Migraine Presentation

Although head pain is the most debilitating aspect of migraine, a migraine attack may unfold through a series of four phases: (1) prodrome, (2) aura (when present), (3) headache, and (4) postdrome. Not all individuals experience all phases. The prodrome occurs in up to 60% of migraine patients and consists of vague vegetative or affective symptoms that herald the onset of the attack. These symptoms may include food cravings, constipation, neck stiffness, increased yawning, irritability, euphoria, or depression. With resolution of the prodrome, the aura (when present) occurs generally just before or during the opening minutes of the headache.

The migraine headache is usually (but not always) unilateral. In fact, the term migraine is derived from the ancient Greek word, hemikranos, which means “half head.” A migraine headache tends to have a throbbing or pulsatile quality that at times is superimposed on a constant pressure-like sensation. As the attack severity increases over the course of one to several hours, patients may experience nausea and sometimes vomiting. Most individuals report abnormal sensitivity to light (photophobia) and/or sound (phonophobia) during attacks. Individuals may also report cutaneous allodynia over the face or scalp on the same side as the headache. Allodynia is a tenderness or hypersensitivity in the context of which even a light touch may be perceived as painful. In adults, an untreated migraine headache will attain at least a moderate level of pain intensity that can persist from 4 hours to 3 days. Many attacks resolve with sleep that can occur as a part of the natural course of the migraine attack or as the result of treatment of the headache with sedating medications.

As the headache is resolving, many patients experience a postdromal phase in which they feel drained or exhausted, although some report a feeling of mild elation or euphoria. During the postdromal phase, sudden head movement may cause transient pain in the location of the recently resolved spontaneous throbbing of the headache.

Frequently cited precipitating factors (triggers) of migraine headache include stress, fasting, sleep disturbances, weather changes, bright light or glare, ingestion of alcohol, strong odors, smoke, nitroglycerin or other vasodilating drugs, nasal congestion, withdrawal from caffeine or ergotamine-containing medicines, exercise, intercourse, and certain food substances, such as chocolates, sharp cheese, processed meats, and hot dogs. There are reports that migraine headaches frequently begin in the morning on arising and may have a predisposition to occur on a Saturday or after a prolonged or intense period of work or study. For most patients, migraine attacks occur unpredictably.

One of the most potent and frequent triggers of migraine in women is the monthly fluctuation in gonadal hormones that underlies the menstrual cycle. Typically, the headaches appear 1 to 2 days before or the first day of menstrual flow, although they may also appear during the menstrual cycle itself. Some women also experience migraine headaches at midcycle with ovulation. The headaches can be quite severe and are usually without aura, although women can also have headaches preceded by aura at other times of the month.

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