What to Expect During the Four Migraine Stages

Migraines strike in stages

Almost everyone knows someone who experiences migraines, or has them themselves. Migraine is the third most common illness globally, according to the Migraine Research Foundation, and some one in four American households include someone with migraine.

Everyone experiences migraine differently. But most headache specialists will tell you there are four common migraine stages that many people experience during a migraine attack.

Here’s what the experts want you to know about the four migraine stages.

What is migraine?

“Migraine is a chronic neurologic disease characterized by attacks lasting from four to 72 hours, associated with moderate to severe pain intensity, throbbing in quality, made worse with activity, and associated with nausea, vomiting, and sensitivity to light and sound,” says Lauren R. Natbony, MD, American Headache Society (AHS) committee member, headache specialist, and assistant clinical professor of neurology at the Icahn School of Medicine at Mount Sinai in New York.

Migraine is an extremely common condition. In fact, and around 18 percent of women, 10 percent of children, and 6 percent of men in the United States experience migraine.

In many cases the pain and other symptoms associated with migraine are severe enough to be disabling. Even though an estimated 39 million Americans experience migraine, the true total may be even higher, since many people go without a diagnosis.

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What are the four migraine stages?

Many people experience four migraine stages, each with different symptoms and timelines. “When we think of migraine as a disease, obviously the most well-known stage during an attack is the headache or head pain, but we know the disease has multiple other components,” says A. Laine Green, MD, FRCPC, MSc, FAHS.

Dr. Natbony explains that the four stages of a migraine attack include prodrome, aura, headache, and postdrome.

Prodrome

Prodrome is the first stage of migraine and generally occurs within a few hours to days before the other stages of migraine occur. The prodrome stage of migraine generally causes symptoms that are easy to ignore or symptoms that someone may experience commonly that can be caused by other conditions.

According to Dr. Laine and groups like the American Migraine Foundation (AMF), common symptoms associated with prodrome include:

• sensitivity to sound or light
• trouble concentrating
• trouble reading
• nausea
• trouble sleeping
• muscle stiffness and fatigue
• food cravings
• increased urination
• irritability
• depression-like feelings or feelings of euphoria
• yawning
• trouble speaking properly, such as difficulty finding or using the right word
• feeling very thirsty
• mood changes
• unexplained exhaustion
• constipation or diarrhea

Dr. Laine says one of the most common symptoms people complain of during the prodrome stage is neck pain or stiffness. “Many people become distracted by their neck pain and think it is somehow causing the migraine, when in fact, it is a sign of the migraine developing,” he says.

Aura

Aura is the second migraine stage for some people that normally occurs between five minutes to an hour before the headache stage of migraine develops. But for around 20 percent of people who experience the migraine stage known as aura, the stage last longer than 60 minutes.

Those who experience aura may experience it in different ways, but some common symptoms during the aura stage of migraine include:

• visual symptoms including seeing colored or dark spots, sparkles, zigzag lines, stars, flashing lights, blind spots, or geometric patterns
• temporarily losing sight
• numbness and tingling
• a pins-and-needles sensation
• slurred speech or trouble speaking
• hearing changes
• vertigo or dizziness
• temporary partial paralysis (loss of muscle control)
• feeling anxious or fearful
• confusion
• memory problems
• fainting

Headache

The headache stage of migraine involves moderate to severe pain in the head that lasts between four and 72 hours.

The head pain associated with this migraine stage is often:

• throbbing, pounding, or pulsating
• made worse with movement
• on one side of the head, though this may spread as the headache progresses
• drilling
• like the sensation of an icepick hitting the head
• burning
• in the cheeks or behind the eyes

Other symptoms associated with this migraine stage include:

• nausea
• vomiting
• intense sensitivity to light, sound, or smells
• depression-like feelings
• nasal congestion
• anxiety
• neck stiffness and pain
• giddiness
• euphoria
• insomnia

Postdrome

Postdrome, which is frequently referred to as the “migraine hangover,” is the period of time after the headache stage of migraine occurs.

Postdrome is referred to as the hangover phase because most people feel similar to how you feel after indulging in too much alcohol or having the flu. Many people experience the prodrome stage of migraine for a day to several days.

Common symptoms of the postdrome migraine stage include:

• exhaustion
• depressed or euphoric mood
• trouble concentrating and comprehending information
• similar or opposite symptoms experienced in the prodrome stage (for example, if someone was feeling very hungry during the prodrome stage, they may now have lost their appetite)
• generally feelings of being unwell
• dizziness
• body pains and aches
• sensitivity to light, sounds, or smells

Is there a fifth stage of migraine?

Dr. Laine explains that while many people are familiar with the four migraine stages, there is actually a fifth migraine stage, too.

“There is technically a fifth stage of migraine which is the interictal, or the time between attacks, ” he explains. “For most people during this time they don’t have any noticeable symptoms, but we do know from things such as functional MRIs and other functional imaging tools that there are still brain changes occurring during this time that may lead up to the next attack.”

Does everyone experience all four migraine stages?

Not everyone experiences all four migraine stages during each attack. And not everyone experiences the same migraine stages with each attack. For example, someone may experience the prodrome and aura migraine stages without experiencing the actual headache stage or the postdrome stage.

“Most people have the headache phase, though someone can have the other three stages without experiencing the headache phase,” Dr. Laine says. When a person has some of the migraine stages but not the actual headache stage, it is sometimes called a “silent migraine.”

How long each migraine stage lasts, or the symptoms it causes, can also vary drastically between people and between each attack. Children often experience migraine for less time than adults. The aura stage of migraine may also occur at the same time as the headache stage of migraine.

“Aura occurs in about one-third of people with migraine,” Dr. Natbony says. Around 75 percent of people with migraine experience the prodrome stage and 80 percent experience the postdrome stage.

How can you treat migraine?

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The pain associated with migraine typically reduces on its own over time. But many people require the use of medications to prevent a migraine from developing once it starts or to ease headache pain.

Common medications used to treat migraine include:

• over-the-counter pain medications such as non-steroidal anti-inflammatories (NSAIDs) or paracetamol
• prescription triptan
• anti-nausea medications such as Gravol

Dr. Natbony says there are also many non-pharmaceutical interventions that can be done at home to ease migraine symptoms. “A simple one is to turn off the lights and minimize sounds. Migraine often increases sensitivity to light and sound and thus diminishing these external stimuli can help decrease pain,” she explains. “A nap, even a short one, can be helpful as sleep is a natural pain reliever.”

Dr. Natbony adds that using a hot or cold compress on your head or neck can ease pain. Ice packs can have a numbing effect that may decrease the sensation of pain, she says, and hot packs can relax muscle tension. She says drinking a caffeinated beverage may also help as caffeine, in small amounts, can be a potent pain reliever at the beginning of a migraine attack.

During the prodrome migraine stage, some people benefit from:

• doing relaxing activities or practicing relaxation techniques
• avoiding migraine triggers
• drinking plenty of water
• avoiding or reducing stress

Can you prevent migraines?

Dr. Laine says when it comes to managing and preventing migraine, the importance of using non-pharmacological or lifestyle modifications should also be strongly emphasized for people who experience migraine.

“One of the underpinnings for the management of migraine that is often very helpful is what some people call lifestyle modifications or non-pharmacological treatments,” he explains. “I think this really needs to be emphasized to everyone with migraine because there’s plenty of research to show that some of these things can be as potent or even more potent than traditional medications.”

Some of the top lifestyle modification tips Dr. Laine recommends to his patients include:

• Exercise. Dr. Laine says he often suggests his patients are active more time than not throughout the week. “I typically recommend people get 15 to 30 minutes of some sort of activity that gets them to the huffy and puffy state every day; really any activity that motivates someone works,” he says.
• Eating well. Though no specific type of diet works for everyone, Dr. Laine says generally eating a healthy, well-balanced diet and not skipping meals is important. He adds that some people benefit from eating a source of protein, not necessarily animal protein, with every meal.
• Staying hydrated. It’s important to drink at least eight 8-ounce glasses of water every day.
• Avoiding alcohol and caffeine. While in some cases a small amount of caffeine may help reduce migraine once it develops, in general, experts like Dr. Laine recommend that people with frequent or severe migraine avoid caffeine altogether. Avoiding alcohol may also help reduce migraine.
• Maintaining a regular sleep schedule. Many of us won’t like to hear this, but getting up and going to sleep at the same time every day may help manage or prevent migraine. Dr. Laine says he understands in real life things often interfere with our ability to keep a good sleep regimen, but he recommends that people get up at the same time or go to bed at the same time and have a short nap during the day if needed.
• Managing stress. According to the experts, stress is one of the most common triggers for migraine. Dr. Laine says while you can’t live a stress-free life, you can learn ways to reduce or better manage stress that can be beneficial.

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Can you stop a migraine?

If someone realizes they are experiencing symptoms associated with the prodrome or aura migraine stage, there are several things they can do to potentially stop a migraine in its tracks.

Ways to prevent a migraine once it begins to develop include:

• taking pain or migraine medications
• avoiding triggers
• relaxation techniques, such as mindfulness or meditation

Keeping a migraine diary that tracks symptoms, how long each stage lasts or if they occur, and things that may trigger migraine attacks can help someone more easily recognize when they may be having a migraine. In most cases, the earlier someone recognizes a migraine and treats it, the better their chances of stopping the migraine.

What are common migraine triggers?

Many lifestyle factors or environmental factors can trigger migraine in some people. As Dr. Laine explains, experts don’t think these triggers actually cause a migraine to develop, but rather push someone who is predisposed to migraine to experience an attack.

Everyone with migraine has different triggers, but some of the most common according to Dr. Natbony and migraine organizations include:

• certain smells
• loud noises
• bright or flashing lights
• changes in the weather
• stress
• menstruation and hormonal changes
• sleeping too much or not enough
• skipping meals
• alcohol or caffeine consumption
• concussions and traumatic brain injuries
• certain foods or ingredients, most often MSG, cheese, other dairy products, chocolate, artificial sweeteners, cured meats, caffeine, citrus fruits, and cured meats
• dehydration
• medication overuse

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