Each phase of migraine is associated with different symptoms, which can help to identify the progression of a migraine attack. Learn how to recognize these specific migraine phases and work with your doctor to create an effective management plan.
Migraine is more than just a headache. There are multiple phases of a migraine attack, each of which brings a unique range of possible symptoms. No two people’s experiences of migraine are the same, and even for one person, symptoms may change from one migraine attack to the next. We hosted a webinar exploring the four phases of migraine, how to recognize each phase and how to address symptoms throughout the different phases of an attack.
The webinar featured Dr. David W. Dodick, Professor Emeritus at Mayo Clinic, and Chief Science Officer and Chair for Atria Academy of Science and Medicine; Dr. Peter Goadsby, Director of the NIHR-King’s Clinical Research Facility, King’s College London, UK, and Professor Emeritus of Neurology at the University of California, Los Angeles; and Dr. Jessica Ailani, Clinical Professor of Neurology at MedStar’s Georgetown University Hospital, and Director of the MedStar Georgetown Headache Center.
What are the phases of migraine?
If you understand the distinct phases that make up the general timeline of a migraine attack, you can better recognize and manage symptoms. The four phases of migraine are:
- Prodrome – This phase can last anywhere from a few hours to several days and may include symptoms like mood changes, sensitivity to light and sound, difficulty focusing, food cravings and others.
- Aura – Only 25% to 30% of people with migraine experience the aura phase. Symptoms include sensory disturbances like seeing “sparks” or unusual visual patterns, the inability to speak clearly, and feelings of numbness or tingling in certain parts of the body. During the aura phase, symptoms typically evolve and change over at least five minutes and can last up to one hour.
- Headache – The headache phase involves pain on one or both sides of the head, and the location and severity of pain may vary from attack to attack or even over the course of a single attack. Other common symptoms of the headache phase include nausea and sensitivity to light and sound. This phase may last anywhere from a few hours up to three days.
- Postdrome – Around 80% of people with migraine experience the postdrome phase, which typically lasts one to two days following the headache phase of an attack. Symptoms during the postdrome phase may include fatigue, trouble concentrating, dizziness and body aches.
Many people do not experience every phase of migraine during an attack, and the specific phases you experience may differ from attack to attack. Additionally, there is often significant overlap between the symptoms and characteristics of each phase.
For example, Goadsby explains that brain fog or cognitive dysfunction is common at the start of the prodrome phase, but it can also occur during the headache and postdrome phases. “What we’re beginning to understand is, while we label these phases, there’s much overlap,” Goadsby says. “So be generous with yourself as you’re thinking about symptoms.”
How does a migraine attack start?
The prodrome phase, also called the promo or primary phase, can happen for hours or even days before a headache starts. It is common to experience light sensitivity, sound sensitivity and a sense of fatigue during this phase. The prodrome phase of migraine may also involve some unusual symptoms like increased urination or craving sweet or savory foods. “These are all things that are [triggered by] the brain,” Goadsby says.
About 60% of people with migraine will experience the prodromal phase for around one day. Goadsby encourages people to pay attention to what happens just before the headache phase and document these observations in a headache journal if possible. By learning to recognize the symptoms you experience during the prodrome phase, you can develop preventive treatment strategies, avoid potential migraine triggers and better prepare yourself to deal with the oncoming headache phase.
Do all people with migraine experience the aura phase?
The aura phase of migraine occurs after the prodrome phase, but only 25% to 30% of patients that have migraine experience aura. “I describe [the aura phase] to my patients as a brain sign—something that’s happening in your brain where it’s been activated and you’re having a physical [sign] of that activation,” Ailani says.
Most people who have migraine with aura will experience some sort of visual sign, like light patterns or a bright flashing spot in their vision. Ailani notes that most people describe their visual aura as a bright flash that starts in a corner of their visual field before moving toward their center of vision and becoming a dark spot or gray blur. Additionally, some people have difficulty with speech or find that one side of their body goes weak during the aura phase of a migraine attack.
These symptoms can be frightening if people don’t recognize that they are elements of the aura phase. In some cases, the aura phase of a migraine attack can also blend into the headache phase.
What symptoms occur during the headache phase?
The headache phase tends to come with moderate to severe pain in one or both sides of the head. However, head pain is often accompanied by a range of other symptoms, including:
- Nausea
- Vomiting
- Sound or light sensitivity
- Neck pain and stiffness
- Problems concentrating (brain fog)
It’s common for people experiencing the headache phase to be able to feel or hear their heartbeat in their head. Movements like walking or climbing stairs can make the pain worse.
Ailani emphasizes that while headache pain is the symptom most commonly associated with migraine, it is a mistake to focus solely on this phase of an attack. “[The headache phase] is what patients and clinicians spend the most time focusing on because it’s the most bothersome symptom to patients. It’s painful, it’s disabling,” Ailani says. “Most of our patients feel like we can understand what headache pain is, so they spend the most time talking about it.”
However, for people in the early stages of their migraine journey, it is just as important to pay attention to the symptoms experienced during the other phases of an attack. This not only enables a person’s doctor to make a more accurate diagnosis, but is also critical to forming effective preventive and acute treatment plans.
“We spend so much time on [the headache phase], unfortunately, that we may forget to talk about the other phases,” Ailani says. “So we have to go back and talk about prodrome, postdrome and aura—because when we look at migraine, it’s not only headache but other symptoms as well.”
Can people with chronic migraine still identify distinct phases of a migraine attack?
Chronic migraine is defined as experiencing 15 or more headache days per month, with at least eight of those days featuring other migraine symptoms. Only 3% to 5% of people in the U.S. live with chronic migraine. While people with chronic migraine experience pain and other disabling symptoms more frequently, Ailani believes it’s still important to understand the phases of chronic migraine.
“Even with chronic migraine and continuous pain, there are going to be fluctuations in pain and symptoms,” Ailani says. “Someone might have constant brain fog or fatigue, but there are going to be other symptoms that fluctuate day-to-day or even hour-to-hour. When we’re trying to create a treatment plan, we might start by trying to pick out the right moment to take acute treatments [to avoid medication overuse].”
Creating and revising a treatment plan for chronic migraine often involves identifying the specific symptoms that signal an oncoming attack and distinguishing these from the persistent symptoms that are unlikely to respond to acute medication.
View our doctor-verified resources for more information on the phases of migraine, managing symptoms and talking to your doctor about a treatment plan.
The American Migraine Foundation is committed to improving the lives of those living with this debilitating disease. For more of the latest news and information on migraine, visit the AMF Resource Library. For help finding a healthcare provider, check out our Find a Doctor tool. Together, we are as relentless as migraine.
