over the brain (known as cortical spreading depression or CSD). As this electrical wave spreads, the nerves fire in an abnormal way and a range of reversible neurological symptoms develop (typically between five to 60 minutes). These may be experienced as spots, patterns and lines in the vision; numbness, tingling or weakness along the body; and speech or language disturbance. They usually precede the headache.

The headache phase

The headache phase involves moderate or severe head pain. The headache is typically throbbing and made worse by movement. It is usually on one side of the head, though it’s not uncommon to get pain on both sides or all over the head. Nausea and/or vomiting can occur at this stage and the person with migraine may become sensitive to light, noise or smells. Painkillers work best if taken early during this phase, or they may not work at all.


Resolution occurs as the symptoms slowly fade after four to 72 hours, but will stop sooner if treatment is timely and effective. Sleep can also be helpful.

The postdrome phase

The postdrome phase is the final stage of an attack and is characterised by a drained, fatigued or ‘hangover’ type of feeing that can last for hours or days.

Being able to recognise the different phases of a migraine attack will help to ensure the most appropriate types of treatment are used, and how best to take them. Explaining and educating others will also help mitigate suffering and frustration, and enable better lifestyle and workplace adjustments.

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