The Four Phases of a Migraine: A Clinical Overview
Unlike a typical headache, a migraine can progress through four distinct clinical phases, each involving different mechanisms and symptoms.
Understanding these phases provides valuable insight into early detection, intervention, and the personalised management of migraine conditions.
1. Prodrome (Premonitory Phase)
Onset: Hours to days before the headache phase
The prodrome phase marks the earliest stage of a migraine and often serves as a warning sign. While symptoms may be subtle, many individuals begin to notice changes in their physical, cognitive, or emotional state prior to the onset of pain.
Common prodrome features may include:
- Generalised fatigue or lethargy
- Cognitive difficulty (poor concentration, brain fog)
- Mood changes (irritability, depression, or sudden euphoria)
- Food cravings or appetite changes
- Neck discomfort or stiffness
- Increased urination or thirst
- Frequent yawning
Identifying prodromal symptoms can allow for early management strategies, such as rest, hydration, or preemptive medication.
2. Aura (Neurological Phase)
Duration: Typically 20–60 minutes; may occur before or during the headache
Aura is experienced by approximately one in four individuals with migraine and is characterised by transient neurological disturbances. These symptoms are usually reversible and develop gradually.
Aura manifestations may include:
- Visual disturbances (flashing lights, shimmering lines, blind spots)
- Sensory changes (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 is often a key diagnostic feature and can offer a critical window for early therapeutic intervention.
3. Headache (Pain Phase)
Duration: 4 to 72 hours if untreated
The headache phase is the most recognisable stage of a migraine attack. Pain is often described as throbbing or pulsating, commonly affecting 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 (Resolution or Recovery Phase)
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 Sydney Headache and Migraine Clinic, our team will help diagnose and treat 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
Migraine with aura is a type of migraine that involves temporary neurological symptoms, known as aura, which typically develop before the headache phase of a migraine attack. Aura symptoms usually last between 20 to 30 minutes and can serve as a warning sign of an incoming migraine.
Common aura symptoms may include:
- Visual disturbances such as flickering lights, zigzag lines, dark or white spots, or temporary loss of vision
- Sensory changes like tingling, prickling sensations, or numbness affecting the face, body, or limbs
- Speech disturbances or difficulty speaking clearly
- Nausea and vomiting
- Sensitivity to light, sound, or smell
- Muscle weakness or abnormal sensations on one side of the face or body
- Feelings of confusion or mental fog
Recognising aura symptoms early can assist in managing migraine attacks more effectively and support timely migraine headache treatment.
Migraine without Aura
Migraine without aura is the most common form of migraine, affecting approximately 70-90% of individuals who experience migraine headaches. Unlike migraine with aura, these attacks occur without any visual disturbances such as flickering lights, colourful lines, or temporary vision loss. Migraine without aura often begins suddenly and is typically characterised by moderate to severe throbbing pain on one side of the head.
Common symptoms may include:
- Nausea and vomiting
- Fatigue and low energy
- Mood changes or irritability
- Sensitivity to light, sound, or smell
- Gastrointestinal symptoms such as diarrhoea
- Cognitive difficulties, such as confusion or trouble concentrating
Understanding these symptoms is essential for proper migraine headache treatment and developing an effective migraine management plan to reduce migraine attacks and manage symptoms long-term.
Migraine without Headache (Silent Migraine)
Migraine without headache, often called a silent migraine, occurs when an individual experiences migraine symptoms without the typical migraine pain. Although head pain is absent, this type of migraine can still be debilitating due to the neurological and physical symptoms it causes.
Silent migraines are often challenging to diagnose because the absence of headache pain may lead sufferers to overlook the connection to migraine. However, recognising the associated symptoms is essential for effective migraine headache treatment and management.
Common symptoms may include:
- Visual disturbances, such as flickering lights, dark or white spots, zigzag lines, or temporary loss of vision
- Speech difficulties or trouble finding words
- Nausea and vomiting
- Sensitivity to light, sound, or smell
- Numbness, weakness, or tingling down one side of the face or body
- Mental fog, confusion, or difficulty concentrating
- Mood changes or irritability
- Fatigue and low energy
- Gastrointestinal symptoms, such as diarrhoea
Understanding the symptoms of silent migraine is a crucial step in managing migraine attacks and reducing their impact on daily life.
Chronic Migraine
Chronic migraine is a debilitating condition defined by experiencing headaches and migraine attacks on 15 or more days each month, lasting for at least three consecutive months. To meet the diagnostic criteria, at least eight of these monthly attacks must display migraine symptoms, including throbbing pain, sensitivity to light and sound, or aura symptoms.
Chronic migraine can involve both migraine headaches and other headache types, such as tension-type headaches. This condition often results in severe headaches and disabling symptoms that significantly impact daily life, mental health, and overall quality of life. Proper migraine headache treatment and preventive medications are essential in managing chronic migraine and reducing the frequency and severity of migraine attacks.
Episodic Migraine
Episodic migraine is diagnosed when migraine attacks occur on fewer than 15 days per month. These episodes can present with or without aura symptoms and often involve moderate to severe headache pain, sensitivity to light and sound, and nausea. Despite being less frequent than chronic migraine, episodic migraines can still cause disabling symptoms that interfere with daily activities.
Episodic migraine is common and, when combined with chronic migraine, affects around 14% of the global population. Studies show that women are more frequently impacted, with up to 18% experiencing migraine headaches. Early diagnosis and migraine headache treatment are important to help manage symptoms and reduce the risk of migraines becoming more frequent over time.
Migraine with Brainstem Aura (Basilar-Type Migraine)
Migraine with brainstem aura, previously known as basilar-type migraine, is a rare but complex form of migraine. It tends to occur more frequently in adolescents, particularly teenage girls, and is sometimes associated with hormonal changes during the menstrual cycle.
This type of migraine involves aura symptoms that originate from the brainstem, often without muscle weakness. Due to its impact on the brainstem and vestibular system, it can cause balance issues and other neurological symptoms, making it challenging to manage without proper migraine headache treatment.
Common symptoms may include:
- Dizziness and vertigo
- Imbalance and coordination difficulties
- Tinnitus (ringing in the ears)
- Fainting episodes
- Temporary partial or total vision loss, or double vision
- Throbbing pain on either side of the head
- Nausea and vomiting
Early diagnosis and targeted migraine management are important to help prevent migraine attacks and concurrent disabling symptoms.
Hemiplegic Migraine
Hemiplegic migraine is a rare and severe type of migraine that can cause temporary weakness or paralysis on one side of the body. This neurological symptom typically occurs before or during the migraine attack and can last from an hour to several days. The weakness may affect the face, arm, or leg and is often accompanied by numbness or a prickling sensation.
Because hemiplegic migraine symptoms closely resemble those of a stroke, these attacks can be distressing and frightening. Some individuals may experience typical migraine symptoms such as throbbing head pain, while others may have minimal or no headache pain during an attack.
Common symptoms may include:
- Vertigo or dizziness
- Tingling or stabbing sensations in the face or limbs
- Difficulty speaking or swallowing
- Confusion or disorientation
- Muscle weakness or paralysis on one side of the body
- Temporary partial or complete vision loss
Early diagnosis and a tailored migraine headache treatment plan are essential to managing hemiplegic migraine and reducing the risk of future migraine attacks.
Ocular & Retinal Migraine
Ocular and retinal migraines are rare forms of migraine that cause temporary visual disturbances. Retinal migraines affect one eye only and may involve brief vision loss, blind spots, or flickering lights. These symptoms are believed to be caused by reduced blood flow or spasms in the retinal blood vessels. In contrast, visual aura associated with other types of migraine typically affects both eyes.
Common triggers for retinal migraine include stress, hormonal changes, poor sleep, and certain foods. Although retinal migraine symptoms usually resolve within an hour, the experience can be alarming due to the sudden visual changes.
Common symptoms may include:
- Temporary vision loss or blind spots in one eye
- Flickering or flashing lights
- Throbbing headache pain following visual disturbances
It is essential to seek medical assessment to rule out other serious conditions like retinal detachment. Early diagnosis supports effective migraine treatment and helps manage symptoms safely.
How Are Migraines Diagnosed?
Diagnosing migraines involves a detailed clinical assessment by a healthcare professional experienced in headache disorders. There is no single diagnostic test for migraine. Instead, diagnosis is based on your medical history, a description of your migraine symptoms, and ruling out other causes of headache pain.
Clinicians will often review factors such as headache frequency, associated symptoms like nausea, visual disturbances, and aura symptoms, as well as potential migraine triggers. Keeping a migraine diary can assist in tracking patterns and identifying common symptoms.
In some cases, diagnostic imaging or tests may be recommended to rule out other conditions. However, these are generally not required if migraine symptoms align with established diagnostic criteria, such as those outlined by the International Headache Society.
An accurate diagnosis is the first step in developing an effective migraine headache treatment plan to reduce migraine attacks and manage symptoms long term.
Common Migraine Headache Treatments
Migraine headache treatments vary depending on the frequency and severity of migraine attacks, as well as each individual’s triggers and medical history. Traditional approaches often combine acute treatments, aimed at relieving pain during an attack, with preventive medications or preventive treatments designed to reduce migraine frequency over time.
Acute migraine treatments may involve triptan drugs, pain relievers, or nasal sprays to manage symptoms such as head pain, nausea, and sensitivity to light. Preventive therapies can include beta blockers, calcium channel blockers, or medications targeting calcitonin gene-related peptide (CGRP), which plays a role in migraine pain pathways.
While these treatment options can provide relief for many, they often focus on symptom management rather than addressing the underlying cause of migraine attacks. This is where the Sydney Migraine and Headache Clinic™ offers a different approach – focusing on identifying and treating the neurological and cervical factors contributing to migraine pain. By doing so, our goal is to help patients reduce their reliance on medications and achieve long-term migraine management.
For many individuals, understanding their migraine triggers, maintaining a migraine diary, and incorporating relaxation techniques can complement clinical care and support a more effective migraine treatment plan.
