The headache phase is the most disabling feature of a migraine attack and is the most common reason for consultation. Typically, the following characteristics apply:
- Headache lasts from 4-72 hours
- Moderate or severe pain
- Usually gradual in onset
- Throbbing, pounding or pulsating in character, although it may begin as a mild non-throbbing headache.
- Unilateral in 70-80% of patients (but can alternate from one side to the other in different attacks)
- Exacerbated by routine physical activity
- Extends from the periorbital and frontal areas backwards to the temporo-parietal and occipital regions and can sometimes extend to the shoulder area.
- Frequently is present on awakening in the morning.
However, the headache is almost always accompanied by other symptoms, which generally intensify along with the headache.
- Nausea accompanies the headache in 70-90% and leads to vomiting in 20-50%.
- Vomiting may occur early or late in the headache phase and when it occurs after the headache is well established, it may result in a precipitious easing of the headache.
- Photophobia, Phonophobia and Osmophobia. These symptoms lead patients to seek seclusion in a dark, quiet room
- Stiffness or tenderness of the neck.
Other possible symptoms during this phase can include blurry vision, diarrhoea, abdominal cramps, facial pallor, sensations of heat or cold and localised edema of the scalp, the face, or the periorbital regions. Cranial autonomic symptoms such as nasal congestion, rhinorrhea, and lacrimation can also occur.