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Migraine Attack

The typical migraine attack is split into four phases (Prodrome, Aura, Headache Phase, Postdrome) . Not every patient will experience all four phases and even in patients that do, the phases can vary from one attack to the next.

Migraine Prodrome

Although the migraine Prodrome occurs hours or even days before the headache begins it is considered to be an integral component of the migraine process. It often acts as a warning sign that a migraine is imminent. About 60% of people with migraine experience prodromal symptoms.

Typical prodrome symptoms can include:

  • Physical symptoms
  • Muscle stiffness, especially in the neck
  • Altered perception of heat and cold
  • Increased thirst
  • Increased urination
  • Food cravings
  • Loss of appetite
  • Yawning
  • Constipation
  • Diarrhoea
  • Fluid retention
  • Sensitivity to light and/or sound

Psychological symptoms

  • Depression
  • Euphoria
  • Irritability
  • Restlessness
  • Hyperactivity
  • Fatigue
  • Drowsiness
  • Difficulty in concentration

Some patients are not always aware of these symptoms or may mistake them for migraine ‘triggers’. A Migraine Diary can help patients discover their prodromal symptoms, thus giving them valuable time to prepare for the later stages of the attack.

Migraine Diary

Migraine Aura

A. At least five attacks fulfilling B-D
B. Attacks lasting 4-72 hours if untreated or unsuccessfully treated
C. Headache has at least two of the following characteristics

  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity

D. During headache, at least one of the following

  • Nausea and / or vomiting
  • Photophobia / Phonophobia

E. Headache not attributable to any other disorder

Migraine With Aura

Headache Phase

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.

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Migraine Postdrome: The postdromal or resolution phase follows the headache and may last for up to 48 hours. Many of the symptoms of this phase appear initially during the prodrome or with the headache phase. Typically these include:

  • Fatigue
  • Sore muscles
  • Food intolerance
  • Malaise
  • Alteration in mood
  • Impaired concentration
  • Scalp tenderness
  • Decreased energy requiring a period of rest.

A minority of sufferers immediately after an attack feel energised, euphoric and can return to normal activities at once.

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